Essential thrombocythemia

The U.S. Army Reserve plays an important role in the war-fighting capabilities of the U.S. military. There have been concerns, however, regarding the health and physical readiness of this force. Recently Army Reservists were mobilized for Operation Noble Eagle/Iraqi Freedom. We report on both the medical waivers requested and issues related to soldiers found medically nonavailable for deployment on data collected and analyzed from several mobilization sites. Four hundred thirty-one medical waivers were requested. Of 60,000 mobilized, approximately 2.7% were found to be medically nonavailable for deployment, predominately enlisted and male. The most common problems identified were orthopedic, psychiatric, diabetes, asthma, obstetrical-gynecological, and cardiac. The overall prevalence of medically nonavailable for deployment of Army Reservists was low. Most of the conditions leading to nondeployable troops were attributable to chronic disease. Interventions to decrease the level of medically nonavailable for deployment and to lessen mobilization site operations are being implemented.

Introduction

The Army Reserve plays a crucial complementary role to the active component in times of national crises, in particular, in the support areas of medicine, supply, transportation, postal services, military intelligence, engineering, and military police. With this responsibility, however, comes the requirement that when the Army Reserve soldier is mobilized she/he is fit for duty. This allows a timely, efficient, and cost-effective mobilization process. To assure that Army Reserve soldiers are in a state of medical and physical readiness when mobilized, their reserve unit is individually tasked with guaranteeing soldier compliance in specific areas of health, weight, and physical fitness. These units through scheduled soldier readiness processing (SRP) checklists also must maintain individual medical records with updated information. These data are used to determine the overall fitness of the individual soldier for deployment. A myriad of medical conditions that are defined in Army Regulation (AR) 40-501 could disqualify soldiers with permanent 3 or 4 profiles (P3, P4) for worldwide deployment and require immediate follow-up action by their reserve unit. These conditions include hearing loss, visual loss, orthopedic problems, miscellaneous medical diseases (lupus erythematosus, sarcoid, multiple sclerosis, and essential thrombocythemia), heart disease (angina, status after coronary stent placement), diabetes mellitus, asthma, psychiatric disorders, and disorders requiring coumadin therapy, etc.

There are a number of established policies and procedures that allow for the early identification and proper disposition of medically unfit Army Reserve soldiers before their mobilization. Compliance with these policies and procedures is essential, because once a "broken soldier" enters the mobilization site, a time-consuming and costly process could begin, resulting in an administrative quagmire that can last for many months (Fig. 1). In addition, replacement soldiers are quickly tasked to replace those medically nonavailable for deployment.

Some have questioned the actual combat readiness of the Army Reserve although few studies have addressed this issue.1 Weaver et al.2 reported that 28% of 6,000 Army Reserve and National Guard troops did not meet vision requirements without correction during "Call Forward," an exercise to assess the ability of installations to accomplish mobilization and postmobilization missions. It has been suggested that the presence of high-risk behaviors such as smoking, alcohol indulgence, as well as the nature of the civilian pressures on Army Reserve soldiers might affect their overall mission readiness.3

The effects of age may possibly play an important role in soldier readiness. Army Reserve forces called up for mobilization are reported to be older than active duty forces. Amato4 found that in an engineer battalion called for deployment to Southwest Asia, 7% of males were over 40 years of age, 2% were over 50 years old, and 2 of the soldiers were over 60 years old. An older Army Reserve force could harbor more medical problems and chronic disease associated with aging, such as hearing loss, hypertension, heart disease, diabetes mellitus, and arthritis. These conditions place more demands on medical care and military administrative "fitness" and "retention" boards. At a time when the armed forces of the United States are undergoing a major transformation and the exact role of the Army Reserve is under consideration, it is essential that the true wartime readiness of the Army Reserve be known.5 The recent mobilization of more than 60,000 Army Reserve soldiers for Operation Enduring Freedom/Operation Iraqi Freedom/Operation Noble Eagle (OEF/OIF/ONE) resulted in the creation of two data sets to document their physical health and readiness. The first, includes medical waivers requested by the Regional Readiness Commands (RRCs) for soldiers with P3 and P4 profiles. These requests were received immediately before mobilization by the U.S. Army Reserve surgeon who, per AR 600-60, was given the authority to grant an exception to policy for deployment during mobilization. The second contains information on Army Reserve soldiers mobilized and placed on medically nonavailable for deployment status at the mobilization (mob) sites.

