National Defence Committee on March 27th, 2013

[Voices]

Oh, oh!

[Chris Alexander, Conservative, Ajax—Pickering, ON]

It's a surname.

You're also co-chair of the trauma program at the University of Toronto, and a professor. One position that I know you hold because we were there together when you took up this position—and it's not mentioned here—is that you are the Major Sir Frederick Banting Term chair in military trauma research, at Sunnybrook. That is a unique and new position that really fits into the drive that I think all Canadians are trying to see strengthened, and certainly this government is trying to see strengthened, to ensure there's innovation in this field. And what better place to do it than Sunnybrook, which I think was the first dedicated trauma unit in Canada.

Could you tell us how that position is allowing you to take some of your military experiences and bring them to clinical trials, or pursue research in a civilian setting?

[Col Homer Tien]

The Major Sir Frederick Banting chair is a research chair. What it allows me to do as the chairholder is to make connections with the U.S. military, our allies, with the Australians, to do collaborative research, and to fund, say, some young Canadian Forces medical officer who's interested in research that's relevant to the military. Not all trauma research is directly relevant to the military. For example, treating someone at Sunnybrook who is 65, had a drink and got into a car accident, is a completely different proposition than treating an injured Canadian Forces soldier who was blown up by an IED.

The only people who tend to be interested in that type of research are in military organizations. The chair allows me to facilitate that research, conduct the research, and help organize that research. In fact, we are conducting several large trials with the U.S., our allies, on how to better treat patients who are bleeding to death.

[Chris Alexander, Conservative, Ajax—Pickering, ON]

Thank you.

Tell us a bit about a case that became very public, which is somewhere between the two that you described. Last summer, many of us who are MPs in the GTA, and I think across Canada, followed with concern the shooting on Danzig Street, which I believe is in John McKay's riding, which led to multiple wounded and a need for triage.

I understand you were on hand at the receiving end for many of these casualties. Tell us what it looked like, as a professional, and how it compared to your military experience. It was obviously different, obviously rare, in this country, but a shooting nonetheless.

[Col Homer Tien]

And thank goodness it's rare.

It presented as a phone call about multiple casualties. As you know, information can sometimes be very scant at the very beginning. It was that anywhere from 10 to 30 patients with possible gunshot wounds might arrive at Sunnybrook. As the trauma surgeon on call that night, I drove in right away. The helpful thing, I think, is that it was actually similar to an experience in Kandahar. When you get the warning of multiple casualties, what you have to do is organize your teams and call in people. I have to say that I found my experiences in the Canadian Forces very useful, in terms of how to organize teams, how to prepare for mass casualties.

At Sunnybrook, our first priority is trauma care. All the team members were very enthusiastic. Everyone wanted to stay. Everyone wanted to participate. I like to think our teams did a very good job in moving these patients through and treating them.

[Chris Alexander, Conservative, Ajax—Pickering, ON]

No doubt. And it was no doubt thanks to your leadership.

Could you say briefly what you think lies ahead for Canada and our allies when we are looking at how to prevent and then treat blast injuries, which obviously were so central to the challenge in Afghanistan, and may well be in other conflicts?

[Col Homer Tien]

There are huge efforts in terms of doing research on this. What you really need is better detection, better prevention. Once you're in the blast, if you're right on the blast, there's very little that medical care can do.

From the medical side, a lot of the research focuses on the mild traumatic brain injury—what does that shock wave actually do to people?—and the rehabilitation and the chronic pain issues. Those are at the forefront now in research priorities in Canada, in the Canadian Forces Health Services, as well as for our allies.

[The Chair, Conservative, James Bezan]

Thank you.

Ms. Moore, go ahead.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Thank you very much.

I would like to come back to the education and training of trauma health care professionals. I was a medical assistant in the armed forces, but I am also a critical care and emergency nurse. We know that not much training is provided on military bases for trauma situations. Such training is provided occasionally, but not very often.

How do you ensure that those nurses are able to react quickly and that they possess the knowledge and skills they need when they're part of a mission on the ground? We could be talking about something as simple as initiating an IV line. If nurses don't do that often or don't do it under stressful circumstances, problems may arise when they find themselves in this kind of a situation. Starting an IV should not take 15 minutes. However, if the nurses never do that kind of work, or don't do it often, it's more difficult in those conditions.

How do you ensure that health care professionals are able to react quickly in trauma situations?

[Col Homer Tien]

Thank you very much for that excellent question. I'll speak both about the medical technicians and about nursing.

You've probably heard of this thing called tactical combat casualty care. This is a system of pre-hospital care that focuses directly on what injures soldiers on the battlefield. The Canadian Forces have run several large courses to prepare medical technicians to deploy. This paradigm came out in 1996, but it was really adopted probably in 2001-2002 with the beginning of Operation Apollo.

It focuses on simple manoeuvres, such as providing a tourniquet or providing a needle decompression for a collapsed lung. In fact, IV training in the pre-hospital setting is actually frowned upon now. It's less important, because there have been some studies to suggest that giving fluid early on in the field may actually be detrimental to patients.

The medics now are trained within this new paradigm called tactical combat casualty care. Having served in the Balkans in the nineties and in Afghanistan in this decade, I have to say the medical technicians have really come into their own. They have a defined mission. They have a defined specialty. No one provides better pre-hospital trauma care than they do. We have a pretty good way of providing pre-hospital care training for the medical technicians.

