U.S. Department of Defense
Office of the Assistant Secretary of Defense (Public Affairs)
|Presenter: Lt. Gen. Eric Schoomaker, Army Surgeon General; Brig. Gen. Gary Cheek, Commander, Warrior Transition Command; Maj. Gen. David Perkins, Commanding General, 4th Infantry Division, Fort Carson, Colorado||April 26, 2010|
GEN. SCHOOMAKER: Well, good afternoon. Thanks for joining us here today.
As you know -- as you may know, there was a New York Times article yesterday about our warrior transition unit at Fort Carson, Colorado, that probably raised concern about how the Army is caring for its wounded, ill and injured soldiers.
I want to take this opportunity today to address some of the issues raised and to give you a better understanding of our approach to warrior care.
And I probably should have prefaced this by saying, I'm Lieutenant General Eric Schoomaker. I'm the commanding general of the United States Army Medical Command and the surgeon general of the Army.
And I'm joined today by Brigadier General Gary Cheek, who is my assistant surgeon general for Warrior Care and Transition and also commands the Warrior Transition Command within the Army Medical Command, with oversight over the units out there to include the warrior transition unit at Fort Carson.
Soldiers that are assigned to the warrior transition units generally have complex medical, personal and spiritual needs that require personal and tailored care. This presents a significant challenge to Army leaders, which we Army leaders view as an Army responsibility, not simply the job for our medical department and my command.
Each part of the Army is joined together and contributes in providing leaders, oversight, resources and services to yield the best possible outcome for the soldier and the family.
We want these warriors to mend in body, mind and spirit. Our patient-and-family-centered care is based upon this concept. And it brings together medical providers, social workers, medical case managers, behavioral health providers and chaplains to focus on individual recovery.
Our goal is to return the soldier to duty or to depart the Army as a proud veteran and a viable member of the community. Our cadre and support staff, both medical and administrative, are trained. They're competent and they're committed to taking care of our warriors in transition.
They do this extraordinarily well on a daily basis. With 9,300 soldiers currently in the program, we don't always get it right. To that end, we take every criticism and concern seriously and continuously strive to improve our program.
We welcome outside visitors, military leaders, family members, members of Congress, local leaders and news media. We also employ numerous feedback methods for looking at ourselves critically, including monthly town hall meetings with our families and soldiers, inspections by the Army Inspector General, and satisfaction surveys.
In fact, an Army IG inspection of warrior transition units will soon be completed, and Brigadier General Cheek, who commands the Warrior Transition Command, is slated to visit Fort Carson to review policies and practices of their warrior transition unit later this week.
Although our surveys -- through those surveys, we know that overall MEDCOM WTU satisfaction is at 81 percent; 81 percent of our soldiers are satisfied with the care that they are receiving within the warrior transition unit. Overall WTU satisfaction at Fort Carson is even higher; it's at about 90 percent.
Fort Carson is also similar to the overall Medical Command in that satisfaction with their case managers and with their cadre -- that is, the individuals who are caring for them and providing administrative support -- is above 90 percent.
In the last year we focused attention on some of our more challenging problems, to include soldiers at high risk for suicide, for drug problems, for multidisciplinary pain management, and diagnosis and management of our traumatic brain injuries. While I anticipate the pace of operations and demand will continue to increase, we're responding to this demand with more flexibility and agility than ever before. In theater and at home, military medical personnel deliver outstanding health care to our troops and civilians alike.
I thank you again for being here today, and I'll take your questions now.
GEN. SCHOOMAKER: Yes, ma'am.
Q When you say that the satisfaction rate at Fort Carson has been over 90 percent, then are you saying the New York Times article is incorrect?
Or have you been aware of the problems that they identify in the article? If so, for how long?
GEN. SCHOOMAKER: Well, ma'am, I don't think -- I don't think the two are mutually exclusive. I think that the Times article focused upon a select number of soldiers and families that were -- had encountered problems. And even with 90 percent satisfaction you're going to have some people with very complex problems that are not going to be in that satisfied group.
So I don't see them as necessarily crafting fiction. I -- but I do believe that it's a wholly unrepresentative of the totality and the context of what we've done for warrior care, especially in the last three years.
Q So you would disagree with the description of the program they've become "warehouses of despair, where damaged men and women are kept out of sight, fed a diet of powerful prescription pills and treated harshly by noncommissioned officers?"
GEN. SCHOOMAKER: It's interesting. Of all of the descriptions in there, with the exception perhaps of the suffering that individual soldiers and families have had, that sentence alone is among the most offensive to us. And I think it wholly describes a situation that we feel is not present. And we welcome you and any member of the press to go out and physically visit warrior transition units, to talk with those soldiers, to talk with their cadre and to see the larger context of how care is being delivered.
Q The Times story said that the soldiers at the WTU are given a lot of meds. And this is something we've heard before, that rather than treat something -- the base cause of someone's problem, that each individual symptom is treated individually, a different pill for each symptom. Are you finding that? Was that true at Fort Carson?
GEN. SCHOOMAKER: I can't speak about Fort Carson specifically, but I can tell you that we are concerned about overmedication.
The fact is that, as I said in my opening statement, many of these soldiers experience physical and behavioral health challenges, which require a variety of treatments by a multi-disciplinary team.
Also we need to recognize that management of pain is -- at this point is -- not just within the Army or the military services but across the nation, is largely reliant upon the use of medications, some -- we've just gone through an era, quite frankly, where the nation as a whole and those that accredit and look at how we deliver care were very, very concerned about our under-treating and under- recognizing pain. But we're very concerned about the panoply of drugs that are being used and the numbers of drugs that are being used.
