Thursday, January 4, 1996 - 1:30 p.m.
[NOTE: Also participating in this briefing was Captain Michael Doubleday, DATSD(PA)]
Captain Doubleday: Good afternoon.
To start the presentation this afternoon we've asked Lieutenant General LaNoue, who is the Army Surgeon General, to give an overview of the medical support structure that has been established for JOINT ENDEAVOR. He has a few charts that he'll go through initially, and then he'll answer some of your questions. Following that, I'll come back up to the podium and try and field some of your other questions.
General LaNoue: Thank you. It's a pleasant surprise to have the exposure to the press. Usually we military medics are in the background and ready like the fire department to take care of the emergencies and attend to problems.
The point I would like to make is that we in the Army medics have a major contribution to the Army effort, no matter where it goes. I think you'll see that in some of these charts.
We have a variety of functions that we provide on the battlefield. The most important thing is to keep the Army healthy. If you look back over history, there have been more armies defeated by disease than by other armies. Going into some of these places which are at the end of the world in environments that are extremely hostile, are problems that we need to solve so that people can survive and be effective soldiers when they get there.
So you'll see preventive medicine crops up in many places. Having a toothache can be just as bad as having a bad cold. So our dentists are just as much a part of our preventive medicine. We have to have people that go there. Particularly during the 2nd World War, we'd have people come in that were going to be casualties almost any day, so we have moved our dental community to a point to where we've almost put them out of business because our soldiers are dentally so healthy now that we've never had that level before. People usually don't talk about the dentists, and I do.
As you look at how we're moving into Tuzla, you'll see that we have hospitalization, evacuation, clinics, preventive medicine, dentistry. Why veterinaries? We don't have mules any more. But soldiers continue to eat, it seems to be an old habit, so the Army moves on its stomach. We have to make sure the water and the food is clean and satisfactory so that the soldiers can remain healthy. It's very, very important.
Of course laboratories, to find out what's going on. Not only to test people's blood to find out what disease they have, but to test the soil and the air and make sure the environment doesn't have anything that we haven't expected. Indeed, we have become progressively more involved in mental health. Before the Persian Gulf, I guess, we never had the large, combat stress companies as we have now. That was our first effort to do that. The Israelis taught us how many casualties can be limited by having far forward mental health care.
We look at mental health now as having a much larger requirement. For the soldier the foxhole, for the families who are back in Europe, and for the families who are back in the communities here at some of their home stations. So our emphasis on preventive mental health, on preventive mental hygiene, is much higher than it's ever been in our history, so all these areas require our attention. All this happens before the first casualty takes place, otherwise there would be a whole lot more casualties.
I'll do these very generally, because I know your questions are more important. One hundred and twenty minutes by air, when the Air Force flies us back. If anybody needs hospitalization for more than five days, we're going to bring them back. Home for most of these folks is in Europe, but if their home is here, we'll bring them back home.
A new change in the Army medical department has been that besides my being a senior bureaucrat, the major medical adviser to the Chief of Staff of the Army and the Secretary of the Army, I've also become a commander. I command the medical resources here in the United States, the hospitals and the clinics. Indeed, that has expanded to where the hospitals in Europe now come under my command.
When the TOE units, the combat support hospital, mobilizes in Europe to go into Bosnia or into Hungary as the case is here, the people in my hospital go with that unit. It makes no sense to have doctors and nurses sitting there cleaning trucks and painting stones and rocks. They're there to take care of patients. As those doctors and nurses and X-ray techs and lab techs all mobilize, I need to make sure they have a backfill so that the families and the rest of the soldiers in Europe continue to get quality care.
The Chief of Staff advised me that since we're disrupting the people who are mobilizing into Bosnia and we're disrupting the families in Europe, that for me to take all the people out of Walter Reed and Brook and the hospitals here in the United States, the active component, would disrupt the families here. So his emphasis was, let's get the reserves to do the primary mission of backfill.
Since the reserves can't move as quickly as the active component, I immediately sent 23 key people, even before the mobilization in because the response time has been slower. Even today I've been asked for another 19 doctors and nurses to get over there more quickly.
There are two waves of these units that are going on over there. They're being hand picked because the mission was not anticipated. Our mission of these units in Europe are to take care of communities -- mothers, families, soldiers. The mission originally designed for the hospital units that are going over there was for combat casualty care. So we've had to pick from each unit to get the right numbers of people. Not the whole unit is going, but just selected people from each of these units going over.
