National Defence Committee on June 12th, 2008

[The Chair, Conservative, Rick Casson]

I call the meeting to order.

I welcome past and new members to the committee.

Today we have the continuation of our study on health services provided to Canadian Forces personnel, with an emphasis on post-traumatic stress disorder.

We have Major West with us, who is base surgeon at the Canadian Forces Health Services Centre, Ottawa. We have Commander Wilcox, regional surgeon with Joint Task Force Atlantic. You guys move around so fast we have trouble sometimes keeping up with you. We also have Colonel Flaman, a surgeon at Land Force Western Area, CFB Edmonton.

I welcome all of you.

I understand each of you has a short opening statement. If you'd like to do that, we'll get into a round of questioning afterward.

[Commander D.R. Wilcox, Regional Surgeon, Joint Task Force Atlantic, Department of National Defence]

Thank you.

My name is Commander Wilcox. I am the Joint Task Force Atlantic regional surgeon. In other words, I'm the senior physician for Atlantic Canada. I'm responsible for clinical oversight of all of the clinics in Atlantic Canada, and I'm also responsible for being the eyes and ears of the commander for Canadian Forces Health Services Group.

I'd like to clarify three items from previous testimony, if I may.

The first is in regard to staff qualifications. I want to assure you that all of our staff are qualified. Our psychiatrists are duly licensed; they are also in good standing with their respective colleges. Our psychologists either have a master's or a PhD. In fact, in my area of responsibility, two-thirds of the psychologists have PhDs. The social workers have either a BSc or a master's, and again, in Atlantic Canada, my area of responsibility, 100% of them have a master's. The mental health nurses have a BSc, and they're also certified in mental health from either a university or the Canadian Nurses Association.

In addition to those qualifications, during the hiring process we utilize terms of reference and merit criteria and conditions of employment to select people who have the skill sets we're looking for. For instance, a skill set would be a proficiency in cognitive behavioural therapy. A skill set would be the eye movement desensitization and reprocessing, and psychodiagnostic skills. We use the selection process to further select people who meet our needs.

In addition, we have ongoing in-services in CME. In Gagetown this past year they had a four-day session on cognitive behavioural therapy. They have a similar session planned in EMDR. In fact, 1% of their salary goes to continuing medical education.

In addition to that, we practice collaborative medicine. That means no one person has to be an expert in all aspects of the treatment of post-traumatic stress disorder. We can utilize mental health nurses to provide portions of the treatment and social workers to provide portions of the treatment. For instance, part of the treatment is psychoeducation, and a mental health nurse could easily perform that. A social worker could do the stabilization, such as relaxation techniques. The advantage of having a collaborative practice is that we can do concurrent activities, rather than have one person do all the treatment sequentially.

The second thing is that we do practice evidence-based medicine. We did have a standardization committee that standardized the assessment of our patients, and we have an ongoing standardization treatment committee that will standardize the treatment.

While that committee has been meeting, we have been using best practices. We use the VA and Department of Defense from the U.S. We use their guidelines for the management of post-traumatic stress. We use guidelines from the American Academy of Family Physicians. While we are in the process of standardizing a treatment, we are using approved guidelines. We do use a multi-phase, multi-modal cognitive behavioural therapy protocol, and we do not use the brief therapy model.

The last thing I wanted to clarify is that management never determines how many clinical sessions a patient will receive. It's always done by clinicians. We never limit the number of sessions to 20. They get how many sessions they require. We do ask that after every 10 sessions we get progress notes. Related to that, we would never refuse a patient to be seen off-site if they had legitimate reasons.

Thank you for letting me clarify some of the previous testimony.

I'll hand it over to Henry.

[Lieutenant-Colonel H. Flaman, Surgeon, Land Force Western Area, CFB Edmonton, Department of National Defence]

My name is Henry Flaman. Some people know me as Hank. I've been in the Canadian Forces as a medical officer for 30 years. After 30 years, I transferred over to the primary reserve list. I've been on the primary reserve list and have continued to provide continuity of care. They have requested that I remain, and I am remaining for one more year, which will give me 32 years of service in the Canadian Forces.