I chartered a pain management task force a year ago to look at specifically at this problem. We've gotten assistance from my -- our fellow services, the Navy and the Air Force, that -- and -- that conduct care for sailors, Marines and airmen, and for the Veterans Administration as well as academic partners, to look at the problem of multi-disciplinary pain management and to employ other non- pharmacologic means -- for example, complementary and alternative medical practices -- yoga, meditation, acupuncture, movement therapy, lots of other ways of approaching pain management.
So quickly, to your point, we're concerned about the -- about medication use. We're concerned about the use of what's called polypharmacy and multiple drugs. We are monitoring it very, very closely, and I've got our partners from Fort Carson on the line right here, that we could speak to them about what they're doing at Fort Carson specifically to monitor pain medication.
Dave, can you comfortably take that?
GEN. PERKINS: Yes, sir. For the people there in Washington, this is Major General Dave Perkins. I'm the commander of the 4th Infantry Division in Fort Carson. I'm joined here today by Colonel Jimmie Keenan, who's the commander of our hospital and our senior Medical Command officer here. Also I have Colonel George Brandt, who's our chief of behavioral health here at Fort Carson; and Colonel Andy Grantham, who's the commander of our Warrior Transition Battalion.
And I will tell you, the specific question here with dealing -- what are the tools that we use to deal with our warriors in transition, to deal with both behavioral health and, quite honestly, just the physical symptoms they may have -- and are very concerned about the over-prescription of drugs -- in fact I'd like to pass this to Colonel Jimmie Keenan, who can tell you, in fact, what our first line of defense is and put this whole thing in perspective.
So Jimmie, if you could take that.
COL. JIMMIE KEENAN (commander, Evans U.S. Army Hospital, Fort Carson): Yes, sir.
What you need to understand here at Fort Carson is, especially in behavioral health, 85 percent of our providers are non-prescribers. That means these are social workers, psychologists that work with our soldiers to do actually therapeutic care with them, not by using medication.
When we look at our overall prescription rate of our soldiers here at Fort Carson, we are at about 26 percent that are on a narcotic. Those are closely monitored, because here at Fort Carson what is unique is we do have a clinical pharmacist assigned to our warrior transition unit, who specifically monitors all of the medications that our soldiers get.
They monitor, according to the Warrior Transition Command policy for polypharmaceuticals, any use of four or more medications. And that's any medication that a soldier is on.
So we monitor those medications closely with our soldiers. Those are reconciled not only with the primary-care manager that's assigned to that warrior in transition, but also to that behavioral-health provider, if indeed they have a behavioral-health diagnosis.
GEN. PERKINS: Okay. Does that answer the question?
Q Can I get a follow-up, General? I'd like to follow up on what -- well, I forget Keenan's rank.
GEN. PERKINS: Colonel.
Q Colonel? Colonel Keenan's statement that 20 -- if I'm not mistaken, she said 26 percent of soldiers at Fort Carson are on some kind of medication. But what is that percentage among those in the warrior transition units, one? And --
GEN. SCHOOMAKER: Twenty-six percent of the warrior transition unit soldiers are on a narcotic, is what she said.
Q Okay, and --
GEN. SCHOOMAKER: We know that across the Army, soldiers in the warrior transition units -- we can take a snapshot. We have the capability, because of an electronic health record and the fact that we record in electronic databases all prescriptions for all soldiers and family members that are given within the direct-care system of uniform care, whether it's Army, Navy, Air Force, and any pharmacy in the civilian sector that is billed for the care that -- or, excuse me, for prescriptions they give. So we have a fairly -- fairly comprehensive snapshot at any one time of all of the prescription use across the Army. And we can target that to the 9,000-plus soldiers that are in warrior transition units.
We know that warrior transition units in general -- soldiers within that have a higher prescription-drug use than non. They are patients with complex problems. We -- our snapshot in February, for example, showed that about three-quarters of all warriors in transition within WTUs are on -- have a prescription for some kind of medication.
That might be a narcotic, it might be a sleeping medicine, it might be an -- a drug for anxiety, it might be an antibiotic. What Jimmie is saying -- Colonel Keenan is saying, who's the hospital commander and the senior officer over the warrior transition unit command out there, is that 26 percent of her soldiers within the warrior transition unit are on a narcotic of some kind. But there's probably a larger number that are on all the other medicines that they might be on.
Q And what about the claim in The New York Times that some of the soldiers in the warrior transition unit have turned to using heroin in the barracks? Has the Army found any evidence of that? And if so, what is being done about it?
GEN. SCHOOMAKER: Well, I can make a general statement, and then -- and I'll turn it over to General Cheek about this. We have concerns about the diversion of prescription drugs that can be used for recreational uses, just as in the nation at large. That's a big problem right now across the country.
We're also concerned because illegally obtained drugs can be used as complements to these other drugs. And we're very, very concerned and we monitor very closely for them. And I'll turn to General Cheek for that.
GEN. CHEEK: Well, I mean, any illicit drug use, either illicit use of prescription medications or illegal drugs, is a huge concern for us. And frankly, we would view illegal drug use as absolutely contrary to the recovery and the -- and the progress of the soldier moving to their -- to their future.
So our commanders have a number of tools available to them to try and either stem this, prevent it and identify the soldiers that might be using those drugs, either through urinalysis and inspections and other things like that. And so what we -- what we ultimately do is we follow the Army's regulations and guidance on how do we handle those situations. And the Army requires us to process for separation a soldier that's using illegal drugs.