The purpose of this study was to determine the state of physical and medical readiness of U.S. Army Reserve troops mobilized for OEF/OIF/ONE by identifying those medical conditions leading to either requests for medical waivers or those designated medically nonavailable for deployment status.

Methods

Medical Waivers

During a partial mobilization of the U.S. Army Reserve the Military Occupational Specialty/Medical Retention Board (MMRB) Convening Authority, the Commanding General of the U.S. Army Reserve, gives authority to the U.S. Army Reserve surgeon to waive (exemption from policy) the requirement for MMRB evaluation of a soldier with a P3 or P4 profile due to operational necessity. The medical waiver must certify that the P3 or P4 profile does not preclude the soldier from performing his or her primary military occupational specialty duties worldwide in a field environment. Waivers submitted by the RRCs to the U.S. Army Reserve Command Surgeon before mobilization from January 2003 through May 2003 were collected and analyzed for soldier sex, age, military personnel classification (MPC), medical condition, and waiver acceptance or denial. Average ages by sex and MPC were calculated.

Medically Nonavailable for Deployment

Medically nonavailable for deployment was an unofficial term for the population of both mobilized Army Reserve soldiers who were unable to deploy with their units due to a medical condition and redeploying soldiers with injuries, illness, or aggravated preexisting conditions. These soldiers with permanent and temporary conditions were held at mobilization stations awaiting medical disposition. Data were collected January 2003 through May 2003 from the mob sites (Forts Hood, Dix. Lewis, Benning, Buchanan, Rucker, Stewart, and Aberdeen).

Data regarding sex, age, MPC, medical condition, and unit branch was collected from a population of 1,800 (2.7%) of 60,000 Army Reserve soldiers placed on medically nonavailable for deployment from late January 2003 until May 2003. Medical Evaluation Board/Physical Evaluation Board (MEB/PEB) status was also documented. The MEB summarizes the soldier's medical status, determines whether the soldier meets retention standards, and makes recommendations to the PEB as to duty limitations. The MEB does not address deployability (Fig. 1). The PEB is part of the Physical Disability Agency and determines whether the soldier should be retained or not. Information was also gathered as to the unit branch of service. An "unknown" category was established for those soldiers where demographic data were reported without a medical diagnosis. Calculation of age distribution and estimation of chronicity of the disorders were made on available information. The date of birth of the National Guard troops was not available; therefore, they were excluded from the study. Total confidentiality of names and identifying numbers for the soldiers was strictly maintained. The files were kept on a secure database in the locked office of the Army Reserve surgeon to preserve the soldiers' confidentiality.

Statistical Analysis

Statistical analysis using tests for linear trend was determined for each medical condition across mean age using SAS software (version 8.2, SAS, Cary, North Carolina).

Results

Medical Waivers

There were 430 medical waiver requests including 322 (74.9%) men and 108 (25.1%) women with 307 (71%) enlisted and 123 (29%) officers (Table I). Frequency distribution of the most common requests for waiver are noted in Figure 2 and includes conditions such as legal blindness, Crohn's disease, lupus erythematosus, sarcoidosis, essential thrombocythemia, function-limiting orthopedic problems, psychiatric disorders, and so forth. Medical waivers were granted for 343 (80%) soldiers for worldwide deployment and 36 (8.4%) for continental U.S. deployment. Fifty-one (11.9%) were denied a waiver (Table II).

Medically Nonavailable for Deployment

Information was obtained on 791 Army Reserve soldiers medically nonavailable for deployment, although complete data were not reported from all mob sites as reflected in the variation in denominators. There were 534 (73%) of 736 men and 202 (27%) of 736 women, 699 (95%) of 736 of whom were enlisted and 37 (5%) of 736 officers (Table I). The medical problems most frequently documented were lower extremity (back, hip, knee, tibia, fibula, ankle, foot, and toe), 201 (25%); upper extremity (cervical, shoulder, arm, wrist, and hand), 72 (9%); mental health, 72 (9%); pulmonary (asthma); 46 (6%); diabetes mellitus, 38 (5%); cardiac, 35 (4%); pregnancy, 35 (4%); gynecological, 25 (3%); sleep apnea, 15 (2%); dental, 14 (2%); allergy, 13 (2%); hearing, 9 (1%); and seizures, 8 (1%) (Fig. 3). Seventy-two (10%) were categorized as "unknown" (Fig. 3). There were 24 (3%) administrative cases (hardship, etc.) placed into a medically nonavailable for deployment status. A MEB/PEB was initiated on 175 (22%).

