MILITARY MEDICAL RESEARCH NEEDS AND OPPORTUNITIES

Karl E. Friedl, PhD, COL (US Army, retired)

A hiatus exists between the inventor who knows what they could invent, if they only knew what was wanted,

and the soldiers who know, or ought to know, what they want and would ask for it if they only knew how much science could do for them.

- Winston S. Churchill (1929)

WHAT ARE THE DOD MEDICAL RESEARCH PRIORITIES? (WHERE DO THEY COME FROM?)

• National strategic plans (e.g., Quadrennial Review)

• Secretary of Defense & other authoritative sources in the DoD and Services

• Armed Services Biomedical Research Evaluation and Management

• Near-term problems identified by field commanders & COCOMs

CORE MEDICAL R&T RESPONDS TO THREATS TO SOLDIER HEALTH AND PERFORMANCE

Environmental Hazards

Heat and Cold

Altitude

Toxic Industrial Chemicals & Materials

Systems Hazards

Laser

Blast

Biomechanical Insults and Stresses

Noise

Operational Stressors

Sleep Deprivation

Traumatic Stress and Situational Stressors

Physical Work Load

Cognitive Burden & Operational Complexity

Endemic Disease Threats

Parasitic Diseases

Bacterial Diseases

Viral Diseases

Chemical/Biological

Warfare Threats

Bacterial Threats

Viral Threats

Toxin Threats

Nerve Agents

Vesicant Agents

Blood Agents

Combat Injuries

Hemorrhage

Head Trauma

Blast Injury

Inadequate

Medical C4ISR

TAKING CARE OF INJURED SOLDIERS HAS BEEN A HIGH PRIORITY

Apart from the war, this department and I have no higher priority than to ensure wounded servicemembers have the best care and facilities and ample assistance navigating the next step in their lives. That is what we intend to give them.

Secretary Gates, 2007

Recognize the critical and permanent nature of wounded, ill and injured, traumatic brain injury, and psychological health programs. This means institutionalizing and properly funding these efforts in the base budget and increasing overall spending by $300 million. The department will spend over $47 billion on healthcare in FY10.

Secretary Gates, 2009

Congressional Special Interest Programs: Neurobiology

> $1B

ENDURING CHALLENGES:OLD MEDICAL THREATS, NEW SCIENCE

SHELL SHOCK

HEMORRHAGE

LIMB LOSS

DOD BLAST INJURY RESEARCH EXTENDS BACK TO WORLD WAR II

Cave blasts

Armored Med Res Lab

Nuclear &

conventional explosions

Los Alamos & Albuquerque

“Laying the tracks for the train”

New Science and Technology Options:Modernization of Military Medical R&D

Prevention

(Mitigate Risk)

Acute Treatment

(Mitigate Injury)

Reset

(Mitigate Disability)

Personalized Medicine Diagnostics Regenerative Medicine

Individual Resilience Provider Training Individual Retraining

Biomedical Standards Wound Care Advanced Prosthetics

Injury Surveillance Optimized InterventionsReturn-to-Duty

Standards

Systems Biology Methods

Advanced Training Technologies & Neuroplasticity

Computational Bioengineering, Biomaterials & Nanotechnologies

Electronic Health Record Outcomes Research

Problem Trends and Low level Persistent Conflict

MEDICAL RESEARCH AND RELATED PROGRAMS IN THE DOD

USAMRMCARO

NMRC

ONR

AFMOA

AFRL

ONR

AFOSR

Services

DARPA (e.g., DSO)

DTRA (e.g., TMTI)

SOCOM (e.g., BISC)

VA-DoD sharing

(e.g., JIF)

Other Agencies

Understanding underlying science creates rule base to help

solve future problems

Low Emphasis on

Fundamental

Understanding

High Emphasis on

Basic Science

Low Emphasis

on Applications

Pure basic research (Bohr)

High Emphasis

on Applications

Pure applied research (Edison)

Use-inspired

basic research

(Pasteur)

DoD Problem-solving Focus: Use-inspired Medical Research

Revolutionary

Evolutionary

TECHNOLOGY READINESS LEVELS (TRLS)

Source: http://as.nasa.gov/aboutus/trl-

introduction.html

Not our job/no requirement for this research (lack of commitment; lack of agility)

Users don’t want it/don’t know how to use it (no CONOPS; no voice for user “pull”)

We’ve never done it that way before(disruptive to current processes)

Ideas and data cannot be shared!(secrecy, stovepipes, meeting restrictions)

Important but it has never been done before (no protected incubator; zero risk mentality)

