There have been no posts to this blog over the past several weeks because there has been an avalanche of military bovine merde for most of this month and I have been swimming upstream in what we will call “comparative coprology” in the words of Elaine McNinch in a publication called Medical post on October 12 1999. This is an attempt to dress up the BS of the Army behavioral health system and I think the entire Department of Defense. The confused objectives of our current military leaders are more political manipulations than the product of thoughtful analysis and recent published objectives are summarized in the statement of the current Secretary of Defense who wants to reduce the strength of our military forces (mostly Army) to pre-9/11 numbers. Do we call this an oxymoron or just fecal smearing in an election year? The details of this mandate are itemized in recent editions of Army Times which can be easily accessed on the web. This reduction is another REACTION to electoral politics favoring the popular sentiment: bring our boys home now, which is always fodder for a stump speech. Feeding this delusion to the public–the false belief that we are in a better place in comparison to a decade ago– will result in more votes. I would indeed love to know there will be no more loss of American lives in the Afghanistan/Pakistan disaster, but the notion that our circumstances are substantially safer than in the Fall of 2001 is part of our comparative coprology. But enough of my political bias and on to more definitive observations. I have been able to sit in the front row of the comic opera of the Army behavioral health system. Here are two examples of the Army style of doing business. For the better part of this month our unit, the RTF, for care of soldiers with substance abuse problems, has been in a frenzy of preparation for a visit by a delegation from the office of the Army Surgeon General. This delegation of 15 administrative types, mostly 06 or full Colonel in rank, arrived from the Pentagon, Texas and Florida, to receive a two day presentation on the Fortitude Center (FC). The FC is a manufactured and artificial concept that could potentially cost some 40 million dollars plus to do something we are already doing quite effectively. Conceivably, the FC would bring together the RTF, minor traumatic brain injury (TBI) services and comprehensive pain management. It is interesting to note the other major behavior related issue for the military, Posttraumatic Stress Disorder, is not part of this conception; but more on PTSD in the second part of this post. There is no question substance abuse, TBI and pain are very critical issues. This writer has, in fact, devoted a major part of his professional life to all three of these disorders. And the care of soldiers with these disorders should indeed be “world quality,” as the commander of our hospital boasts, and where these disorders exist in an individual the care should be coordinated. In fact we are doing this very thing, and quite well, if I do say so myself. However, for want of something better to do, and there are a multitude of vital things to be done in the behavioral health service of the US ARMY, Colonels from the Office of the Surgeon General and Colonels from the Eisenhower Army Medical Center got together for two days to say nice things about how well they were doing and to massage a concept that already exists. By and large the content of the presentations of the care and coordination of care were presented by civilians, who do most of the care. It is ironic that we were told the by the gathered wise men that the content of our work was not important…it is the “process” that must be the focus of this conference for the Fortitude Center. I do not know how the name Fortitude came to be used for this exercise, but it does seem to have the necessary grandiose and vainglorious quality for Army operations. And I might add it meets the criteria for inclusion in our study of comparative coprology. Finally, the Colonels came together with the following statement: we will recommend the Surgeon General approve the commission of a demonstration to establish the efficacy of the concept of the Fortitude Center. The current Surgeon will come into discussion of the second chapter of this post. For sure, the fecal smearing will continue. There is another story, temporally simultaneous with the Fortitude Center build up, which qualifies for our comparative coprology analysis. In late January the Seattle Times and then the Army Times published stories that the Army Surgeon General had intervened in an investigation into the reversal of the diagnosis of PTSD in 14 soldiers at Madigan Army Medical Center in Washington state. With the reversal of the diagnosis the soldiers would not receive the significant disability benefits attached to this diagnosis. This prompted Congressional interest of course, with attendant self-righteous indignation from Sen Patty Murray. Shortly thereafter, on 3 February it was announced physicians involved in the review process at Madigan were removed from clinical duties. It was reported that MedCom (Medical Command) had “initiated a top-to bottom review of the process associated with the forensic psychiatric reviews…we are sensitive to the issues that have been raised to this command and working hard to address them.” It seems the entire investigation was prompted by statements of one of the physicians expressing concern that some soldiers seeking compensation for PTSD were malingering. The physicians poor judgment in going public with this contention, while true to a limited extent, resulted in the Army REACTION that reached all the way to the offices of behavioral health providers at Fort Gordon. The above mentioned Senator pontificated “Gen Horoho has taken this seriously…I think it is important to send a message that this will not be tolerated.” General Horoho is the current Surgeon General of the Army. In addition, the Seattle Times stated, “Army officials said the removal of the two doctors was temporary and did not constitute a prejudgment or adverse action.” However, it is standard operating procedure that someone will pay with their career when there is a such a political faux pas. But who exactly is responsible for the “tactless blunder?” Perhaps the Office of the Surgeon General has found the culprit; better said they have targeted the designated victim of the investigation, and indeed his career is over. On 21 February, the same day the Fortitude Center dog and pony show was happening, it was announced that the head of the Madigan Army Medical Center was removed, or relieved of his duties. The Army covered its ass with the following statement: “This is common practice during ongoing investigations and nothing more, said Maj Gen Phillip Volpe, who heads the western Region Medical Command, said Monday about the removal of Col. Dallas Homas.” It was also reported that Colonel Homas is a West Point Graduate whose career has included deployments to Afghnaistan and Iraq, where he served as command surgeon…his military honors include two Bronze stars. It is fair to say Colonel Homas will not make General and it is unlikely he will have another command in his future. By the way, Colonel Homas was not present at Madigan when the review process was being done. He was only there when the doctor made the injudicious remarks about soldiers who did not meet criteria for PTSD. The person who was the commander at Madigan during the time of the reviews was the current Surgeon General of the Army, LT. General Patricia Horoho, who has supported the investigation. She has not instituted an investigation of her own responsibility in this SNAFU. The fecal smearing is at all levels; it is currently illegible but the odor will remain. There is, however, more to the story about the politics of PTSD. On 22 February it was reported that the Army, at the direction of the same General Horoho, is investigating “whether personnel with PTSD who are able to return to duty had better access to care and were offered wider array of treatments than those with PTSD who are likely headed for medical discharge.” This problem is said to originate at various medical facilities in Europe. In regard to this latest REACTION, the spokesperson for the Surgeon General said, “As part of that commitment, we consistently review our programs to ensure they meet the needs of our beneficiaries and we strive to listen to those whom we serve.” Gen Horoho, in testimony before the House Appropriations Committee’s defense panel said, “So, I am looking at the entire spectrum…I am looking at this very, very hard. We take it seriously.” It seems a fair question to ask, who is looking at you Gen Horoho? As part of this looking at the entire spectrum of the PTSD debacle, there has been an Army wide “emergency” Inspector General (IG) investigation into the practice of ALL mental/behavioral health providers throughout the US Army. So, this last week I spent an hour with a representative of the IG answering questions that will, no doubt point the finger in various directions, or shall we say spread the smear even wider. The press and the politicians will play this to their particular views and advantages and the soldiers with PTSD will be sent to suspended animation in WTUs and will be be designated as malingering , or getting preferential treatment, or more prominantly highlighted as a new generation of veterans who become violent and serial killers. The ultimate chapter in our study of comparative coprology is yet to come with an examination of the Medical Evaluation Board System.