Habitrol

Preventive medical services have become standard at fixed military medical facilities worldwide. Unfortunately, offering these same programs can prove difficult during military deployments, because of mission demands and at times limited medical resources. We present successful implementation of physical therapy and smoking cessation programs at a level I aid station supporting soldiers during Operation Iraqi Freedom.

Introduction

Today's armed forces deploy more often and for longer periods. Six- to 12-month deployments to Bosnia, Kosovo, Kuwait, Iraq, or Afghanistan are the rule, rather than the exception, for both active duty and reserve components.

Offering medical care comparable to that of a home duty station in these foreign countries can prove difficult. Typical Army clinic resources such as physical therapy and smoking cessation programs were scarce during Operation Iraqi Freedom I. Only one physical therapist supported the 20,000 soldiers of the First Armored Division. Similarly, we were aware of only one other smoking cessation program supporting 130,000 soldiers.

Smoking and poor rehabilitation after injury were health problems frequently encountered at our deployed level I aid station. Unfortunately, both conditions were difficult to manage because ancillary services were missing. However, we relate the experiences of two level I providers' successful implementation of two preventive medicine programs for deployed soldiers. We hope to demonstrate how level I providers can assume these ancillary services in addition to performing their normal clinical duties.

Smoking Cessation Program

The formation of a smoking cessation program grew from three fundamental observations. First, the incidence of cigarette smoking in this theater of operations appeared very high. second, the close living conditions and the single treatment facility allowed us to identify smokers easily. Third, the time and pharmaceutical resources existed to implement a program with a high likelihood of success.

Initially, we screened all patients who presented to our aid station to identify active smokers. Once identified, active smokers were further categorized as precontemplative or actively contemplating quitting. The smokers who appeared ready to quit were praised and then scheduled for a formal screening. Patients were handed a short questionnaire consisting of 15 questions exploring their smoking history and previous attempts to quit smoking. The patients brought this completed form to their screening appointment. The screening process assessed their suitability for starting bupropion therapy and requested that they pick a quit date.

During deployment, soldiers form significant interdependent relationships. To capitalize on this phenomenon, the screening questionnaire was reviewed in a group setting. The candidates shared previously successful strategies, as well as pitfalls for resuming smoking, e.g., life stressors and the "after-meal cigarette."

Once cleared to start bupropion, all candidates took a 150-mg tablet for the first 3 days. This increased to 150 mg twice per day for the anticipated 60-day course. All patients were given a 30-day supply, with instructions to return at 30 days for a refill. All patients were also prescribed the nicotine transdermal system (Habitrol Take Control). Patients who smoked >10 cigarettes daily were instructed on the use of and prescribed all three steps of the transdermal system. Those who consumed

Particular emphasis was placed on choosing a quit date that corresponded to an important date in the patient's life. Patients were instructed to record their quit date as a self-contract, to reinforce the importance of quitting. Finally, patients were strongly encouraged to completely abstain from smoking after their quit date. Because soldiers in our theater of operations are limited in the areas in which they smoke, patients were also strongly encouraged to avoid designated smoking areas, particularly during periods when they felt the strongest urge to smoke.

Our experience with this program was very rewarding. Anecdotally, quite a few long-term, "hard-core" smokers returned to our aid station having successfully quit. They were very appreciative of our assistance, especially given the deployment circumstances. Furthermore, these soldiers became our best marketing tools. They were in part responsible for the growth of our program, which, in a period of

Physical Therapy Program

Properly executed physical therapy remains the cornerstone of rehabilitating acute and chronic orthopedic injuries. Specifically in deployed environments, a physical therapy program results in low rates of air evacuation to the home station and high rates of return-to-duty status.' Unfortunately, therapy in a deployed environment is often neglected because of mission demands and lack of facilities. There were three main observations that prompted the start of our physical therapy program, i.e., the lack of physical therapy support, the need to streamline clinic operating procedures, and the increased workload of the soldiers.