For the last eight years, since 2000, I've been the area surgeon in Land Force Western Area, which is a large area. It goes from the Manitoba border, including Thunder Bay and the Lakehead, all the way to Vancouver Island and Yellowknife. It basically covers all those. I'm the regional medical advisor to the base surgeons in Shilo, Edmonton, Winnipeg, and Cold Lake, in that western region. In western area we started the Roto 1, or Roto 0, actually, into Afghanistan, so we have taken our fair share of.... The mounting units were force-generated from the western area. We started to take the casualties first, in Canada, out of the rotations, and I guess we had to then develop the processes, which were not necessarily all the best. We had to create our linkages, mainly with Capital Health, but we also had Winnipeg Health Sciences Centre as our main reception area for casualties. We had to work with the chain of command to make sure the processes for reception of casualties were done in a manner with due regard for the needs of the casualties, the families, the chain of command, and all that sort of stuff.

There is the command net, and then there is the professional technical net, meaning the clinicians, psychiatrists, and all the linkages there. We have a very robust professional technical network that in fact keeps everyone informed and anticipates what information needs to be fed to others that may be receiving somebody, so the task force surgeon receiving a casualty in Afghanistan will be able to call his counterpart in a part of Canada, knowing that is where the casualty is coming from, to give them a heads-up to say “be aware”. This is still not out in the command network, but we already have our informal network to be able to prepare people for what they need to do. We work behind the scenes to be able to facilitate the command elements.

I'll give you an example: notification of next of kin is something very delicate. It has to be done in a manner that is empathetic and compassionate. The AOs, those young officers or commanding officers, have to go up to the house and tell somebody that their son or daughter is injured or dead or whatever. We, in fact, will have the ability to nuance that and give information by having a clinician there who can provide that information to add more context to the case. I have had feedback from that, saying people were very thankful they had somebody who could provide that information to them.

Those are things we've now codified since moving from the mounting area in western area to central area to Atlantic area. Each one of us now is well versed in taking the lessons learned, moving them, improving on the process, and then, as it comes back, getting better at it. Getting better at it just means we've had casualties and stuff, and we just get better the more we do it.

That's all I need to do for the interim.

[The Chair, Conservative, Rick Casson]

Thank you very much.

I'm sure there will be some questions.

Major West.

[Major S. West, Base Surgeon, Canadian Forces Health Services Centre Ottawa, Department of National Defence]

I'm Major Sandra West. I first joined the forces as a medical student in 1985. I actually left the forces in 1992, at the end of my period of service, in order to go into civilian practice. I did that for seven years. In 1999 I moved back to the clinic in Ottawa as a civilian, and I was a civilian practitioner within the clinic for several years. In 2005 I transferred from the primary reserve list to the regular force and put my uniform back on. Since then I've been the base surgeon in Ottawa--other than a 10-month period in the past year, seven months of which I was in Afghanistan, in our Role 3 hospital.

As base surgeon in Ottawa, I am the clinical oversight for the clinicians who work in the clinic on a day-to-day basis. That is essentially the primary care clinic. Ottawa is structured a little differently from most clinics in that mental health does not fall directly under me, essentially because our mental health program is too large for that. They have their own oversight. However, I work closely with them. I also maintain a small clinical practice of my own.

In terms of the role of the clinic in Ottawa, we provide primary care and specialist care services where possible to all members serving in the Ottawa area. We do provide some backup to some of the bases nearby--Trenton, Kingston, Petawawa.

In terms of casualty repatriation, Ottawa of course has no large operational unit but some small ones, so we don't see units deployed out of Ottawa. However, given the special circumstances in Petawawa, it being a rural community with strains on their own medical system there, when Petawawa deploys, we back them up for their casualty care. Most of their casualties end up coming through Ottawa and, with our coordination, are cared for in the appropriate Ottawa hospital, which is usually the Civic campus.

[The Chair, Conservative, Rick Casson]

Thank you.

What were the dates you were at Role 3 in CAF?

[Maj S. West]

It was from August of last year to the end of February this year, sir.

[The Chair, Conservative, Rick Casson]

Okay. The first time we were there it was January of 2007, so we weren't there at the same time.

I understand you were part of a TV documentary or something.

[Maj S. West]

Yes, sir.

[The Chair, Conservative, Rick Casson]

We haven't seen that yet, but we will.

We've heard about some issues concerning possible regional problems. I'm sure you'll get some questions on those issues.

We'll start with Mr. McGuire, who will open up the round.

[Joe McGuire, Liberal, Egmont, PE]

Thank you, Mr. Chair.

You've seen quite a few soldiers coming and going over the last number of years. We were out to Wainwright, and some there are being trained for their second and third rotation. Maybe you've come to some conclusion on just how much psychologically a soldier can actually take in a situation like Afghanistan.

How many rotations do you think a human being can take in Afghanistan, particularly on the front lines in Afghanistan, and still have a reasonable expectation of having his health in his remaining days?

