National Defence Committee on March 27th, 2013

[The Chair, Conservative, James Bezan]

Good afternoon, everyone. We'll get our meeting 74 under way as we continue our study on the care of ill and injured members of the Canadian armed forces.

Joining us for the first hour is Colonel Homer Tien, a Canadian military trauma surgeon and military trauma research chair at Sunnybrook Hospital with the Department of National Defence.

Colonel Tien has been with the Canadian Forces since 1990. He has an undergraduate degree in biochemistry from Queen's, and received a medical degree from McMaster in 1992. He then posted with the 2 Field Ambulance at CFB Petawawa, and served as the unit medical officer for the 1st Battalion of the Royal Canadian Regiment. While at 1 RCR, he deployed to Croatia on Operation Harmony. He then deployed to Bosnia with IFOR on Operation Alliance. He then served with Canadian special forces at Dwyer Hill Training Centre as their first unit medical officer.

He has also deployed to Vancouver and to the Golan Heights, and has worked with Veterans Affairs in the recovery of RCAF airmen missing from World War II, in the Burma recovery mission.

He went to the University of Toronto to complete his general surgery training, his fellowship training in trauma surgery, and his master's degree in clinical epidemiology. He is now posted at Sunnybrook Health Sciences Centre as a trauma surgeon. He is the medical director for the Tory Regional Trauma Centre at Sunnybrook, and is co-chair of the U of T's trauma program. He is an assistant professor of surgery at the University of Toronto.

We welcome you, Colonel, to committee, and look forward to your opening comments.

[Colonel Homer Tien, Canadian Military Trauma Surgeon and Military Trauma Research Chair at Sunnybrook Hospital, Department of National Defence]

Thank you very much, Mr. Chairman, and members of the committee. I'd like to thank you for the opportunity to appear at this important committee and to participate in the study you're conducting on the care of ill and injured military personnel.

As you can understand, this is a subject very close to me and I hope to be able to assist your deliberations in any way that I can. You've been provided with my biography so I'll try to avoid duplicating some of the talk on that. I did want to say that with my experiences as a general duty medical officer there were incredible experiences that helped to shape my career in the medical profession and during these deployments I treated injured Canadian Forces members in the pre-hospital and in the Role 1 setting. What I mean by that is I was attached to small operational units and provided capabilities in first aid, immediate life-saving measures, and triage.

You heard about my background in trauma surgery after that. As a Canadian Forces surgeon, I've also deployed to the NATO-led multinational stabilization force in Bosnia in 2003, to Kabul with ISAF in 2004, and multiple times to the Role 3 Multinational Medical Unit in Kandahar.

Role 3 refers to providing capabilities in specialist diagnostic resources, specialist surgical and medical capabilities, preventive medicine, and operational stress management teams. In my position as the national practice leader in trauma for the Canadian Forces, I'm the Surgeon General's adviser regarding hospital-based acute trauma care on deployed operations. I also provide advice to the Surgeon General regarding pre-hospital trauma care on deployed operations.

Based on my training and experience in Afghanistan, I'd like to inform the committee that I rate the acute trauma care provided to Canadian Forces members who are injured on deployment in southern Afghanistan as outstanding. I'd like to shed a little light on the process that injured military personnel go through when they become injured in Afghanistan. From January 2006 to July 2011, Canadian Forces members injured in southern Afghanistan were first treated in a pre-hospital setting by themselves, by their buddies, and by Canadian Forces Health Services combat medical technicians using the principles of tactical combat casualty care. Casualties were then transferred by either a road ambulance or by helicopter to the Role 3 medical unit.

Once there, Canadian Forces surgeons, anesthesiologists, and physicians would resuscitate and conduct life- and limb-saving surgery on injured members. When stabilized, the injured members would then be evacuated by the U.S. Air Force to the Landstuhl Regional Medical Center in Germany, a U.S. Army and Air Force institution. After ongoing treatment at the Landstuhl Regional Medical Center, Canadian armed forces medical teams would then transfer Canadian Forces members back to university-based trauma centres in Canada to receive quaternary-level care.

As I previously mentioned, our pre-hospital trauma care was outstanding and compares either similarly or more favourably to our allies. The Canadian Forces take the health care of our military personnel seriously and we published a study in 2011 looking at Canadian Forces members who died on deployment in southern Afghanistan. Of those who died, we classified only 2 of 63 as potentially preventable pre-hospital deaths. It's important to clarify that these were only potentially preventable as our methodology could not evaluate the tactical situation, which may have actually rendered the death non-preventable.

In a similar study of U.S. special operations deaths published in 2007, investigators rated 12 of 77 pre-hospital deaths as potentially survivable. In a larger U.S. study published in 2012, U.S. investigators using a slightly different methodology rated 24.3% of 4,596 pre-hospital U.S. military deaths as potentially survivable.

If a Canadian Forces member was injured and arrived with vital signs at the Role 3, an internal Canadian Forces Health Services study showed that a Canadian Forces member had a 97% chance of making it back to Canada alive. This represents a significant achievement in acute hospital level trauma care and, again, compares favourably to the experiences of our allies.

One reason why the level of CF trauma care is high is that many Canadian Forces clinicians are embedded within civilian hospitals. Research suggests that trauma care is better if centralized at regional trauma centres. Clinicians are more experienced with severe trauma cases and as a result, their patients have better outcomes. Of seven active duty Canadian Forces general surgeons, five are posted to university trauma centres. One is posted to a large community hospital and one works as a transplant surgeon at a university hospital.

With that, Mr. Chairman, I'd be happy to explore any of these areas, or any others, if you wish. I hope my opening remarks have provided you with a little background on the role of a Canadian Forces surgeon, and what it takes to provide care to these patients.