Age distributions were as follows: 18 to 29 years, 34%; 30 to 39 years, 29%: 40 to 49 years. 25%: and 50 to 59 years, 11%. Average ages for the major disorders are listed in Figure 4. with the overall average age of 34.9 years (Fig. 4). The linear test for trend across mean age was statistically significant (p

Discussion

The majority of medical conditions responsible for mobilization problems appeared to be chronic. The significant number of P3 and P4 profiles noted in the waiver set supports this hypothesis. Most medical problems in the medically nonavailable for deployment were presented by soldiers ages 18 to 39 years. This finding challenges the prejudice of ageism that the "geriatric" 40- and 50-year olds account for the majority of "broken soldiers." The average age of soldiers requesting a waiver, however, was over 43 years old, almost 10 years older than those nonavailable for deployment. An explanation might be found in the higher number of officers represented in the waiver group and the high percentage of those with hearing loss. Army Reserve soldiers designated as medically nonavailable for deployment diagnosed with cardiac disease were also older than the mean and included individuals with coronary artery disease, angina, status after coronary artery bypass, status after angioplasty, cardiomyopathy, congestive heart failure, atrial fibrillation, right bundle branch block, previous cardiac stenting, pacemakers, abnormal electrocardiograms, and myocardial infarction.6 The mean age of soldiers with diabetes (many treated with oral hypoglycemic agents or insulin) was also higher.

Chronic orthopedic problems affecting the back, knee, shoulder, and cervical spine accounted for the majority of the medically nonavailable for deployment and in the waiver group. These disorders can limit the field capability of a rapidly moving hard-charging soldier and the repetitive trauma could potentially exacerbate these conditions. At the mob site, this group requires subspecialty consultations, scans, and imaging studies, with varying degrees of pain control, and places a significant burden on the staff.7 Mental (psychiatric) problems were common in the nonavailable for deployment cell and. occurred more often than pulmonary and cardiac disease. These disorders included major depression, post-traumatic stress disorder, attention deficit disorder, schizophrenia, bipolar disorder, drug or alcohol abuse, and personality disorder.8 Many individuals were receiving treatment with a variety of psychoactive drugs such as antipsychotic medications, mood stabilizers, and antidepressants. The deployment of persons with preexisting psychiatric conditions is risky for a variety of reasons. First, individuals with psychiatric problems, particularly men, are at increased risk for committing suicide. The death of any soldiers is traumatic, but the psychological aftermath of a suicide is particularly devastating. In the short term, a suicide can lead to decreased morale and questioning of the mission. Longer term, it can lead to lifelong symptoms of guilt and anger. second, psychiatric disorders can be associated with acute decompensations during times of stress. In the case of a psychotic disorder, the soldiers may act in ways that endanger himself/herself and fellow troops, such as talking inappropriately and giving away a position. Third, some individuals can become violent during a psychiatric decompensation and may attack fellow soldiers. The relatively low number of psychiatric conditions in the waiver group might be explained by the higher average age. Asthma and other pulmonary conditions were also prevalent and of concern considering the crowded living conditions and an austere and rugged environment with the threat of exploding munitions and burning vehicles. The high number of gynecological problems and pregnancy reinforces the need for adequate female soldier health care.9 Also noted were several cases of sleep apnea, a disorder characterized by daytime sleepiness, a condition being described with increasing frequency in active military personnel and associated with adverse health outcomes.10,11 Eye (glaucoma, visual loss, cataracts, retinal detachment, and decreased visual acuity) and dental problems appeared less frequently than predicted based on previously published data.1 The larger percentage of enlisted personnel compared to officers (officers are approximately 17% of Army Reserve soldiers) may be accounted for by the particular branch of service.

A disturbing trend was the number of significant and difficult to treat active medical conditions such as lupus erythematosus, multiple sclerosis, sarcoidosis, Graves' disease, ulcerative colitis, thrombocytosis, colon cancer, von Willebrand disease, etc., in either the waiver and nonavailable sets. Patients with these diseases require frequent follow-up with medications and must be carefully monitored. Some soldiers were on treatment with corticosteroids or chemotherapeutic agents, precluding adherence to standard vaccination protocols as well.