Now, that said, the commanders have some discretion as to what they will do, should that happen. And in a case where we have a soldier with medical conditions, that discretion is widely used to get that soldier some in-patient treatment and follow-on outpatient treatments, to help them overcome that addiction.
Because ultimately whether we return that soldier to an active- duty or a reserve component unit, or if that soldier is going to depart the Army back to civilian life, we want them to be proud and productive and good members of the community.
So commanders use a wide array of tools to either prevent drug use and also, once identified, to try and help the soldier overcome that.
Q Has the Army found any evidence of heroin abuse in the barracks? And how many soldiers have gone through that in-patient procedure, to try to clean them up?
GEN. SCHOOMAKER: I don't have specific statistics. And we may be able to ask Fort Carson to give some of the specifics on what they have dealt with.
But I can feel comfortable in telling you that I don't think there's any specific drug of choice per se that is at an alarming rate. And I think our I guess soldier drug use in warrior transition units is probably very closely aligned with the Army's overall average.
And I say that mostly –when we look at the use of nonjudicial punishment by warrior transition units and other units in the Army. The rates are like within a tenth of a percentage point. They're very, very close.
Q Well, I mean, I think you're dodging the question quite frankly.
You, General Schoomaker, said you have all of these records on what medications soldiers are taking.
GEN. SCHOOMAKER: Right.
Q If in fact people are put through the in-patient cleanup system for taking illegal drugs, there should be records on that, in terms of the number of soldiers, particularly in the warrior transition units, who have been taking illegal drugs and have gone through in-patient treatment.
GEN. SCHOOMAKER: And my understanding is that the treatment -- in-patient treatment in the alcohol- and substance-abuse program for opiate addictions, which are the class of drugs that heroin is related to, is in the -- is the minority of overall. It's like one in 20 of soldiers are in that program.
Jimmie, do you or Colonel Grantham -- can you address heroin use within the WTU out at Fort Carson, or General Perkins? Over.
GEN. PERKINS: AA, sir. General Perkins here. I will talk overall, and then we'll pass off to Jimmie for some specifics.
As General Cheek says, within the Army we take illegal drug use very seriously. We have a number of ongoing initiatives here between our drug-suppression team and Colorado Springs Police Department. To give you some specific numbers, here at Fort Carson, in our substance- abuse program, 6.58 percent of our soldiers enrolled in that are for opiate-related issues, so heroin would be in that number. Within the WTU here, of all illegal-drug incidences, in 2008, we had 22; in 2009, we had 42. So far in 2010, we've had a precipitous drop-off, and we've only had 14 -- although that's 14 too many.
I'll pass it off to Colonel Keenan here, who'll give some more specifics on how within the WTB they are getting at this, not only the heroin use, but as far as controlling drug dispensing and making sure that there's not illegal drug activity going on within the WTU of prescription drugs.
COL. KEENAN: This is Colonel Keenan.
We do a hundred percent urinalysis screen on all of our warriors in transition every month. We also do a 4 percent random testing a month in our warrior transition unit. So a hundred percent of all soldiers, to include cadre, are screened every month, as well as a 4 percent random is done each month.
With that, if we have a soldier who does screen in, we automatically refer them to the Army substance abuse program. We also determine if they need to have an inpatient or an outpatient stay.
We have several programs that we use here in Colorado Springs to support that for us because we don't have an inpatient substance abuse program. But we partner with our civilian counterparts for usually a four- to six-week intensive rehab program for our soldiers.
The other things that we do to deter illicit drugs in the warrior transition unit is, we do daily room inspections. And when our cadre come in, they're looking specifically for anything out of the ordinary that our soldiers might have in their room. And they also have a list of medications the soldiers actually prescribe. So they know if it's a medication that the soldier's not supposed to have.
Additionally, we do inspections of on-post housing, if we have a married soldier, as well as off-post housing, as well to make sure that we deter illicit drug use.
Along with this, I have to tell you that we do a lot of training with our soldiers. We do mandatory training on the use of illicit medications and how that will potentially affect their healing process, because some soldiers don't understand that -- how alcohol mixes with medications, as well as other medications that they might try to take from other soldiers.
So a lot of education in that process and a lot of deterrence with the urinalysis.
GEN. SCHOOMAKER: A comment that although your focus is on heroin and other opiates, the drug that I'm most concerned about and that we have most problems with is alcohol.
Q Just I wanted to clarify that with the colonel. I assume when you gave the instance of illegal drug use, that is not alcohol; that is either -- well, help me out, first of all. Is that heroin, marijuana, street drugs, ecstasy? Is that include prescription pills that they're not supposed to have, that are not their prescriptions? Just help me understand --
GEN. SCHOOMAKER: Yes, ma'am, all of the above. You hit them all.
Q All right. How is it that this stuff, then, over time, some 88 cases over the last two and a half years, keeps getting into the WTUs? And what does it say to you, General Schoomaker, about the medical command climate there that this just continues to keep happening?
And what is your professional experience about illegal drugs of this sort in the rest of the WTUs? How is it that this stuff is so readily available and coming into the wounded warrior unit?
GEN. SCHOOMAKER: Barbara, I'm not sure it's any more readily available within warrior transition units than it is within the community at large or the soldier population at large. But I think added to that is the problem that probably 50 percent of all of our warriors in transition have some behavioral health challenge, some psychological problem that they're trying to overcome. Many have brought that into uniform, quite frankly.
We know from the triennial survey of health behaviors of soldiers, sailors, airmen and Marines that anonymous surveys have taught us that 30 (percent) to 40 percent of our people bring into uniform some rather significant behavior-health problems, to include prior experiences with drug and alcohol problems.