Thank you very much.

[The Chair, Conservative, James Bezan]

Thank you very much, Colonel.

In the interests of time, we're going to do five-minute rounds with the hour we have with Colonel Tien.

Mr. Harris, you have the floor.

[Jack Harris, NDP, St. John's East, NL]

Thank you, Colonel, for joining us.

Do you get called Colonel or Doctor? Can we call you Doctor? Is that all right?

[Col Homer Tien]

You can call me Homer, if you'd like.

[Jack Harris, NDP, St. John's East, NL]

Either way? We'll call you Homer.

Well, Homer, Doctor, Colonel, thank you for joining us. I appreciate your opening remarks. I'm pleased to hear your statistic on the success rate of avoiding preventable pre-hospital deaths, which has been demonstrated by this one comparison you've used.

When we're talking about trauma here in the medical term, we're talking about physical injury primarily, whether it be a wound or another type of physical injury mostly, not the kind of trauma when we're talking about post-traumatic stress disorder. That could be part of the trauma too, I suppose, but they're two different concepts, are they not?

[Col Homer Tien]

Because I'm a surgeon, I'm speaking of trauma in the physical sense.

[Jack Harris, NDP, St. John's East, NL]

Okay.

I'm interested in the fact that you also have quite impressive medical training, part of which is clinical epidemiology. Have you made use of that in your military work? One of the areas we're obviously looking at is the kind of care injured soldiers receive, and I think you've outlined very well the success we've had with that.

Have you participated in any studies, or are you aware of any studies linking PTSD experience in a military frame and suicides that may have occurred at a later date? Is that part of any of the work you do or any work that's being done within the military medical system?

[Col Homer Tien]

First of all, I do clinical research within the Canadian Forces Health Services, but my research tends to focus on pre-hospital physical trauma care and in-hospital trauma care, and how we stop bleeding.

I did one study that looked at the causes of death within the Canadian Forces over a 20-year period. Of that, suicide was in the top four.

In terms of linking it to....

I'm sorry, what were you asking?

[Jack Harris, NDP, St. John's East, NL]

I'm looking for the linkage between the experience of post-traumatic stress disorder or trauma in the field and a later suicide.

[Col Homer Tien]

No, I have not done a study on that.

[Jack Harris, NDP, St. John's East, NL]

In Afghanistan, for example—and perhaps you can tell us about the other operations you have been party to—the medical treatment experience is obviously not just limited to Canadian surgeons or Canadian medical personnel treating Canadian casualties. Can you tell us how that would have worked with allied forces? How was that organized, and were there any issues or difficulties with that?

[Col Homer Tien]

We work very closely with our allies, to the point where, let's say—because you can't be on call every night—perhaps if there were two of us, we'd be on call every second night, as the primary surgeon or the primary person to resuscitate the trauma patient.

[Jack Harris, NDP, St. John's East, NL]

This would be in a joint medical facility.

[Col Homer Tien]

Yes, Role 3 was a joint medical, multinational facility. Each nation would work as part of a team, and we would take our turn on the rotation.

Obviously, if we weren't on one night but heard that a Canadian Forces member had been injured, we would always come in, because we obviously felt a special attachment. If a Canadian surgeon were on, we would notify the U.S. surgeon as a courtesy if a U.S. member were injured, and the U.S. surgeon would always come in.

[Jack Harris, NDP, St. John's East, NL]

You talked about a special arrangement that might have been made. If you had an injured solider who was given emergency treatment, what was the normal course of follow-up? Where would that soldier then go? How long would he or she stay on base, and where would the soldier be transferred? What's the procedure?

[Col Homer Tien]

It would depend on the severity of the injuries. If they were severely injured, we would usually stabilize them; we would have to stabilize them within the first 24 hours. The pattern then would be an air evacuation to Germany within 24 hours after a request for an air evac. They would stay at the Role 3 for a very short period of time.

[Jack Harris, NDP, St. John's East, NL]

Then they would be looked after in Germany by...? Was there an American facility in Germany?

[Col Homer Tien]

It was a U.S. Army and Air Force tertiary-level hospital in Germany. They'd be cared for there until they were again deemed to be stable for transport, and then a Canadian Forces medical specialist team would come and bring them back to Canada.

[The Chair, Conservative, James Bezan]

Thank you.

Time has expired. Five minutes goes quickly.

Ms. Gallant, you have the floor.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

Thank you, Mr. Chairman.

Dr. Tien, would you describe how the trauma treatment at the Role 3 in Kandahar evolved from when we first stood up there to 2011? For example, was there an improvement in diagnostic equipment, an increase in numbers of caregivers?

[Col Homer Tien]

It was improved in many different ways. Purely from the actual structure of the building.... I was the first to arrive in 2006, so I took over from the U.S. combat support hospital that it was. At the time it was a small plywood shack, which I'm sure you've seen pictures of, with one OR. I was the last to leave in December 2011, and at that time it was a modern brick building, manned by the U.S. Navy, and there were three ORs. It was quite a facility. The diagnostic capabilities had improved by that time, we had new equipment. So there was quite an evolution of capability in that time.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

You obtained a CT scan there. What about an MRI machine, was that ever put in there?

[Col Homer Tien]

There was always a CT scan machine, as far back as early 2006, the difference was in the type of scanner. There was a two-slice scanner in 2006 that evolved to a two-slice and a sixteen-slice—that refers to the speed at which it can scan. An MRI machine showed up in 2011 from the U.S. Navy, but it was purely for research, strictly for research in mild traumatic brain injury.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

Did you see an improvement in the survivability of the trauma patients over time as a consequence of implementing certain procedures in the field for when the buddies first came upon them? If you did, can you tell us what those procedures were?