This study may have limitations. One potential limitation is that since all mob sites did not release their data our sample may not truly represent the entire group. Another restriction is the inability to calculate exact prevalence rates by sex, MPC, or unit because of lack of sensitive information. Several questions, therefore could not be adequately answered. Were specific medical disorders more prevalent in certain types of units? Do the high number of enlisted only reflect a larger percentage of mobilized enlisted? Are the age distribution findings significant? Why are more officers noted in the waiver request group compared to the medically nonavailable group? Another limitation is our estimation (premobilization troop medical records were not available) of chronic or acute disorders. The number of waiver requests for soldiers with P3 and P4 codes would indicate the presence of preexisting conditions. Another limitation is the lack of statistical information on medications. Did the soldiers bring adequate supplies of prescribed medications, especially those not on the military formulary? How often were drugs with potential for adverse effects in a field environment (i.e., antipsychotic medications and temperature regulation) prescribed?

Another factor limiting or impacting on the results of this study was the explanation for the significant number of "broken soldiers" mobilized. Discussions with medical personnel suggest that the reasons for "broken soldiers" reporting to mob sites were multifactorial. Some soldiers were profiled either too stringently or too leniently, indicating the need for better education and training in standardized numerical profiling for reserve physician health care providers. RRC commanders were under extreme pressure to fill their troop quotas and were unfamiliar with the major consequences of mobilized "broken soldiers," assuming the function of the mob sites was to simply determine qualification for deployment. Another factor was the arrival at mob sites of soldiers with problems under treatment by civilian physicians but unreported on the SRP. It was also noted that a number of medically nonavailable for deployment had suffered injuries while going through the mob process itself. One soldier injured his leg in a motorcycle accident at the mob site and subsequently developed a pulmonary embolism from a deep venous thrombosis, requiring warfarin therapy and close monitoring of his International Normalization Ratio. International Normalization Ratio is a standardized method of assessment to determine the therapeutic effect of warfarin. Another mobilized soldier fell off the roof of his home while cleaning the gutters, necessitating medically nonavailable for deployment status.

The approximately 3% of Army Reserve soldiers called up for mobilization who were designated medically nonavailable for deployment actually represented a small portion of Army Reserve soldiers. It demonstrates that the Army Reserve is a healthy, viable entity that is physically ready to perform its role during wartime. There, however, is a need for further reduction in the number of medically nonavailable for deployment for future missions.

A question of concern especially relevant to the findings of this study and to the mobilization process in general is how do we improve the mobilization process for future missions? Health promotion and preventive medicine play a pivotal role in maintaining a physically and mentally robust military force capable of operating in a broad range of missions and operating environments. As the current war in Iraq so vividly demonstrates, the battlefields of the future will demand a fit force. The combination of fast-paced battles and highly technical jobs with increased deployments with fewer personnel will subject our forces to increased stress and exposure to health risks.

Since 1990, Army Reserve Soldiers have been mobilized for several contingencies both home and abroad (Table IV). The conflicts today have no "safe zones," which places higher risk to all our troops, even the traditional "behind the front lines" combat service and combat service support. These health risks may be from harsh environmental conditions, such as poor sanitation, disease exposure, or threats of biological, chemical, or nuclear weapons.

The current operations in Afghanistan and Iraq highlight the need for a more aggressive posture on health promotion and preventive medicine measures. This is especially true for Army Reserve forces that lack access to military treatment facilities (MTF) for impairments not incurred in the line of duty. Army Reserve soldiers with medical impairments that generate a P3 or P4 profile are precluded from mobilization/deployment until the soldier has been before a non-duty related PEB or Military Occupational Specialty/MMRB. MMRB convening authority has only been granted to U.S. Army Reserve Commands Regional Support Commands since September 2002 and Training Support Division Commanders since May 2003. Therefore, many Army Reserve soldiers who met the medical retention standards of AR 40-501 but had profile limitations for non-line of duty impairments had no process to change from nondeployable to deployable status through this board action.