We knew from the study that was done out at Fort Carson, the epidemiological (sic) consultation study that was done addressing the violent crimes that occurred around the 4th -- excuse me, the 4th Brigade of the 4th Infantry Division, that of soldiers who come into uniform that have prior alcohol or drug problems, that rate of recidivism is two- to three-fold higher. So if you couple that with a physical injury or a psychological wound that takes them into the WTU, I think you have concentrated a population of soldiers that are going to be seeking relief in a variety of sources to include illicit drugs that we're very, very concerned about.
Q But this -- (off mike) –these are the troops that are the most vulnerable, perhaps, in speaking to that kind of thing. That just goes back to my question, which is, does it not require more command attention? And is there going to be any sort of review at Fort Carson about this kind of issue or any of the other WTUs?
And I mean, why are -- one has compassion for the wounded, certainly, but are any of them prosecuted for what would -- or disciplined for what would certainly be illegal activity in any other part of the military?
GEN. SCHOOMAKER: Yes, ma'am. I think I'll turn to Gary. But I'd like to believe that what Colonel Keenan just outlined are the steps that they're taking to ensure that the barracks and the living spaces and that the -- whatever sources that a warrior in transition has to illicit drugs are being looked at very carefully.
I -- we did the same thing at Walter Reed, I recall, when I commanded out there: looked very, very carefully at allegations of illegal drug use within barracks and the Malone House, and found, through a very careful study of that, that it didn't exist.
Q But why at Carson? Why at Carson?
GEN. CHEEK: Well, but I think the other point that you have to consider here is we have a very high turnover rate and transition. And so every month across our -- what we currently have is 9,300 soldiers -- we probably have somewhere between six (hundred) and 800 soldiers who depart the program, and six (hundred) to 800 soldiers who come into the program. So it's constantly changing. And that 50- percent behavioral-health issue is fairly constant, and has been for about the past year.
So we have a new cohort, if you will, every month, of soldiers coming into the program, where we're just starting to address their medical needs, their personal issues and so on. It's difficult -- it's difficult work. And that's why they're in this unit, and not left in their operational unit that has a mission, a deployment, et cetera, that they're focused on.
Q Could I speak to you? And any indication of how many instances of heroin usage in the war-wounded transition units are wounded troops? How much are they using heroin?
GEN. CHEEK: I think I'd have to -- the only statistics I have -- and I'd probably defer to what Colonel Keenan said -- but I can tell you this much about Fort Carson, as we did a review after some criticisms of non-judicial punishment use in our warrior transition units. Last year we looked at that, and Fort Carson, just as an example, their punishment rate was 50 percent of the Army's. It was much lower there.
And sometimes, these real, I'll say, very focused efforts of testing for drugs are a wonderful deterrent in helping to keep a soldier straight.
But you're going to discover some early on, and then you have the opportunity to work with the soldier and to help him.
But I don't sense and have feedback from across our commanders of a(n) extraordinary reliance on heroin or a rising use of one particular drug over anything else. And I would -- and I don't have -- unfortunately, if I had known the question, maybe I could have actually looked at it in greater detail, but I would say that we are probably very, very close to the Army's average in what soldiers doing in any illegal activity.
GEN. SCHOOMAKER: Let's go back here to the middle of the room.
Q Thanks. Will you launch any new investigations, based on what you've read in this article, on treatment from NCOs, whether it be illegal drug use or prescription drug abuse? Are we looking at any new investigations?
GEN. SCHOOMAKER: Well, we have -- we have a(n) ongoing inspector general review of warrior transition units that we -- I discussed earlier that -- one of General Cheek's responsibilities, as is the -- as the commander of the Warrior Transition Command, is to systematically look at all warrior transition units, the issues of misconduct, policy adherence and the like.
But to your point, at Fort Carson, the commanding general of Fort Carson, General Perkins, has all of the authorities necessary to look further, at his discretion, about any allegations within this story, and I'll turn to him.
Dave, do you feel comfortable in discussing your plans at this point?
GEN. PERKINS: Yes, sir. As you know, the Army, as an institution, we are very introspective and are always our worst critic. So we are continually examining ourselves.
But we are looking at some very specific areas, and as mentioned earlier, General Cheek is coming out here later this week.
So we're going to partner with him and his organization, along with General Schloesser's, to provide some subject matter expertise. But we're going to be looking actually at even areas beyond what were mentioned in the article, just because that's what we do routinely.
So we're going to look at all the medical processes that we have here at Fort Carson. We have a lot of initiatives that have started. And so we're also going to look at, what has been the result of those initiatives?
We've started mobile behavioral health teams, which take our behavioral health experts out of the hospital and embed them down in the area where our combat brigades are quite honestly to prevent people from having to end up in a transition unit, so they can develop the resiliency skills and we can identify issues earlier on.
We are going to look at a lot of the issues, ongoing processes we have, with the polypharmacological issues that we've talked about. We have a lot of initiatives here where we regulate that, where we coordinate what's being done, with our doctors as well as those in the local network, to coordinate both what their processes are for dealing with our soldiers as well as them understanding what the requirements for soldiers are.
So quite honestly our look is going to go well beyond any specific issue brought up in this particular article.
Q There's nothing new that's going to happen. That's what I've taken from this, no new investigations.
And one follow-up question. One of the perceptions you get after reading this article is that suicide in WTUs is a problem. Do you have any numbers about overall suicides since 2007, specifically in warrior transition units?