You folks have challenged us to the N'th degree on trying to report what's going on on the battlefield. In the past, I was always satisfied with knowing where patient was a week later, because the people on-line are accountable, doing good work, and I didn't have to have that kind of awareness of where everybody was. Now families are finding out through the telephone, through satellite, through newspapers, through CNN and NBC and others, I don't want to stay in it with any one corporation, but the information is getting out there before I find out about it. So we've had to put together something so that I find out.
I've gotten a report this morning, by name, who's in Landstuhl, who's at the 67th, who's at the 212th, and what their diagnoses were. What do I need that for? Just to get a pattern, just to understand what the workload is. It's not my responsibility to pass judgment on each case, but by having that knowledge and by sharing it with the corporation, if you will, at large, we're able to anticipate the needs of the folks that are over there in charge.
There's a danger there. We've got families and we've got private information that needs to be protected, so I have to be very careful about divulging too much information when I know what happened to who the day after it happens. As a matter of fact, the Chief of Staff asked me a question this morning that I had a partial answer for. An hour later I got a call from Europe, from the doctor over there who has the answer, and he'd already found out I'd been asked. That's how our communication system is now giving us a sense of awareness of what's important and how to adjust and how to respond and get the answers to questions as it needed.
This is the exciting thing, what we're doing with telemedicine. Telemedicine is going to revolutionize health care in this country more than most folks understand. The reason it's going to help is that it's going to change the pattern of care. We've been caring for patients based on consuming the time of the physician. The [patient] and the physician together in a room was the health care event.
The health care event of the future is the movement of information. The consumer of information, usually the patient, needs to know what to do about what I've got. The physician who needs information to answer that question, needs to know the information from the patient. As this information moves and is more readily available, we don't have to have patients move to the doctor. We'll be able to anticipate the patient's needs by analyzing information from the patient, responding to the patient by telecommunications. Then when procedures are necessary, set up the appointment and make the arrangement.
We are moving telemedicine into each of our medical units in Bosnia. We're on the way there. It's not installed. We're going to get down to the brigade level in a couple of months. Before we're through, we're going to get down to the battalion level, right down to the aid station so that if a PA is having a problem, needs information about Joe, and that information is in Tripler, we need to make that information available to him because it may be he doesn't have to go any further than that aid station, and look at the payback to the Army. Joe stays there, and stays there on the job instead of evacuating him all the way back to Tripler and the information finally dug out.
I'll let you read those. I've already talked too much.
This is an interesting concept in telemedicine. There's always some expert awake somewhere around the world, and we're deployed around the world. If you include our allies, we're deployed in every time zone there is. So if we need a dermatologist, we'll find somebody who's awake and fresh and ready to serve you right now. So we're going to try to take advantage of that. That's an experiment, but we're going to find a way to do it. Sort of a 1-800 number for any expert you want, and we'll find them somewhere on the globe to serve the soldier that we need.
The first, ongoing, and always the last, I know you probably have questions about Persian Gulf illness. The more we're able to monitor and survey all aspects of health and the environment, the more information we're going to have and the more expert we're going to be. We need to have unlimited data collection on every event that takes place in the battlefield -- both before the soldier gets there, while they're there, and then in the aftermath, which means we need to track these folks so that we don't have misinformation and a lot of anxiety about what may or may not be related.
Very good news. Just yesterday Secretary Dorn approved the request that the reservists who are coming on active duty, their families will not only be CHAMPUS and Tri-Care eligible, but they will be excused of the deductible on the CHAMPUS. So good news, that we're bringing these folks on, we're giving their families the kind of health care they deserve.
Mental health services. I already made that point. We have combat stress control in the field; we've got mental support for our families. We don't want to have a rash of child abuse and wife abuse and suicides and things of that sort. We've got to have preventive mental health services at all levels of soldier care and family care.
Q: General, you've described the medical facilities that you're making available primarily it looks like in Tuzla where the headquarters will be, but so far most of the troops are not in Tuzla, they're on their way. As I understand it, the conditions for some of the troops, particularly those working on the bridge project, are living in squalor. Some of them are in warehouses that are infested with rats and feces and lack of heat and general lack of sanitation. Are you aware of those conditions, and are you concerned about that as part of the health of those several hundred or thousands of soldiers?
A: Like a good bureaucrat, I want to defer that to the commander on the street. Yes, I'm aware of it, and yes, I'm tuned into it, and yes, I'm worried about the number of rats and the number of lice on the rats and I have people there counting the rats and counting the lice and counting the bugs that are in the area. Sanitation is important. The command is aware of that. The command is entering an environment that is very stark. First, you've got to get there and then you've got to start fixing things. I'm assured that they are in fact doing that.