The nursing staff are now using the same model the physicians are using, which is the realization that if you're going to prepare for treatment for critically injured patients, you need to see critically injured patients in your normal day-to-day activity. Nursing staff are more and more embedded in hospitals, or they're sent for what we call “maintenance of competence”. There is a program under which we send nursing staff, particularly emergency medicine nurses, critical care nurses, and OR nurses to work in civilian hospitals to provide these skills so that when they deploy, they're able to treat our soldiers.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Thank you.

Do most nurses who are already working for the Canadian Forces have previous clinical experience in the field? Are most of them new nurses who are recent graduates? How do you balance all that?

[Col Homer Tien]

Actually I don't know the answer to that; I can get back to you. I don't know the breakdown of how many are new nurses or experienced nurses.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Thank you.

We have been asked to raise the following question. Why do physicians who work for the Canadian Forces opt to leave that organization and practise in the civilian world? Have any of your colleagues left the forces and decided to go back to being civilian doctors? What reasons have you heard the most often to justify that kind of a departure?

[Col Homer Tien]

Like anything, I guess, when anyone changes their career, there are probably multiple reasons. I think the biggest cohort who leave after their obligatory service, after their training.... For example, when I joined, my goal actually was just to pay for medical school. My intention was to serve my three years. My full intention at that time was to leave the military. I actually really enjoyed my experiences, both with the units in Petawawa and then with the Canadian special forces, and I elected to stay.

It's like anything. I think some people just find that the military is not for them. Like any other job, they may find that it's not for them. Most people, I think, leave after their obligatory service if they were funded through medical school.

[The Chair, Conservative, James Bezan]

Thank you. Your time has expired.

Mr. Norlock, it's your turn.

[Rick Norlock, Conservative, Northumberland—Quinte West, ON]

Thank you very much, Mr. Chair. Through you to the witnesses, I say thank you to them for appearing today.

I have just a few quick comments. I was watching the news some time ago when of course there was a breakthrough with regard to a double amputee from the Iraq war. You saw him walk towards the cameras on stage, as it were.

It reminded me of our trip to Downsview and the facility there. I don't know if it was there or here, but we were told that some of the great advances in medicine, particularly with regard to transplants and those types of issues, were as a result of our experience in war. It reminds me of my wife saying “un mal pour un bien”, which means that out of something bad comes something good. Would you say that's a fairly accurate statement and that what we've learned in trauma on the battlefield can sometimes, as bad as it sounds, yield good outcomes to medical science?

[Col Homer Tien]

Throughout the course of a war, I think trauma care is usually advanced, because what happens is that all the trauma clinicians see a problem and they try their best to improve the care on the battlefield or at the combat support hospitals or the field hospitals. For that reason, care is usually improved during the conflict.

[Rick Norlock, Conservative, Northumberland—Quinte West, ON]

If I can move along to what I call cyber-medicine or something like that, I was watching a television program, and I've gone to the Minister of Health with this: there are now apps for iPhones, and in these apps, you can take an ECG at home on your iPhone and ship it to your doctor. The particular cardiologist who did that also has another app, a little device that he puts on his abdomen, and it tells him by the minute what his blood glucose is.

But surprisingly in that same interview, and I don't know if you've seen it, he says that his group is very close to commercializing it. I think there might be some application here for apps in the battlefield. That's why I'm suggesting it. It's actually being developed like a tri-corder—we've seen Star Wars—and they're actually developing those that take your heart rate, etc. He says that he's developing an app that will tell your iPhone when you're going to have a heart attack. A nano smaller than a grain of sand is put into the bloodstream and can detect the beginning of cells coming off the cell wall and send a signal to your iPhone, thereby sending an alarm. Then you call the doctor.

Are you aware of any studies being done by any nation—usually it's our neighbour to the south, in collaboration—that might be looking at apps that can be used in the field and that will greatly assist the medical personnel there in being able to transmit from the scene of the injury to the hospital, let's say, so they can better prepare for it? Is that being looked at?

[Col Homer Tien]

I'm not aware that it's being looked at in terms of an app. The device that we were talking about previously, the ultrasound, is a device that, if developed and if it works out in clinical trials, would be given to the medics to provide information about their clinical status that might be important in our treatment.

[Rick Norlock, Conservative, Northumberland—Quinte West, ON]

Thank you very much.

Do I have any time left?

[The Chair, Conservative, James Bezan]

You have a minute.

[Rick Norlock, Conservative, Northumberland—Quinte West, ON]

We had a witness before us, Dr. Alice Aiken, who spoke about research being done to draw a relationship between mild traumatic brain injuries or concussion injuries and post-traumatic stress. Has your experience or work found any similar correlations? What do you think are some of the main contributors to developing PTSD?

[Col Homer Tien]

My work doesn't focus on mild traumatic brain injury or post-traumatic stress, so I can't say. It's not my area of expertise.

[Rick Norlock, Conservative, Northumberland—Quinte West, ON]

I know you haven't studied it, but you might be able to comment on to what degree you believe the effectiveness of the Canadian Forces' current array of PTSDs and other operational stress injury treatments...? Do you think it's important that resources be contributed to the research and institutionalization of new forms of treatment?

[Col Homer Tien]

In attending general NATO medical meetings my sense is that our allies greatly respect our current programs, and we're considered leaders in the world on how we manage post-traumatic stress disorder, the degree of our inclusiveness and the size of our programs.

As a researcher myself I'd always say research is great because you never have enough answers. Every time you answer something you will always come up with a new question because you can always improve care. I think research funding is always important.

My understanding of where the priorities are for Canadian Forces Health Services is that during 2006 there was a tremendous focus on acute trauma care. Certainly now in the aftermath, I believe and I see in the amount of funding—$50 million a year for mental health and an additional $11.4 million for mental health—that the focus now, rightly so, is on mental health.