Editor in Chief

“God help us, if, the first time something fails—and something will fail—we crush whoever it was … whoever’s responsible,” —Gen. John “Mike” Murray

by Chester Buckenmaier III, MD COL (ret), MC, USA

June 11, 2019

Gen. Mike Murray made this comment as he became the first commander of the Army Futures Command. The command’s website describes the mission of the organization with the following statement: “Army Futures Command leads a continuous transformation of Army modernization in order to provide future warfighters with the concepts, capabilities and organizational structures they need to dominate a future battlefield.”

The general’s comment resonates with me, because I identify entirely with his concern regarding the culture of risk aversion that permeates our military. I believe he is expressing his angst about leading an organization designed to continually modernize and transform the army within a military bureaucracy that appears to favor leadership that does not question or challenge the status quo.

During my 30-plus years working within the Military Health System, I feel our military medical culture has slowly slid from an activity that embraced innovative thinking and continual improvement tweaks to our system to an activity that I perceived has a growing distaste for change. Certainly, the constant pressure from advancements in medical science and technology force a level of change in our system as we adopt new therapies. I often express to medical students that the medicine I practiced as a recently graduated physician 27 years ago is almost unrecognizable to the medicine I practice today. That type of change is unavoidable and not what I am discussing. Instead, I am concerned about the ability of young medical officers with innovative ideas to succeed and be encouraged within the present MHS bureaucracy.

Perhaps I was fortunate to finish my training in 2001, just as the 9/11 terror attacks occurred, resulting in all that followed and continues today for our military. The wars placed unique pressures on the MHS to perform and innovate quickly, and this pressure was undoubtedly felt within the anesthesiology and pain communities of which I was a part.

Early in the conflicts, there was a real need for new ideas and approaches as the MHS literally developed the best trauma system on the planet while on the fly. I am proud to count myself among the many medical officers and enlisted that brought significant changes to military medicine in response to the challenges of the Iraq and Afghanistan conflicts. I also am willing to admit that, as one of those innovators, I was not always received positively by the “system” that was in place at the time.

Fortunately, I feel we were blessed early in the wars with leaders who were willing to intercede on behalf of the innovators who at times ran a little roughshod over the MHS. I was certainly guilty of pressing the system a bit hard, but my bosses had my back, since they understood my efforts would ultimately be good for service members.

Were there failures and missteps as we made these changes? Absolutely. We had spectacular failures, but we would pick ourselves up, dust off, learn from the incident and drive on with the program. Did we “piss off” a few folks and senior leaders along the way? Certainly. I have been told there was an Air Force slide presentation with my picture as physician Public Enemy No. 1 (Buy me a beer, and I will relate that story).

We would always contritely go back to these leaders to plead our case, note how our efforts were good for servicemembers and their families and find a way forward. In short, we caused disruptive change to the system, and it was often perceived by many to be very disturbing, but the system leadership at that time prioritized a desire to achieve better care for the wounded over the occasional hurt feelings. These were heady times and, despite my bureaucratic sins, I still managed to retire as a colonel and more importantly, effected significant positive medical change.

Sadly, I am not convinced the conditions or leadership I perceive exists today would support the positive disruption my younger self effected at the start of the conflicts. I am sure many readers of this column would disagree with me, which is the beauty of editorials. You do not have to agree with me; you are only required to read, consider and think. I will provide an example of my current MHS experience to illustrate my point. I imagine many readers have their own experiences and can relate:

As I have mentioned many times in this column, I work for the MHS as a pain medicine specialist or “painiac” as we in the pain business affectionately refer to ourselves. It is no secret that one of the most significant issues surrounding pain is the misuse and abuse of opioids leading to one of the deadliest epidemics in U.S. history. Death from an opioid overdose (morphine, fentanyl, heroin and the like) is usually caused by respiratory depression, which can be reversed with the drug naloxone, an opioid antagonist that counters the effects of opioids and has saved countless lives from opioid precipitated impending death. Naloxone has few side-effects, can be administered intravenous, intramuscular or intranasal and works, often miraculously, within minutes to revive an opioid overdose patient.

Because the death rate from opioid overdose is presently so high (about 130 deaths a day in 2018, according to the national Centers for Disease Control) many providers, including myself, feel this medication should be as freely available in the same manner as fire extinguishers and automatic defibrillators. In fact, many states (and the VA health system to their credit) routinely co-prescribe naloxone with any opioid prescription as a safety precaution.

Notwithstanding that many people are dying daily from opioids, it has been strangely challenging to gain traction within the MHS on co-prescribing of naloxone. From my perspective, this seems like a no-brainer, akin to keeping a fire extinguisher near the kitchen stove. Naloxone is the opioid fire extinguisher, not just for the person prescribed the opioids but for anyone else in the home who might erroneously or illicitly come into contact with said opioids. While the answer to whether the MHS should adopt an aggressive approach to naloxone co-prescribing seems intuitive, the system appears paralyzed to institute this change. There seems to be a need for unanimous consensus (which I have never witnessed on any serious issue beyond, “I will have another beer.”) and guarantees that nothing will go wrong. As Gen. Murray understands, I guarantee something will go wrong, but that should not deter us for one moment at moving aggressively forward if one life could possibly be saved.

Recognizing this is but one example from my little corner of the MHS, I think it does not portend well for our medical response in the next war if we cannot execute on such low hanging fruit during the opioid crisis. This feeling that I share with Gen. Murray that we might have become so risk-averse as to be paralyzed is a topic much broader and far too complicated for the confines of this editorial. I would ask MHS leaders to consider this issue, determine how we got here, and work collectively to bring back the conditions that served us so well after 9/11.



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