Cold injuries are a major concern for us. We're trying to educate commanders and soldiers about how to prevent cold injuries. Indeed, considering the circumstances, we haven't had any serious cold injuries. A lot of minor ones, and the minor ones are being attended to so that they don't become casualties because of it.
But the sanitation is atrocious. We've got to get that fixed. What we're doing is we're taking a city such as where Fort Detrick is, the size of that town, and we're moving it into a very remote area in the middle of the wintertime. That's the Army's business, but when you first land, is the beginning of when you try to fix things. First we had to get across that river during a 100-year flood. I think they're doing an admirable job under the conditions, and we do not accept the fact that the way things are is the way they're going to remain.
We've got to fix the area so that the soldiers can have a clean and safe environment in which to live. A hot cup of coffee, hot soup, dry tent, dry boots, and be able to warm up when it gets too cold.
Q: There's been, supposedly, a Tuzla flu going around in the Tuzla area in the civilian population. There is clearly rather bad air pollution from burning of the soft coal all throughout Bosnia. How are you going about monitoring that? How do you view that in terms of the health threat that the soldiers face in addition to the cold and the possible contaminated food?
A: Tuzla flu. This is the first I've heard of the term Tuzla flu. A pulmonary reaction to air pollution is very common -- ask anybody from Los Angeles, although things have gotten better there. I get the Tuzla flu in Los Angeles.
We're getting a Theater Army Medical Laboratory in there which will have the capability of testing the air. Because the warfighters need to get there first, so that if anybody starts shooting we can shoot back, our laid back kind of medical support gets in there a little bit later. The TAML is on the way, but it's not there yet. They'll have the capability measuring that sort of thing. In the mean time, we've got preventive medicine folks who are expert in that area and can recognize the need and send for an expert if necessary.
Q: What are you doing regarding environmental monitoring that would be different than what you did during the Gulf War? The second question is, can you bring us up to date on these 30 or so soldiers that came down with this virus, and when will they be out of quarantine? And why did the Army sit on that information for so long before making it public?
A: First, what kind of environmental or surveillance is different than the Persian Gulf. Since the Persian Gulf we've put together a small unit. It's part of the Center for Health Promotion and Preventive Medicine which is located at Aberdeen. Basically, it's a major computer program; and preventive medicine folks that are attempting to create a database registering every individual in Department of Defense, in fact, who are authorized to go into the combat zone. We find out who the individual is and we collect all the health information that we can about that individual to include, for instance, the serum that we have in data banks. Every time a soldier gets his HIV test, we have a serum that goes into a refrigerator and becomes a data bank for the future so that we can do serologic tests if the individual is suspected of having some sort of disease, so we can have a before and after if that's the case.
We are setting up this database. It's actually on the grounds of Walter Reed at the present time, and we're attempting to follow every person that goes into country. We collect all the information we can find about any health interaction that he has or she has. Find out where the unit he belongs to has been through the period of the engagement, and indeed, follow that individual for as long as they remain on active duty in the aftermath. So this is a brand new database. How it's going to work, we don't know. We think it makes sense and we think it's worth making the effort.
The second question was about the viral exanthem that some of our engineers have had. I guess the follow-on is why are we sitting on it.
The viral exanthem was something like a modest cold with a rash. At first they thought it was the measles. I just found out the details today, talking to my man on the site back there.
These engineers came from Fort Benning and went into Belgium to a CEGE [Combat Equipment Group - Europe] site which is a logistical storage site for engineer equipment. They had to load the trains with the bridge building material that they needed to get across the Sava. I don't recall how many days they were there in Belgium loading these, and they were with several other engineers who are regularly at that site.
They then got on a train and headed for the theater, and it was the next morning that they then noticed the first patients who had the flu-like symptoms and the rash.
In backtracking this, we find there are patients in Belgium, there are engineers in Belgium with the same syndrome, and I've been lead to believe that has happened once before. I don't recall how long in the past, because this is an ongoing study and we're trying to understand it. We don't know exactly what it is, but it has the appearance of being a virus. Not the measles. It's self-contained. We exercised not strict isolation, but tried to keep them separate, if you will, and we feel by tomorrow since there hasn't been a new case in that group in the last two days, that by tomorrow they'll all be ready to go back to duty.
The first question was, do we have to send another unit in there. The answer was no, this was self-contained, they'll be ready in a couple of days. I think the answer is now that by tomorrow they're ready to move on out.