GEN. SCHOOMAKER: Suicide rates, gestures and completed suicides, are higher within warrior transition units. Again this is a high-risk population that comes heavily weighted with psychological problems that predispose -- like depression, fractured relationships and the like -- which predispose to suicides.
Jimmie, can you talk about the suicide rate, or Colonel Grantham, within the warrior transition unit at Fort Carson?
COL. KEENAN: Yes, sir. In FY '09 we had four suicides in the warrior transition unit at Fort Carson. Since June of -- the last one was in June of '09. Since that time, we've had no suicides. In 2010 we have had eight suicidal ideations, which meant that they expressed that they might want to commit suicide, and we actually had two attempts. But we've had no completed suicides in FY '010.
GEN. CHEEK: To put that in perspective, for instance in 2009 there were 40 ideations and 12 attempts. So this year a dramatic reduction down to eight ideations and two attempts and no suicides.
Q Soldiers in these warrior transition units,if they want to seek out help, they can probably seek out help for psychological stress, emotional issues. Are soldiers assessed regularly for those -- from the Army side, touching on each soldier on a regular basis, even if they're not asking for it?
GEN. SCHOOMAKER: Absolutely. In fact, one of the reasons that I feel confident in saying that the characterization of these warrior transition units is being -- warehousing soldiers who are simply placed on drugs and sort of put aside and out of view is such a poor characterization and almost 180 degrees of the truth is the work that is ongoing to build a program around an aspirational model of focusing on residual abilities and transitions into either return to duty or effective employment, education, outside of the Army.
And General Cheek has been one of the leaders in this. I'll let him describe what we're doing in what we call comprehensive transition plans.
GEN. CHEEK: Yeah, I really view what we're doing in the Army as really the opposite of the way the article portrays us, in that we are doing more and more to get soldiers excited about their future. And I can sum it up in one event that we're doing next month in Warrior Games, where we are bringing warrior athletes to compete against other services. And part of that is all about proving to these soldiers -- the servicemembers, because it's all services -- that you can get out and compete, and that you can have an effective and a productive future.
And we are doing this with so many different types of events, partnered with well-known organizations like Outward Bound, where we have done a couple of expeditions and several more on a pilot; organizations like LifeQuest, which the WTU at Fort Carson uses very regularly. We've partnered with the U.S. Paralympics to send trainers to each of our warrior transition units to train our leaders in adaptive sports, and to train their physical therapists so that we can run those programs at our -- at our units.
The Red Cross has been a wonderful partner, and has donated a lot of sports spinning equipment and other things like that. And then, other programs like Ride 2 Recovery and Wounded Warrior Project, that sponsor things like cycling events that are very, very physically challenging. And the intent is some of these physical, mental and other challenges will translate to that soldier's sense of well-being and get them oriented on their future.
And so this comprehensive transition plan that we do is run by a social worker, where we do -- their in-processing includes intense goal-setting.
And as that soldier sets their goals, we help them develop that through every issue area that stands in the way of that goal. It's reviewed weekly with their NCO leader. It's reviewed at the six-month mark with their commander. And for those that are most seriously wounded that would be in the Army wounded warrior program, we will send that plan also to their gaining advocate that will assist them, whether they separate from the Army or remain in.
But we have -- we have gone from, I think, a medical hold program, where we did -- and I don't even want to speak pejoratively about it, but that was closer to one that just simply set soldiers aside to recover -- to the warrior transition units, where we provided leadership, case managers and integrated the entire Army, the operational Army and the involvement of senior commanders like General Perkins, as well as our commanders, all under the medical command.
And now the next step is to take this to one that now inspires soldiers to get excited about their future. And so I think we're on a terrific path, one that personally I find very exciting and one that I think our soldiers are also beginning to be able to take advantage of and reap the benefits of, which is why we have a 65-percent return-to- duty rate and so many others that will go on and be productive in civilian life.
Q (Off mike) -- to clarify: Is it -- is it possible for a soldier in a warrior transition unit to sink back into the woodwork and hide from the eye of leadership and assistance, or is leadership and assistance seeking those soldiers out individually and on a regular basis?
GEN. SCHOOMAKER: There's prescribed -- there's prescribed interaction between squad leaders and those soldiers that are -- for whom they are responsible. And that's one of the reasons we set the ratio of warriors in transition to squad leaders at no greater than 1- to-10.
And right now, at Fort Carson, I think, Jimmie, it's 1-to-8 or 1- to-7 for you?
COL. KEENAN: Correct, 1-to-8 for squad leaders, and 1-to-15 for nurse case managers. So we actually have more squad leaders than nurse case managers to focus on our soldiers, sir.
LIEUTENANT COLONEL ANDREW GRANTHAM (commander, Warrior Transition Battalion): Hey, sir, this is Lieutenant Colonel Grantham, the WTU commander. One thing I'd like to add about this too is getting to the heart of tapping the soldiers and seeing them on a regular basis.
That's the beauty of how this WTU is set up. We have the squad leaders and what we call the C2, or the command and control element, that is strictly responsible for the accountability of these soldiers and making sure that we know where they are and that they're safe at all times. That's why we have them come to formations, because some of these soldiers are on meds and we want to make sure that they're safe at all times.
And through the triad of care that the WTU uses, with the nurse case manager and the primary care physician for each of those companies, they are tapped on a weekly basis. They are talked about on a weekly basis. They are seen on a regular basis by their nurse case manager, daily by the squad leaders, to make sure that these soldiers are in good health and that they're going to the appointments that are prescribed by the doctor that sets up the program.