Inability to consistently receive rehabilitation at the distant physical therapy clinic was a major impetus for implementation of a physical therapy program. Travel to that facility involved arranging an armed convoy or riding a scheduled shuttle bus along routes that were continuously bombed by adversaries.

The time stress that the orthopedic patients placed on our routine sick call load necessitated a set-aside time and place to carry out a treatment plan. Twenty minutes was the minimum amount of time required to properly assess and treat an orthopedic injury. Most of this time involved discussing preprinted therapy handouts and demonstrating proper stretching techniques. This time-intensive education of the patient could instead be performed during the scheduled therapy sessions.

Finally, deployment conditions seemed to exacerbate common muscle strains and ligament sprains. Continuous operational requirements did not allow injured soldiers to receive sufficient time to heal. Soldiers were often left to rehabilitate their injuries with little supervision or motivation. In addition, suboptimal field gear made it difficult for injuries to improve. Soldiers often slept without proper lumbar support, i.e., using cots for extended periods. Issued desert boots constructed with minimal padding and little ankle or arch support worsened chronic knee conditions and resulted in increases in both ankle sprains and plantar fasciitis. Together, these exacerbating factors allowed lower back, knee, ankle, and shoulder injuries to evolve into chronic conditions. Soldiers repeatedly returned to the clinic because of lack of relief of symptoms. Although these patients endorsed taking the prescribed anti-inflammatory medication as directed, they confessed noncompliance with their assigned physical therapy regimens. When asked to perform their prescribed rehabilitation exercises, patients typically demonstrated as few as one of the assigned eight to 10 stretches.

In an effort to ultimately prevent chronic joint pain, we started a physical therapy program. The program consisted of a 1-hour block divided into three phases, i.e., heat therapy for the affected body part for 10 minutes, stretching/strengthening of the joint for 40 minutes, and cold therapy for the remaining 10 minutes. Two physicians and one medic facilitated each thrice-weekly session.

Initially, we encountered obstacles; the heat packs issued through supply channels were ineffective, and we quickly ran out of the surgical tubing needed for the isometric strengthening exercises. Field expediency provided our solution. A large water heater borrowed from the dining facility heated towels; when placed in a plastic bag, these towels produced the needed heat. A substitute for standard physical therapy tubing at first came in the form of linked Penrose drains. The rubber tubing of a M998 (high-mobility multipurpose wheeled vehicle) tire bead O-ring became the preferred solution.

Our eventual success came in many forms. The chain of command provided great support for the program. Leaders who were often unsure of soldiers' limitations and rehabilitation requirements were relieved when injured soldiers had a specific program to attend. Nearby aid stations validated our success with numerous referrals of chronic injury patients.

One unforeseen benefit afforded by the program was the continuous reevaluation of the patients during non-sick call hours. We providers could note improvement or regression at each session. These frequent encounters also aided evaluation of a patient's degree of motivation for rehabilitation. Most importantly, every soldier who participated in the program showed improvement. Of the 50 soldiers enrolled in the program, only one was unable to perform the required Army physical fitness test before redeployment.

Conclusions

World events have placed a greater number of U.S. soldiers in more austere environments. There is no indication that this trend will reverse in the foreseeable future. When soldiers are deployed to a developing country, the care they receive cannot match that they had previously known. Nevertheless, a combination of initiative and improvisation can provide ad hoc services otherwise not available to soldiers. We demonstrate through our preventive medicine programs the ability to narrow the gap between the excellent medical services provided at home stations and the deficiency in these programs in a theater of combat operations.

Reference

1. Teyhen DS: Physical therapy in a peacekeeping operation: Operation Joint Endeavor/Operation Joint Guard. Milit Med 1999; 164: 590-4.

Guarantor: CPT Christopher B. Soltis, MC USA

Contributors: CPT Peter H. van Geertruyden, MC USA; CPT Christopher B. Soltis, MC USA

Copyright Association of Military Surgeons of the United States Jun 2005
Provided by ProQuest Information and Learning Company. All rights Reserved