Was information withheld? It seems to me I've been hearing about it in the press as quickly as I've been hearing about it over my network. So I think it's just a question, if there's a group of people with a bad cold -- I've got a bad cold. I woke up two days with it. But other than my wife, not too many people have known about it until now. It's a mild illness. It's not something you make a big deal about until you say geez, there's 18 guys from one unit. Then you start to get some focus on it and attention on it.
It needed to be looked at, needed to be analyzed. We have the serum now from enough of these soldiers that we'll eventually know what the virus was.
A: I don't know exactly. The first number I got was about 18, and then I've heard something in the 20's, so it's not an enormous number, but a significant number. A significant group.
Q: When you have a cold, you're not quarantined. You are not bridge-builders. When they were in acute need of moving bridge-builders to the front. So this unit does have a strategic importance, and the Army has actually known about it for a number of days and has not been talking about it.
A: A number of days is three or four. You heard about it first today or yesterday?
A: I heard about it yesterday.
A: Today is the 4th. I think it had to be the last day or the last two days of the year. Again, I don't even have a final report. I've had a couple of telephone conversations with the folks that are there. I don't have a written report as to what the facts are yet.
Q: Can you run down for us the other diseases or health problems that have cropped up so far?
A: About 100 people have been hospitalized there, and about 500, less than 500 have been seen and the event recorded. They're all over the place. It's like you would find at a Fort Benning. You add to it, if there is such a thing as Tuzla flu. There have been some asthmatics who have been inflamed. Minor cold injuries were, the only diagnosis is mild cold injury and released, or released to duty. So it's not...
A: Not frostbite. You can get redness of the tip of the finger or your ear or if you've had immersion foot for awhile your feet can be painful and red, and you spend a day drying out and warming up and the symptoms resolve. You go a step further and you've got yourself a serious casualty and a handicap.
The commanders are obviously tuned into the problem, and they're pulling the soldiers out of trouble in time.
Q: Did you hear anything about, I just heard about it, something called mouse fever. A rodent-carried disease. It apparently crops up in the spring time.
A: There is a tick-born encephalitis that our scientists are watching. There's a vaccine for it; but it's not been approved by our FDA. Two countries in Europe have a vaccine for it. We don't know just how much of an exposure we may have to it. Of course while it's cold we're not worried about ticks because the ticks aren't awake right now. We need to have our scientists give us the right answers by the time the spring thaw comes as to what to do about it. Then what we have to worry about is do we have a vaccine? Should we vaccinate? Can we just kill all the ticks? Should we put protective clothing on people so they won't be bitten by a tick if they're nearby? We have to answer those kinds of questions. So what's the smartest thing to do in that environment for those soldiers?
If we were going in in the springtime and we were attacking, we would immunize for everything. We, fortunately, have a less active environment in terms of combat so we can be a little bit more thoughtful and take our time, do it a step at a time.
Q: Do you know in fact if what you're talking about is what in fact is referred to by the locals as this mouse fever or...
A: I don't know that. That's the only disease that I know of that's endemic that's carried by a tick or anything like that.
Q: The combat stress teams, when do they actually go in? What do they do? What are they looking for? Are they circulating or are they waiting for things to trickle up to them?
A: The combat stress teams break up into units of two people. They move out to the battalion level, to the battalion aid station to provide advice and support and counseling to soldiers who were having some adjustment problems or mental problems of any sort. Of course during combat, combat stress becomes a significant factor. Also going to an environment as uncertain as this is can also be a problem.
Q: Are they composed of a doctor, or...
A: They're composed of psychiatrists, psychologists, and enlisted personnel who are trained in psychology.
Q: What are they looking for? What do they tell the commanders? What sort of advice do they give?
A: Number one, they assess the troops. They teach. When they have access to the troops, they work at preventive health, preventive mental health, to keep them informed and to also -- particularly on a private interview basis -- find out what stresses they're struggling with. If they recognize that a particular unit is having a pattern, then they owe it to the commander, and they are trained to do that, to go talk with the commander. It may be that the commander needs to know he's having a problem, needs to do something about it technically, or he may need to do something about it in order to minimize the stress that's on his own troops.
Q: Symptoms that I'm looking for you to describe for me. What...
A: They're all over the place. People are strained with strange behavior. You know people all around you all the time with strange behavior. If we go far enough, each one of us probably could do with some counseling from one of these individuals. That might keep us out of trouble in the next day or two. I've been denied that privilege, so I'm always in trouble.