We encourage them to take part in all of our outreach programs, which we have many of. And some of them are mandated that the go to, because part of this look for the healing process is the holistic piece. We've got to get them out of their barracks rooms. We got to get them back into life -- that's what we always say, get you back into life -- socialize them and get them out and doing things.
One of the things, though, that we have done and that the Army has really started to take on is the spousal piece, or the family piece, addressing the family issues, getting them more involved, getting them involved with the healing process, having them come to the medical appointments, and so that they understand as well what the soldier's going through.
And then the comprehensive transition plan that General Cheek talked about. That's really the roadmap for the soldier, from the time he enters the program to the time that he graduates, what he is going to do. And that's the soldier's roadmap. That's his responsibility to take that on.
But we work on setting that up. We work with him on the goal-setting piece, so that they know -- if they're going to transition out of the military -- what they're going to do.
Are they going to go to school? Are they going to get a job? Et cetera, and just one last piece on that. That comprehensive transition plan is so important to us that if there is ever a case where a soldier comes to me for nonjudicial punishment, it's a requirement that that comprehensive transition plan is brought forward as well.
So I take into consideration everything that the soldier has been through, what they're going through now, and where they're going to be once they leave the program. And then each individual case is taken as that, an individual case.
GEN. CHEEK: I have to point out that everything that Colonel Grantham just described -- the relationship between and among the warrior in transition, at the center of this -- the wounded, ill or injured soldier -- and his or her family by the triad of care -- a squad leader, a nurse case manager and a primary-care physician -- all of that is being done in addition to the ongoing treatment they're getting.
If they're an orthopedic casualty, they're going to be -- they have a team of orthopedics and orthopedic PAs and nurses caring for them there, physical therapists. If they have a behavioral health problem, they have a behavioral health specialty team that is managing them.
This is -- this triad of care is provided for every wounded, ill or injured soldier. I've just been reminded that there are media at Fort Carson. And so I probably need to extend an invitation to anyone at the Fort Carson site, from the media, who has a question for us.
GEN. PERKINS: Hey, sir, General Perkins here. There are two questions specifically directed to you all there.
One is from our local Channel 13, who is our local ABC affiliate. And the question is, will there be any changes to the WTU program following this article?
GEN. SCHOOMAKER: Well, I think, Dave, you know that we're always eager to look at any way that we might improve the program, and in following the ongoing IG study, which we expect to have reported out any time and General Cheek's visit out to Fort Carson this week, coupled with any focused looks that you provide as a consequence of this article or concerns you have out there, I'm -- we certainly will make modification to the program.
This program has been modified dynamically on a continuous basis since we stood up the original Army medical action plan in the March- June 2007 time frame.
And so we anticipate any -- any improvement that can be made in it, based upon these focused looks, we'll do that.
GEN. CHEEK: And sir, I think one of the things I would add too is, we have a lot of policies and things we've put in place, and when we have an article like this one. it causes us to step back, let's review this policy. And one of the specific things we've asked commanders is, are our -- for example, our medical -- our medicine reconciliation programs and our sole provider that oversees that -- is that being effective? And if it's not being effective, give us some feedback from your unit on how we might adjust that policy. So there are a few things along that lines that I've asked them to look at.
I asked our commanders as well to verify this notion of an idle soldier, of not having events and activities. And I -- and it's something that I think we have to guard against, and even for a weekend for a soldier that doesn't have something to do -- I mean, that can be a problem. And this is -- this is where we want to integrate all kinds of therapies and other activities as well to get them back into life.
But depending on what our commanders tell us, there's certainly some room that we may make some adjustments to the program.
GEN. SCHOOMAKER: I think the other area, Dave, that -- and our friends in Channel 13 will tell you -- is that I think we're all very concerned about the resilience, and provider and compassion fatigue, and burnout of our cadre. I mean, these are specially selected NCOs and officers. Though they are not medically trained initially, they are all selected specifically for this cadre duty, as squad leaders or first sergeants, sergeants-major, company commanders and the like. And this is very tough duty.
Many -- they are trained specially for this. We put them through a course at Fort Sam Houston, Texas, which tells them about the program, how it operates, how the physical-disability evaluation system operates, all the problems that we've addressed here today.
And I'm concerned, and we all are concerned, that just as medical professionals, caregivers, can encounter problems of burnout and compassion fatigue, these soldiers are -- certainly can fall victim to that. And so we're going to look very seriously at programs that maintain the resilience and protect our cadre against those problems.
Any other -- have you got a second question now?
Q Sir, in fact, the question sort of follows up on what you just said. And I'll direct it to you, and then you can pass it off to me. And I'll give some specifics. This is from The Gazette, our local paper. And specifically following up on the cadre piece, the article mentioned, you know, some disciplinary activity to soldiers in transition who didn't -- who showed up late to formation or didn't perform some of their duties.
And they want to know, how do we accommodate the special requirements of these soldiers based on their wounds? And then, two, what programs are in place to train our NCOs and cadre as to these special requirements? So I'll let you answer from an -- the overall Army perspective, and then we'll take on the sort of Fort Carson-specific nature of it.
GEN. SCHOOMAKER: I mean, you've heard me already describe the fact that the selection process for the cadre is very specific. You, as a senior commander on your installation, as you know, has a say in that.
We put them through a training course down at Fort Sam, Houston, Texas, that's tailored to this. It was helped to be developed by the first warrior transition brigade that we stood up at Walter Reed three years ago.