[LCol H. Flaman]

Is that directed to me?

[Joe McGuire, Liberal, Egmont, PE]

It's to anybody. You can all answer it.

[LCol H. Flaman]

That is a very difficult question to answer, because it varies with each individual. It varies with each individual's ability to deal with stress and the balance of life and their family life and everything else. There are times in a person's life when they're juggling too many stressors and even one rotation may be difficult for them. For others, depending on what the job is and what the requirements are....

The biggest thing is being prepared for the job and knowing exactly what has to be done, what it entails. Appearing here helped us; we went through some previous notes and so on. There's an educational process in preparing people to go.

So it varies with each person. You can't really say, or I personally can't say; one person sees it as a valued experience and another person sees it as a stress.

As to how we determine whether people can go, we basically have said that people should be 18 months back after a rotation. You shouldn't have any deployment after...or you should be back after 18 months. But that's unless you say that you really want to go and you have no problems. Then we do a further evaluation of your life circumstances and determine whether in fact you want to go. But by and large, the individual himself determines whether they're ready to go or not. And that's in all medicine; it's really up to the individual.

So if they want to go and everything seems to be good--the evidence shows that they have no other complaints going on or that no other background things may not be right--then the member is able to go.

[Joe McGuire, Liberal, Egmont, PE]

But they're in a profession where not going has other connotations. There are other pressures associated with their decision to go or not. There could be a price to pay for voluntarily staying home while others are gone.

As you say, there should be 18 months separating a rotation. But when we were in Valcartier, the wives there told us the members were gone 12 to 18 months--on rotation, in training, or training somebody else--which really puts a heavy stress on them. They don't see their families for an extended length of time. It also puts a heavy stress on the families. The children are missing their father or their mother for extended periods of time.

I don't think there's a healthy period here that you can....

[LCol H. Flaman]

It's one of those occupations where if in fact you're in combat arms--it all depends, but mainly it's in combat arms--your job is training. That's your job: training, training others, and being prepared to deploy when you're ready to go. That is basically how the team goes.

There are--I'll take that exactly--stressors on families, just as there are in the oil patch in Alberta, where guys have to go work up in the oil fields and so on.

So it happens to be an occupation that puts stress on families and family support networks.

[Joe McGuire, Liberal, Egmont, PE]

There's nobody shooting at them in the oil patch, though.

[LCol H. Flaman]

No.

[Cdr D.R. Wilcox]

To a certain extent, people self-select for these different types of occupations. For instance, we don't have any screening criteria for submariners. The people who end up in that field have self-selected to be comfortable in that close, confined environment. The Americans do a screening process.

I think in our military, most people self-select to the different fields, knowing that they are going to be away from home and knowing that they're going to be employed in that fashion.

[Joe McGuire, Liberal, Egmont, PE]

We're hearing in the American experience that the rotations are so long, going on for such a long period of time, that the stresses and the casualties, not only out in the field but in their minds psychologically, particularly in the families, are utterly destroying most relationships.

[Maj S. West]

Mr. Chair, perhaps I could put it in a little bit of perspective.

When I was in the military the first time, I spent three years posted in 1 Brigade at a time when we didn't deploy frequently and were not involved in much conflict. There was the Gulf War, which happened so fast we all missed it. At the end of my three years there, I calculated how much time I'd been in Calgary, and it averaged six months a year.

We've always spent a lot of time training. We've always had risks associated. It's part of what the military does. People do self-select. If this is not the life for you, or if it becomes something other than the life for you, there are ways of moving on--with the skill sets that you've picked up in the military.

[Joe McGuire, Liberal, Egmont, PE]

But you know, six months in a non-combat period is quite different from eighteen months in a combat period.

[Maj S. West]

From six months in a combat period.

[Joe McGuire, Liberal, Egmont, PE]

It's the health of these people and the services that are available to them that we're trying to get at here. Is there anybody to advise them when maybe they want to go but they shouldn't go?

[LCol H. Flaman]

We have programs that try to teach them how to recognize stress in themselves and in others who happen to be there and how to understand what to do with those stressors. We have educational programs that are provided to them. We don't force people to take on any treatment or anything unless it's obvious that they require it, but in most cases the individuals themselves choose to take it on or not.

In an economy like Alberta's, even now recruiting seems to be up. So people generally are staying, or they're staying for reasons.... In fact, some people were looking for combat. They were maybe not fully cognizant of what that would mean to them and their families, but they actually sought out that type of employment.