Q: What would be some of the specific tasks that you want telemedicine to achieve in the theater? What things would telemedicine be doing?
A: I deal with generalities rather than the specifics. What I hope I can influence is to get the communication capability down to where the doctors' and the patients' problems, are so that they have access to the world of health knowledge to tap back into so that you can accommodate the individual's needs where they are. The reason I feel this has a revolutionary impact, that could be the kitchen or it could be a school environment as well as the battlefield.
Q: Is this the first time the military has made any significant use of telemedicine in a deployed environment?
A: No, we've been toying with this. The university, USUHS, The Uniformed Services University of Health Sciences, sent a team to the Persian Gulf, but the commanders weren't interested in it and the medics had no experience with it, so it didn't get very far. A little bit of experimental, and that's all. But it gave it some visibility.
Then when Somalia came along, we discussed the remoteness of this place and the limited assets we were able to get in there. Basically what we're sending in is relatively low grade majors and captains in terms of level of experience, into an environment that we thought -- justifiably so -- might have the world compendium of diseases there, most of which many of them had no first-hand knowledge. So we thought by setting up a communication system we could help them.
Then we discovered that the technology did more for us than what we expected. We were able to take, with cameras -- digitized cameras -- such high definition pictures that they were diagnostic and sent back over E-mail. An eye doctor could look at a wound to the eye and feel very confident as to just exactly what he was seeing. Likewise, the images of X-rays could be sent back. Essentially, the physician had a new tool now, a communications tool. So what I see now is the ability to move whatever information that practitioner and that patient may have need of. Either to send it to the expert to get an opinion on it, or to send to the Library of Congress to find out the latest information on the tick-borne encephalitis because he never heard of it and get the world literature on it, or whatever the need of that practitioner is.
Q: On the tick-borne encephalitis, are you going ahead and preventatively, or protectively asking FDA to approve a vaccine so it will be ready to go in the spring time if you need it?
A: That's the business of Dr. Joseph as the Assistant Secretary of Defense for Health Affairs, and yes, he is doing it. That negotiation is working. Just how far they're going with it, the scientists really need to give us the right answer on that. Some of these things don't have a right answer, and we have to get the best judgment as we go along.
Q: The National Academy of Sciences today released its review of the Pentagon's continuing review of Gulf War illness, and basically as I understand it, supported the Pentagon finding. First of all, could you comment on that? About what that indicates, and does it offer any lessons at all for Bosnia in terms of...
A: The lesson is, as I indicated, that we put together an organization for surveillance. We intend to collect as much information, as we learned we should have had, from the Persian Gulf, that we can humanly put together in a database. We're putting together levels of information that we never considered in any prior engagement.
An Army Medical Surveillance Agency has been set up to try to address that issue, and anything we think may be relevant to understanding this kind of issue, we're going to try to develop a database for it.
Number two, in association with the DCSPER, we're looking at trying to send in, and it's awfully hard to send people into that area because there's a CAP, and there's a lot of minefields around there, so we can't have a lot of scientists walking around there until we've stabilized the area. But we really would like to look at force structure and what causes a soldier to be removed from the battlefield. It's not always medical. Sometimes it's administrative. So we're wanting to do research to get a greater level of detail about what happens to a soldier in this kind of environment.
The Persian Gulf illness is still an open book in my view. Research is ongoing. There has been no established syndrome or disease that we've been able to identify. Indeed, I think it's 80 percent or 85 percent of those who have enrolled into the system, we found a legitimate diagnosis for their problem. Indeed, the incidents of unidentifiable syndromes, if you will, is consistent with the general population. So we don't see a cluster of anything going on, but that doesn't mean we've given up on trying to find it because there's enough people that have enough concerns that make it worth constantly searching for this. I believe as long as these people are alive we owe it to them to try to track their health and see if we can, as time goes on and we get more sophisticated, find an answer to what actually happened.
Q: Are you convinced at your mind that there really, at this point, is no evidence of any Gulf War syndrome?
A: I'm never convinced in my own mind. Scientists are never definite about anything. I'd like to think that at least half of me is a scientist. When I think I know all the answers, that's when somebody is going to prove me wrong. I'm still puzzling with Ptolemy as to whether or not the earth is flat. I'm starting to read Copernicus now to see whether we're the center of the universe or not.
Q: Do you agree with their summary that there's no evidence of any Gulf War syndrome so far, but the numbers could have missed some small, some minor Gulf War illness, or a Gulf War illness that affects a very few people?