They get a special-skill identifier as a -- as a cadre member, and special duty pay. And in addition to that, because of the concerns we've had in the past -- about a year ago we had some stories coming out of Fort Bragg that were -- that expressed concern about soldiers in the warrior transition units that had medically related problems of memory or behavior being inappropriately punished -- I asked General Cheek to look at that specifically.
Gary, do you want to summarize that real quickly before we turn it back to Dave?
GEN. CHEEK: Sir, I -- and those specific things, the -- what we found, the feedback from the leaders and the NCO leaders, is that they were far more tolerant of issues or challenges that the soldiers had, far more likely to use counseling and other techniques to improve, you know, performance or issues and to work with those soldiers in finding ways to make sure we accommodated their treatment and medications and other things like that.
And so the use of nonjudicial punishment was far less likely based upon their experience in other units.
And I think I would also add that having visited almost all of our units and talked with the noncommissioned officers, I just have absolute trust and confidence in what the NCOs are doing.
Just as they are the backbone of the Army, they are the backbone of this program as part of a team, where they work really at the leading edge and the very first face in dealing with the soldiers.
Their -- our charge to them is to treat every soldier with dignity and respect. And I'm confident in the vast majority of situations that's exactly what they do.
But they are human. And they will like anyone else make a mistake. And I expect that their leaders will correct that, counsel them and, if necessary, remove them from the program and send them elsewhere, if they're unable to meet that standard.
So I think we owe a lot to these noncommissioned officers who step outside their career fields in many cases. And they will tell you how challenging this job is.
But they'll also say how valuable the experience is and that it gives them knowledge of this system that they'll be able to use as a leader in their future units. So it's not one without payoffs I think for the entire Army.
GEN. SCHOOMAKER: Dave, did you want to make any final comments about that?
GEN. PERKINS: Yes, sir. I'll comment from my level, then pass it off to Colonel Grantham as the battalion commander.
As the general court-martial convening authority here at Fort Carson, all of the legal activities which would result in the soldier being put out of the Army come to me.
And I will tell you first of all, with the warriors in transition, the first thing I look at is their medical diagnosis and a professional opinion of a medical specialist, a doctor -- as to the condition of the soldier -- and in any relationship to their medical condition and the act of indiscipline, to see if there was any cause and effect, and therefore what mitigation does it have.
But we've taken it a step further here at Fort Carson. And in fact, now any soldier's disciplinary action that comes to me which would result in them being put out of the Army, we have that soldier screened by a medical specialist, even if they are not in the WTU. So even if they're down in the combat brigade, we are now medically screening their file before it comes to me, to make sure we didn't overlook some medical condition that could have contributed to this, before it comes to my desk.
So not only are we taking into account the effect of their medical condition for our warriors in transition, but we have now extended that throughout the post -- again, to make sure that we are fully understanding of all of our soldiers' medical situation and how that does or does not impact any act of indiscipline.
And I'd like to pass off to Colonel Grantham for some specifics in the warrior transition unit.
COL. GRANTHAM: Sir, this is Lieutenant Colonel Grantham.
We have to take each case individually. And that's what's so unique about this. We take each one of these soldiers individually. And you know we have the ratio of one-to-10. That's why it's so important that we have accountability. We want our soldiers to show up at accountability formation so that we know that they're safe, that they're doing the things that they need to do. Because when they don't show, for any type of reason, that one squad leader that's out there that has that ratio of one-to-10 has to go and try to find that soldier immediately, because we need to make sure that that soldier is safe. So it kind of puts a -- that cog in the wheel. And we need to make sure that the soldier is taken care of.
I talked earlier about doing the CTP, the comprehensive transition plan, for every UCMJ action that we do. That is so critical, to really understand where the soldier has been, what they're going through now and where they're going to be.
I have actually stopped UCMJ action on a couple of soldiers, young soldiers who had gotten in trouble for certain things. And when I asked them specifically, what is -- I always do that. I said, what's going on with you? The soldier gave me an explanation.
So I stopped the proceedings and actually brought the family members in, the spouse in to say, look, what's going on with him at home? What's going on? You know, how do we fix this? How do we work this together? And we drove on from there. And we pushed back and actually got the soldier a different type of treatment.
We went back and relooked it again. And that's what's so unique about these units is that we have that flexibility to go and do other things instead of just punishment.
The majority of the soldiers that come to me, I will tell you -- looking through their packets before I read UCMJ action on them -- they have numerous counseling statements -- from their squad leader, platoon sergeant, first sergeant, company commander -- trying to get the soldier to do the right thing.
One of the first questions I ask is, what meds are they on? Have they -- what type of treatment have they been in? And what does their CTP say? So I mean, it's a comprehensive, holistic look at the soldier. What's getting him into that position? And what do we do to make it better?
The NCO training -- the NCOs that come to us that are considered the C2 or the command and control are usually seasoned veterans coming out of the line unit. And they have a lot of great leadership skills that we need to take care of these soldiers.
And we do send them down to BAMC. And they go down there for two weeks training. And they get a lot out of it. They understand what the warrior transition units are all about.
I've actually had to remove some soldiers, some C2 soldiers, out of those positions because they weren't getting it. They didn't understand the complexities of the human aspects of this command. And so sergeant major and I took it upon ourselves to remove those soldiers out, and we got new cadre in.
One of the unique things though I would like to emphasize is that we've taken some WTs that have healed and have brought them on as cadre.
They are now -- because they've lived it and breathed it, they are now some of our -- some of our best soldiers, some of our best cadre members taking care of the -- taking care of those soldiers.
And then, overall, we have -- we have -- I think it's addressed this before, but we have the unit ministry team. I have two chaplains in my battalion, and they are looking at the soldier as well from a spirituality perspective. Both the WTs, the warriors in transition, and also the cadre.