It will never fly (SWaP, affordability..)(lack of vision; no sense of urgency)

BUREAUCRATIC READINESS LEVELS (BRL)

Not our job/no requirement for this research (lack of commitment; lack of agility)

Users don’t want it/don’t know how to use it (no CONOPS; no voice for user “pull”)

We’ve never done it that way before(disruptive to current processes)

Ideas and data cannot be shared!(secrecy, stovepipes, meeting restrictions)

Important but it has never been done before (no protected incubator; zero risk mentality)

It will never fly (SWaP, affordability..)(lack of vision; no sense of urgency)

SOLUTIONS

Convene meetings and facilitate

idea generation and collaboration

Develop resourced centers and

protected research incubators

Facilitate translation of research

findings and talk about science!

CONVERGENCE SCIENCE: SHARP & LANGER

Trafficking of single groups of 5-HT1A receptors in

distinct endosomal pathways measured by QDs

Fichter K M et al. PNAS 2010;107:18658-18663

©2010 by National Academy of Sciences

The current model of GPCR recycling includes a short (blue arrows) and a long (black arrows)

recycling pathway

CONVERGENCE SCIENCE

Fichter and Vu, Oregon Health and Science University

Flajolet and Greengard, The Rockefeller University

DEVELOP THE CONCEPT AND SMART ENGINEERS WILL ALWAYS FIGURE OUT HOW TO REDUCE SWaP

1996 COL Fred Goeringermobile satellite station beaming

images from the satellite dish from

a mobile surgical center

2009 LTC Sloane Guy performed surgery in Iraq with a

head-mounted camera and other

cameras that could be maneuvered

by remote medical consultants

Surgical telementoring

ADVANCED PHASE SYSTEM-ON-A-CHIP PERFORMANCE MONITORING SYSTEM

Credit: NSF, ASSIST program

NSF ASSIST program Veena Misra

VIRTUAL HOUSE CALLS

“Radio Doctor” Concept

1924

Dr. E. Ray Dorsey conducting teleconsultation with a Parkinson’s

patient in the patient’s home

THEN… AND NOW…

TELE-BEHAVIORAL HEALTH: PROVE THAT USERS WANT THE DISRUPTIVE TECHNOLOGY

Improve access to BH providers for soldiers, minimize travel, extend reach of BH far forward to deployed locations

MC4 laptops using

CENTRIXS network

Patient to Provider

TBH session

• Over 10,000 theater teleconsultations since 2004

• 70% of soldiers would not have sought behavioral health care if tele-behavioral health was not available

• BH became the primary means of delivering BH Care in Afghanistan

mCARE: SECURE MOBILE APPLICATION END USER INTERFACE TO MILITARY HEALTH CARE SYSTEM

Needed a system to allow

members of the CBWTU care

team to connect with Warriors-

in-Transition throughout their

outpatient recovery process

through a device they already

own and are familiar using --

their personal cell phone

Why can’t a soldier receive telebehavioral health services in the privacy of their own home?

• timeliness/urgency

• stigma

• travel distance

H.R. 1832, the STEP Act of 2011

Servicemembers’ Telemedicine & E-Health Portability Act

MONITORING EMOTIONAL STATUSVIRTUAL HUMANS AS BEHAVIORAL HEALTH COACHES

http://ict.usc.edu/prototypes/simsensei/

Louis-Philippe Morency

Albert "Skip" Rizzo

Institute of Creative Technologies

University of Southern California

HOW DO YOU REVIEW AND FUND SOMETHING THAT HAS NEVER BEEN TRIED BEFORE?

Triboluminescence, UCLA/TribogenicsNature 2008;455:1089-92

Biospleen, Wyss InstituteNature Med 2014;20:1211-16

Pathogen Reduction, CaridianTransf Apheresis Sci 2006; 35 (1): 5-17

ADVANCES IN PERSONAL PROTECTIVE EQUIPMENT HAVE CHANGED THE DISTRIBUTION OF INJURIES

SHELL SHOCK

BODY ARMOR

PROTECTION

IT HELPS TO BE A LEADERSHIP PRIORITY

CPT Dan Luckett leading

soldiers on patrol in Afghanistan

NEW CONCEPT:

Restore functionality

and continue the

mission

IN THE PUBLIC PERCEPTION, COOL TECHNOLOGY IS A LEVER

Social Support

Cognitive

Behavioral

Therapy

Neurorehabilitation

TALK ABOUT SCIENCE: SF VAMC & UC SAN FRANCISCO

Bob Obana

What have we done for the veteran lately?