The administrative MMRB process will greatly enhance the deployment of profiled Army Reserve soldiers, improve unit status reporting, and ultimately decrease the number of medical holds during the next mobilization. For soldiers not meeting the medical retention standards of AR 40-501, the non-duty-related physical evaluation board (PEB) offers soldiers pending separation for medical disqualification referral to a PEB for solely a fitness determination. The administrative process of referral to non-duty-related physical evaluation board-PEB is time-consuming for unit personnel, often lacking the resources or medical knowledge to gather the required documents, prepare the packet, and forward to the PEB in a timely manner.

That said, the PEB is very responsive in providing a recommendation within 7 to 10 days of reviewing a medically disqualifying case, with action of "fit" or "unfit." Once again, when the soldier is found "fit" and "return to duty within limitations of a profile," the soldier becomes a deployable unit asset. A recent change to profiling guidance, using Standard Form 507, "Functional Capacity Certificate," provides a common sense approach to standardization and consistency to the regulatory guidance in AR 40-501 and allows a less stringent profile, upgrading a permanent profile "3" to "2" when medical limitations permit. In light of increasing numbers of deployments, an accurate analysis of a soldier's medical, physical, and mental status plays an ever-increasing role in rapid deployments and moving soldiers through mobilization stations efficiently with few tagged "nonavailable for deployment."

Force Health Protection was established in response to the National Defense Authorization Act of 1998 mandated to establish a medical tracking system for members deployed overseas. Force Health Protection is a comprehensive program to consider the needs of the service member at various points in a "deployment life cycle": accession, garrison, predeployment, deployment, operation, redeployment, postdeployment, and retirement or separation.12 The Medical Operational Data System was initiated in 2001 to track administrative medical information on individual soldiers and units through the Medical Force Protection System. The Medical Operational Data System functions as a true real-time system, anywhere in the world. This gives the Army Medical Department and commanders a true view of medical readiness. The Federal Strategic Health Alliance program has made great strides in coordinating physical examinations, dental screening, immunizations, human immunodeficiency virus, and DNA to Reserve soldiers, and providing commanders a robust World Wide Web-based snapshot of soldier and unit medical readiness.

Recommendations for Future Mobilizations

1. Expand the Federal Strategic Health Alliance to include a "medical readiness cell" in each state, comprised of medical corps, dental corps, and nurse corps officers, along with enlisted with medical and personnel expertise to manage soldiers through the medical board process. The Medical Regional Command would work closely with the U.S. Army Reserve Command and RRCs in tracking medical readiness. Placing the Medical Readiness Support Cell (MRSC) at the state level provides the visibility, available medical resources, and close proximity to "customer" units for success. Mandate yearly SRPs at the unit level, with Garrison Support Unit assistance as necessary. Coordinate this activity with MRSC for profile review, Annual Medical Certificate (DA Form 7349) and Annual Dental Examination (DD Form 2813). MRSC personnel could be standing members for geographic MMRBs located in their respective state of responsibility under the auspices of the various RRCs and Training Support Divisions. Compliance could be assured through performance improvement techniques at all levels.

2. Develop collaborative programs with Veterans Affairs hospitals in each state for referral of Troop Program Unit soldiers with medical impairment(s) not incurred in the line of duty. Of particular importance are the soldiers lacking medical insurance coverage for injury; this continuity of services would facilitate the soldier's transition to veteran status at a later time. Twenty-two percent of Army Reserve personnel have access to MTFs through line of duty injury/illness while on active duty orders (Medical Command Reserve Component 746 Study, June 1998). When the Army Reserve soldier is on military duty, they are covered for any injury, illness, or disease incurred or aggravated in the line of duty. When ordered to active duty for more than 30 consecutive days, Army Reserve soldiers have comprehensive health care coverage under TRICARE. Formerly known as CHAMPUS, TRICARE is the Health Services and Support Program for the Department of Defense beneficiaries. Through the three TRICARE programs (Standard, Extra, and Prime), MTFs and civilian providers work as partners to help control the overall cost of health care. The Army Reserve soldier's family's health and dental care needs are also covered under TRICARE.

3. Train and educate division, brigade, and battalion level personnel responsible for soldier/unit data processing in Medical Operational Data System/Medical Force Protection System.

