Best Defense

Thomas E. Ricks' daily take on national security.

Why doesn’t D.C. listen to the field on life-and-death issues?: A medical example

By Tracey Perez Koehlmoos Best Defense guest columnist I am going to write candidly here about this issue because when I spoke about it, I went unheard. A recent article in the Wall Street Journal confirms that this is an important issue to those who work in casualty care and as the scientific publication on the issue fell ...

via FDR Library/marist.edu
via FDR Library/marist.edu
via FDR Library/marist.edu

By Tracey Perez Koehlmoos

Best Defense guest columnist

I am going to write candidly here about this issue because when I spoke about it, I went unheard. A recent article in the Wall Street Journal confirms that this is an important issue to those who work in casualty care and as the scientific publication on the issue fell flat, apparently no one is hearing them either. 

By Tracey Perez Koehlmoos

Best Defense guest columnist

I am going to write candidly here about this issue because when I spoke about it, I went unheard. A recent article in the Wall Street Journal confirms that this is an important issue to those who work in casualty care and as the scientific publication on the issue fell flat, apparently no one is hearing them either. 

Maybe because I spent so many years on the front line in the global war against poverty and disease, where children and pregnant women die needlessly every day, I approach improvements to health service delivery with a sense of urgency that may not be universally shared by those who have long worked in clean, air-conditioned buildings, far removed from the moment and universality of human suffering. My ideas are very much in line with the leaders for whom I presently work — and for those familiar will recognize the mantra "More more more, faster faster faster." 

For example, there is the issue of the absence of tranexamic acid (TXA) from medics’ kits. (TXA is a synthetic analog of the amino acid lysine. It is used to treat or prevent excessive blood loss during surgery and in various medical conditions or disorders. Its use has been found to decrease the risk of death in people who have significant bleeding due to trauma and could have a significant impact in the reduction of combat casualty from blood loss.)

The lack of transexamic acid in medic’s kits and ketamine were issues of key concern to providers across Afghanistan when I visited in May 2013. Over and over again, I heard the statistics and the potential described in the article. This was truth on the ground, but no one in Washington was listening. In response to "I am from Washington, I am here to help. What do you need?" the hospital commander of a Role 3 facility pointedly asked me to follow up on the status of a request awaiting signature to get TXA into the hands of medics in theater.

I previously was familiar with TXA, as it is on the World Health Organization’s Essential Drugs List — meaning it is cost effective with good evidence on safety and efficacy and appropriate for use in developing country health systems because it satisfies an essential healthcare need. 

When I returned to Washington and I met with the appropriate health decision-maker inside of the Pentagon, I was gobsmacked and a little outraged by the absolute lack of urgency. This person who had not been near a patient in at least a decade patronizingly told me "that’s a little dramatic" when I noted that soldiers, sailors and Marines might be dying right now whose lives could otherwise be saved.

The response continued, "I am a physician, and when a medic uses a drug it goes against my license" and then went on to say something effete about the complexity of developing and implementing training packages for medics. This call for change was not from the public, from the families of those who had died or from medics — the call for this change came from leading medical providers in theater and was backed by robust evidence.

So, it is a year and a half later. Where are we now? Has the complex development and implementation of a training package for medics using TXA taken place? No. This translational gap between best possible practice and policy-making is daunting.

This is a situation in which the feedback loop supporting evidence to policy is broken. Knowledge translation is a science, not an after-thought in improving health services and health outcomes. When physicians in the field are asking strangers to take their case to the top and the top is not willing to innovate, then knowledge translation cannot happen.

Tracey Perez Koehlmoos, Ph.D., MHA, is the special assistant to the assistant commandant of the Marine Corps, an adjunct professor at George Mason University, an army veteran, and a gold star wife. The opinions expressed in this blog are those of the author and do not represent the opinion of the Marine Corps, the Department of Defense, or any other agency. 

Thomas E. Ricks covered the U.S. military from 1991 to 2008 for the Wall Street Journal and then the Washington Post. He can be reached at ricksblogcomment@gmail.com. Twitter: @tomricks1

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