Ft. Bragg Intrepid Spirit Process Improvement Project
BACKGROUND
Intrepid: characterized by resolute fearlessness, fortitude and endurance; Synonyms: courageous, valiant, fearless, valorous, and simply, brave. (Merriam Webster, 2017)
The National Intrepid Center of Excellence (NICoE), which opened in Bethesda, MD in 2010, is dedicated to clinical care, education and research related to mild TBI and psychological health conditions that affect our nation’s military men and women. Many mTBI, or concussion diagnoses are a result of injuries sustained in combat and have potential long term and sometimes severe effects on work, personal life, families and even the ability to manage basic daily tasks. Often, depression results from an inability to reintegrate into daily unit and mission requirements or integrate back into a civilian life. Early diagnosis, appropriate treatment and specialty referral, and medically prudent return to duty decision making are critically important for this special patient population whose work demands fall into a category requiring the highest level of abilities with the highest level of risks associated with active duty.
The Intrepid Fallen Heroes Fund has been building Intrepid Spirit centers to serve as NICoE satellites and extend the care to the home bases of service members experiencing the effects of TBI. Each Intrepid Spirit (IS) center is approximately 25,000 square feet, costs approximately $11 million to build and focuses on mTBI/concussion diagnosis and treatment. Intrepid Spirit Clinics utilize a holistic, multidisciplinary approach to better determine the cause of persistent post concussive symptoms (PPCS). They provide comprehensive treatment for functional deficits associated with concussion/ traumatic brain injury. Team members, which include primary care providers, rehabilitation therapists, behavioral medicine specialists, complimentary and alternative medicine providers, and case managers meet regularly to discuss individualized patient goals and progress, making changes as needed to ensure maximum recovery. Ft. Bragg is home to one of these Intrepid Spirit Clinics where research and education assets from the Defense and Veterans Brain Injury Center are co-located. Due to the intensive, highly specialized and dangerous training associated with operational readiness, and being that Ft. Bragg is home to the largest concentration of military personnel in the United States, concussions are common and widespread at this installation. Therefore, the Intrepid Spirit is a vital specialty medical resource for the military community it serves.
PRODUCTS
Earlier this year, the Ft. Bragg Intrepid Spirit began to explore reasons why local service members were opting to receive intensive outpatient treatment at NICoE headquarters in Bethesda and at Camp Lejeune’s IS clinic rather than receive services locally. This inquiry, initiated by clinic chief CDR Scott Klimp, led to a clinic wide process improvement goal of creating a robust program that would serve the more elite units that were stationed at Ft. Bragg, including the 82d Airborne Division, Special Operations units associated with the Army, Navy, Air Force and Marines, Army Ranger units, and the Army’s Delta Force unit.
I was asked to analyze the clinic’s readiness for return to duty (RTD) functional assessment program as a part of CDR Klimp’s overall improvement directive. I conducted an extensive literature review on return to work and return to play after concussion, on general military fitness for duty as well as on current clinical practice guidance for concussion. I spent many days with the IS clinic rehabilitation staff in order to comprehensively observe and analyze current practices with respect to RTD clinical decision making. Finally, I conducted numerous interviews with IS clinic patients, and performance enhancement specialists, soldiers and leaders assigned to some of the more elite units stationed at Ft. Bragg. These efforts informed my conclusions and my assessment of the strengths and weaknesses of the current program, and informed recommendations for improvement that were feasible and would produce clinically relevant results. The final products include a leadership brief / power point presentation that was provided to the command staff at the Intrepid Spirit as well as a comprehensive report that provides additional details regarding next steps.
It is exciting to note that we will be initiating a research protocol to further test a novel military specific functional return to duty task that combines a high-level mobility task to challenge the vestibular system with a cognitive challenge and a gaze stability challenge. This task utilizes sophisticated inertial sensors and smartphone technology to provide real time feedback to a clinician on the patient’s performance and how it may compare to uninjured service members who are considered duty ready. Additional performance oriented high-level tasks that simultaneously challenge multiple domains (physical, sensory, cognitive) are the subject of a current funding proposal that would build further on this concept. A resultant highly robust concussion specific functional battery that is military relevant with military referenced norms and cut scores would significantly advance current practice standards, fill a major gap in concussion rehabilitation, and provide an important tool for RTD decision making.
IS Leadership Brief PAR PI Project
REFLECTION
I have been a physical therapist for 27 years, having graduated in a bachelor’s program from NYU in 1990. The clinical focus of most of my career was in neuro-rehabilitation, with a specific interest in TBI. That led me to pursuing a master’s degree in HMSC at UNC about 20 years ago. My goal was to dive deeper into brain anatomy and physiology in order that I would become a better clinician for my severely injured patients; to understand the cognitive components of their injuries, and how those deficits impacted their physical and functional recovery. Along the way, I became an Army wife. This experience had an even greater impact on the direction of my career, as the events that unfolded after September 11, 2001 directly affected my family and my community here at Ft. Bragg. I have seen first-hand how concussions, especially repeated concussions, and the brutal toll of combat deployments affect the physical, psychological, and spiritual well-being of our Service Members. The brain is an amazing, complex, resilient, and mysterious organ that houses so much more than what we manifest in our daily movements, words, and actions. It houses all that a person was, is, and will ever be. And when that person is one who is willing to sacrifice so much for the simple, compelling, life changing concept of freedom, for every citizen anywhere in the world, there can be no endeavor too small in an attempt to protect and heal and care for them.
I came to work in concussion research through the encouragement and mentorship of Karen McCulloch, Kmac, who I continue to work with on novel functional return to duty assessment protocols that are military specific in the types of tasks being evaluated. The opportunity to work in research with members of our military, in the field of mild TBI, is the perfect blending of my head and my heart. There is no perfect solution, there is no perfect assessment, and there will always be risk and danger. I am determined to contribute to the mission of helping clinicians and leaders make the best possible decisions about when to allow these men and women to return to the fight.
ACKNOWLEDGEMENTS
I am deeply grateful for the opportunity to work with the medical community at Ft. Bragg’s Womack Army Medical Center, especially the clinical and support staff of the Intrepid Spirit Clinic. Shaun Carlson, PT, Emily Miller, OT, and Todd Smith, OT have shared their expertise and experience as rehabilitation therapists and offered excellent insight into the challenge of assessing recovery after concussion. Their combined years of service to the Department of Brain Injury Medicine and the Intrepid Spirit Clinic is invaluable and reflects great credit on their professionalism. I am honored and humbled to have had the opportunity to meet, interview and learn from the soldiers here at Ft. Bragg. There are no words to express my amazement and gratitude for their service, for the life they have chosen, and the training they endure in order to be ready, at all times, to fight and win. They represent the fullest realization of what it means to be Intrepid.
LCDR Michael Krok, Chief of Rehabilitation Services at the Ft. Bragg Intrepid Spirit and CDR Scott Klimp, Chief of the Department of Brain Injury Medicine and Director of the Ft. Bragg Intrepid Spirit, have provided thoughtful and insightful direction and feedback throughout this project. Their leadership and vision of success will make the Ft. Bragg Intrepid Spirit a model of care across the network. I am looking forward to continuing to work closely with them as we move these Process Improvement recommendations into reality through our program of research under the incredible guidance, vision, diligence, and commitment of Kmac. None of this would be possible without her at the helm. She too, is an Intrepid spirit.