You talked a little bit about cadre burnout. We have our chaplains looking at how do we take care of our cadre as well. And they've set up retreats. They've set up family retreats to try to take care of our cadre because this is a very tough business when you're dealing with human dynamics.
Q I got you.
: We're going to have to take one more question up here and then close this out. Yes, sir.
Q Thank you, sir. I'd like to talk about what's called -- ask you a question about what's called clinically the co-morbidity problem, or un-clinically the Jack Daniels approach, to the treatment of PTSD and TBI, or the Jack Daniels and marijuana, you-name-it approach to the treatment of PTSD and TBI.
And my heart goes out to the guys at Fort Carson because I'm a Vietnam veteran, so this is going a little bit of personal to it. And it's like we've almost forgotten, sir; it's like we've almost --
: Let's stick with questions, sir.
Q Almost forgotten. The question is, what lessons have we learned from people in Vietnam who had PTSD and TBI and decided to treat it with a Jack Daniels approach?
GEN. SCHOOMAKER: I think --
Q And what are we doing today? Because you read the Times article, sir, plus I go out to a lot of military bases, and I see soldiers and Marines and sailors who are struggling with this problem. And where is the clinical plan to deal with the soldier? And you know that as a clinician that has decided to take the short-term, bound-to- fail drug or alcohol approach to dealing with their TBI?
GEN. SCHOOMAKER: No, I think it's a very good question. It's a very important question.
What we know is that one of the over-the-counter medications -- that's why I said earlier that one of the drugs that I'm most concerned about, we're all very concerned about, is alcohol. One of the over-the-counter drugs, so to speak, that soldiers will turn to to resolve some of the symptoms early on. But as those symptoms become more established and it turns into a disorder, post-traumatic stress reactions, we know that post-traumatic stress reactions to life- threatening events in life -- whether it's from natural disaster, violent crime or combat exposure -- occur in our soldiers somewhere between 15 and 30 percent of the time for a returning combat veteran. We have ample surveys now through our mental health advisory team studies that have been conducted over the last seven years that have -- that have demonstrated those numbers.
So that we can expect that intrusive thoughts, that sleep interruption, that nightmares, the hyper-vigilance, the sense of always being in the fight, can occur in a large number of individuals, to include soldiers, because it's a natural human response to a life- threatening event.
On top of that, we think that, increasingly, that if you have had a concussion in combat -- a so-called mild TBI, but we prefer to now call that concussion -- that the probability of you developing those symptoms later -- I talk about a physical injury, of being in an IED blast or a rollover or having had an RPG go off somewhere during an attack as being a physical injury that later leads to a chemical injury of post-traumatic stress from sustained stress hormone release, that that linkage is very tight.
We know there are are corollaries in the outside world. Women who have been raped have a very high rate of Post-Traumatic Stress Disorder development later after that crime. And we think that in concussive injury the same linkage is very tight.
Now, for the individual soldier, they discover that the use of alcohol can be a drug -- because it is a drug -- that has some of the same kind of blunting effects that therapy can have for them. And one of our concerns is to try to identify soldiers who have post-traumatic stress reactions and the emergence of -- and the development of Post- Traumatic Stress Disorder before they get into these dysfunctional behaviors like alcohol and drug problems, misconduct. Irritability can be a part of that. So -- interpersonal violence or anger management is an issue for them, to include family violence.
So we're trying to identify as close as possible on the battlefield events that can lead to post-traumatic stress reactions. We are putting mental health providers on the battlefield in larger numbers. We're doing that in Afghanistan today. We're also identifying concussive brain injury at the moment of the injury, so that rather than a soldier voluntarily coming in and being reviewed to see if they've had a concussion, we now mandatorily screen anybody who's on that battle roster who has been within a radius of a blast in combat.
We're starting those protocols. We're training soldiers who are going for that, the leaders, fellow soldiers and our medics. And we're testing it for them when they go through their pre-deployment training at the JRTC, the Joint Readiness Training Center down at Fort Polk, or out at the national training center at Fort Irwin. And the brigades are going over there now with the expectations that if you're in a -- if you're in a concussive event, you're going to get mandatorily taken off the line, examined, given a period of rest to make sure that you haven't had a concussion. And then we anticipate that you may also develop post-traumatic stress later and we want to find that much quicker.
Finally, I'll comment that we've just looked at the past few years of work in reintegrating soldiers and units when they come back to home station after a deployment. And what we're developing, in contrast to these periodic surveys for symptoms and problems -- behavioral, health or otherwise -- is a program that we call a comprehensive behavioral health system of care that longitudinally follows a soldier in a family and ties the various phases of the Army force generation -- pre-deployment, deployment support and events downrange -- to their reintegration back in garrison to give a tailored approach to each soldier across that life cycle, and looks for problems before dysfunctional behavior, before alcohol and other illicit drugs are sought.
So we take what you're describing very seriously. Frankly, Lieutenant General -- retired now -- former Secretary of the VA Jim Peake identified that -- who is a Vietnam veteran himself -- that we may have an opportunity here to interrupt a cycle that began with Vietnam of development of resistant Post-Traumatic Stress Disorder, because the longer it stays with someone, the harder it is to reverse. We may have a historic opportunity to find and interrupt the development of Post-Traumatic Stress Disorder in soldiers, which has been a multi-generational problem and probably has been around since the -- since the beginning of war.
So thanks for that. That's a great question.
MODERATOR: Sir, thank you very much.
We're out of time. Thank you.
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