A: There's been no data that's been presented that establishes a Gulf War illness, but I think there are substantial numbers, and it's incumbent upon us to continue the search.
Q: Can you clarify something for me? Your first chart you listed as a 120 bed hospital for the folks at Kazar and the 30 bed MASH unit at Tuzla. Are those in place and operating at full strength?
A: The 67th Combat Support Hospital, and I can't pronounce the name of the town, it's in Hungary, is there. It has, I understand, the last I heard, about 32 beds were operational. The engineers are trying to give them a nice, sturdy, drained area on which to set their equipment, and that's ongoing.
Whenever you set up a hospital in the field, you start off under the direst of conditions, and every day you work towards making it like a Walter Reed, so they're going to continue to do that for the time they're there until they get the whistle that says y'all come on home.
The 212th MASH was sitting there in the staging area when Begosh was injured, in support of the bridge crossing, and has not yet got to its final destination which is in Tuzla.
In Tuzla we've had a forward support team which is sitting next to a Nordic hospital because the teams themselves are not totally 100 percent operational without somebody there to give them some support. They've got to eat some place and live some place.
Q: I noticed in your chart of the evacuation, the C-130s, there's a C-9 squadron of Nightingales at Ramstein. What would they be used for?
A: You really need to talk to TRANSCOM about that, but my understanding is that they're strategic. They're for moving folks from Ramstein back here to the United States most of the time. But TRANSCOM decides...
Q: Severe injuries would go on those?
A: They're shuttling back and forth all the time. We have patients coming back from Ramstein and Landstuhl in the hospitals in that area. They have to go down sometimes to Italy to pick up somebody, and then back here. So it's a very busy airline. Those planes have been around a long time and have put a lot of hours on them.
Q: On the phone medicine. Could you describe how it would work? For example, who would be plugging into it?
A: Let me try to give you some philosophical things about telemedicine. Telemedicine is an unfortunate word. It sounds like television, medicine on television.
Telemedicine is the application of the digitized third wave of Toeffler to the practice of health care. It says that we can take a lot of information and digitize it and move it over great distances, to include the patient at one end of a television screen and the provider at the other end. But that's not enough. It's the movement of information, X-ray views, the lab data, the whole history of the individual which may be on a record some place. So what we're working towards is digitizing all information about health and putting it on the virtual world, if you will, our own internet, medical internet, and making it available on the patient's needs and the provider's interface with those needs.
If a patient sitting in Tuzla has an unusual rash and the physicians present there don't have the slightest idea what it is, they can take a high definition photograph of it and they can send it to our dermatologist, wherever he is -- most likely here at Walter Reed, but it could be a naval institution or an Air Force institution. It might be Mass General Hospital by the time the network grows. Then that dermatologist can sit down over a television interconnection, they can both be looking at the photographs, both talking to the patient, both looking at the whole database and talk over the case. So what you're doing is you're expanding that doctor's office to be the whole world.
Q: How far out into the field could it go?
A: Anywhere in the world.
Q: You talk about it being in Tuzla, right? For example...
A: Wherever you can put a telephone, you've got the potential for telemedicine. Wherever you have a communication device. With our satellite and with our AT&Ts and Sprints and the sophisticated communications, ATM switching, we not only can talk over the phone with a lot of static, we now are able to burst large bundles of information which can be many photographs or many X-rays or the whole history written out on 20 pages about a patient's life.
Q: Can you go back to the cold weather preventative things the Army has done? Apparently you have boosted the calory intake. I don't know whether that was a medical decision or some other part of the bureaucracy that made that decision. There have been some other things that have been done preventatively to help a soldier deal with cold weather. Can you run over any of them that you know of?
A: No, I'm not smart enough to run over them in detail.
A: That's standard. We need to keep them dry. We need to educate them so they understand the risks and the hazards. They need to, even in cold weather, be well hydrated. Proper clothing at the right time, ventilating when you need to ventilate, wrapping up when you need to retain the heat. Having that whole compendium of capabilities needs to be...
The key to it is training of the individual soldiers so that they understand how to care for themselves and keep themselves warm and risk-free under that environment. As soon as they get wet, and I guess those bridge-builders had to deal with that, they were constantly getting wet. How long can you tolerate having your hands wet or your boots wet? When do you stop to change your gloves and get a clean laundered pair of socks on? Those kinds of things. I've been fortunate, I've not had to survive in that kind of environment so I have no personal, first-hand information on them. But we've got people over there who indeed have.
Press: Thank you.