4. Change AR 600-60, Physical Performance Evaluation System, to allow RRC and Training Support Division surgeons, in consultation with commanders, to retain soldiers with high-frequency hearing loss in the 4,000 to 6,000 Hz range. This approach saves the expense of an MMRB (excluding those with inner/middle ear pathology or chronic, systemic disease process) since many of these soldiers are senior level officers or enlisted personnel who are very capable of performing their assigned duties.

5. Engage senior level medical personnel (U.S. Army Reserve Command, Division, and RRC surgeons and staff] with active duty counterparts during mob site planning and processing of deploying soldiers.

6. Enact legislation to provide full-time military health insurance to Army Reserve soldiers and their families for an annual premium waived upon activation, ensuring that medical impairments that limit mobilization are cared for in a timely manner and appropriately worked through the PEB or MMRB processes.

7. Offer incentive programs to employers of Army Reserve soldiers who provide educational programs on health promotion in an effort to enhance military readiness. Topics such as smoking prevention, exercise, proper nutrition, weight control, interpersonal skills, stress/anger management, alcohol and drug abuse prevention, conflict resolution, and domestic violence to name just a few. The study by Alexander and MangelsdorfP in 1994 found that Army Reserve soldiers abused or were dependent on alcohol to a greater degree than their civilian counterparts and less than active duty soldiers. Our data show that although not common, alcohol and/or drug abuse problems were present. It has been hypothesized that healthy lifestyle behaviors stem not only from a sense of individual motivation and responsibility but are also influenced by factors in the social/organizational cultures of the work setting.

8. Incorporate screening for common psychiatric conditions such as depression, alcohol abuse, tobacco use, and anxiety disorders on an annual basis. Those individuals who have positive screens should then be referred for mental health assessment. The young average age of approximately 30 years in our study demonstrates the need for early identification of mental health soldiers who harbor psychological problems. Studies of Persian Gulf War syndrome show an increase in the self-reported prevalence, characteristic of post-traumatic stress disorder (an anxiety disorder), and depression.13

9. Implement a scoring system such as the International Classification of Functioning, Disability and Health to determine duty fitness. Work toward a digitalized profiling system that accurately and reliably allows identification of soldiers with functional limitations that preclude deployment. Such a profile system will allow personnel readiness to be as accurately tracked as maintenance of equipment. An electronic profile system will facilitate strict personnel readiness accountability. This accountability combined with an expeditionary mind set throughout the entire Army will improve personnel readiness.

10. Release within 30 days from active duty reporting Army Reserve soldiers with permanent or temporary conditions that are not qualified for deployment.

Conclusion

A number of U.S. Army Reserve soldiers mobilized for OEF/OIF were unable to be deployed because they suffered from a variety of significant medical conditions, the most common being orthopedic, psychiatric, heart, asthma, diabetes, and gynecological. With the increasing pressures placed on the Army Reserve for worldwide missions, a healthy and fit force that can rapidly respond is required. Early and preventive medical care for all mobilized as well as nonmobilized Army Reserve soldiers will be required to assure this state of readiness. Those individuals, however, who cannot be "fixed" and remain nondeployable will not be retained.

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Guarantor: COL Michael Silverman, MC USA

Contributors: COL Paul Ruble, MC USA*; COL Michael Silverman, MC USA*; COL Janie Harrell, AN USA*; COL Lynnette Ringenberg, MC USA*; COL Jonathan Fruendt, MC USA*; COL Terry Walters, MC USA[dagger]; COL Loren Christiansen, DE USA*; Maria Llorente, MD[double dagger]; Scott D. Barnett, PhD§; COL Barbara Scherb, AN USA¶; COL Eddie Lumpkin, MC USA*; MAJ Deborah Mitchell, AN USA*

* United States Army Reserve Command, Fort McPherson. GA 30330.

[dagger] HHC 1st Medical Brigade, Fort Hood, TX 76544.

[double dagger] Department of Psychiatry and Behavioral Sciences. Veteran's Affairs Medical Center. Miami. FL 33125.

§ Inova Institute Research & Education. Falls Church, VA 22042.

¶ Forces Command HQ, Fort McPherson. GA 30330.

This paper was previously presented at the 6th Annual Conference Force Health Protection. The Albuquerque Convention Center. August 2003, Albuquerque, NM.

This manuscript was received for review in December 2003. The revised manuscript was accepted for publication in July 2004.

Reprint & Copyright © by Association of Military Surgeons of U.S., 2005.

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