The tumor in military healthcare

If we could just get out of our own way…

My boss did something illegal last week. And then I lied so that she could keep doing it. Everyone knows it, and they’re glad.

Let me explain.

Our hospital has a state-of-the-art hyperbaric chamber, where we can treat patients using high-pressure gas (air, oxygen, various mixes). This has many applications: decompression sickness, wound care, vascular gas embolism. It’s also used to treat carbon monoxide poisoning with high-pressure oxygen therapy. During the winter, CO poisoning generally becomes more common because some people make the mistake of using combustion heaters indoors to try and warm up their houses.

We are a military hospital, which means that we only treat DoD personnel, military retirees, and their family members. We are not allowed to treat civilians off the street unless they come to our ER; if they show up at our door in a state of medical emergency, we are obligated to treat them under EMTALA. However, if they call 911 and go to a civilian ER, and then that civilian ER wants to transfer the patient to us because we’re the only ones who can treat them, we can’t accept any transfer patient who is not affiliated with the military.

Our hyperbaric chamber runs 24/7. We have the only after-hours multi-patient hyperbaric chamber within ~400 miles.

A family—father and two kids—went to a local civilian ER in the middle of the night because they were suffering from CO poisoning. While any ER can provide immediate lifesaving treatment, generally the gold standard for preventing long-term problems (basically, brain damage) is immediate hyperbaric oxygen treatment. The civilian ER asked to transfer the family to our hospital for this treatment.

It’s against the law for our hospital to treat them. Defense Health Agency lawyers just sent us a lengthy email two weeks ago, essentially issuing us a cease-and-desist order on treating non-military patients in our hyperbaric chamber.

My boss, the hospital director, accepted the patient transfer. She did it to reduce the risk of long-term neurological problems for that family. She did it knowing she was breaking the law and that the DHA would not have her back if something went wrong. She did it anyway, because it was the right thing to do.

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There are ways around these prohibitions. One such way is the Secretarial Designee (SECDES) program, under which a Service Secretary (for example, the Secretary of the Army or the Secretary of the Air Force) determines that a particular person is eligible for treatment. I’ve most often seen this for important foreign dignitaries, local nationals (Afghans, Iraqis) who supported the US, and other such strategically important individuals. The Secretarial Designee program requires a lot of paperwork that explains why the patient is so important that it would be in the US’ interest to treat them. This paperwork is reviewed by multiple levels of staffers before it gets a Secretary’s signature; it normally takes weeks.

SECDES is not a practical solution for middle-of-the-night emergency treatment.

Another way is so-called “Section 717” designation. This refers to Section 717 of the National Defense Authorization Act of 2017¹. Basically, it states that the Secretary of Defense can determine that treating certain patients at a particular military hospital, even if they are not otherwise eligible for treatment, is in the national interest. Specifically, that providing this treatment is important for maintaining the critical skills of our military medics.

For example, trauma surgeons. If they don’t have any military patients to work on—which is, in all other ways, a good thing—their skills will atrophy. A hospital that doesn’t see enough military trauma cases may receive Section 717 authority to treat civilian trauma cases. This would be in our interest, because our surgeons need experience in treating trauma. Everybody wins.

The thing is, Section 717 requires a determination that the skills in question are a “critical readiness need”.

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My hospital has been treating local civilians who need hyperbarics. Many are victims of CO poisoning. Some have venous or arterial gas embolisms. We had one patient who came in blind; a gas bubble was blocking the blood flow in his central retinal artery. After receiving treatment, he walked out with his eyesight restored.

Characteristic image of Central Retinal Artery Occlusion. Untreated, this usually leads to loss of vision in the affected eye.

We’ve been breaking the law every time we treat one of these civilian ER transfers.

To their credit, when the DHA lawyers sent us the cease-and-desist, they also said “but here’s what you need to do to make this legal: you just have to get Section 717 designation, and here’s how you do it”. So we didn’t need to do a lot of research; we just followed the recipe they provided. Still, it takes time and effort to assemble all the supporting info, prepare the request package, etc. We immediately dropped what we were doing—all the minor stuff, like, oh, I don’t know, running a hospital—and started assembling our Section 717 request. And when I say “we”, I mainly mean “me”, because I was the lucky winner of this task.

The thing is, Section 717 requires that we show a “critical readiness requirement”. And there is no such thing as a hyperbarics “critical readiness requirement” for the Air Force—that’s simply not a mission we do in our wartime role. Same way there is no “critical readiness requirement” for radiation oncology or neonatology—we have medical specialists in these fields, but not too many of them are deploying into field hospitals in that specialty if WW III breaks out.

So naturally, I did what any good staff officer would do in this case: I made the facts fit the situation so I could arrive at the desired outcome. I dug up all our readiness references, found a few items that had some tenuous connection², tied it all together, and wrote up a beautiful memo that proved that planes would literally start falling out of the sky if we didn’t immediately treat more civilian hyperbaric patients.

And then the cherry on top: I showed that this would actually make us money. We can bill the patients’ insurance for $X, and it costs us $Y to provide the treatment, and X is considerably higher than Y.³ (More on this mismatch in a later article).

The entire effort took about a week: researching the rules, assembling data from various offices around the hospital, thinking through creative ways of spinning those data, and finally making it all look pretty. The package went up last week, on time and on target. Our 2-star signed it a few days ago. It should be signed by the DHA 3-star soon.

In the meantime, without an approved Section 717 designation we’re still breaking the law.

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I know who and what I am. In my current position, I’m a high-powered troubleshooter. I don’t treat patients, take x-rays, drive an ambulance, or generate any other direct healthcare value; instead, I find ways around obstacles, help interpret and navigate rules, and train the next generation of young officers who will some day take my place as high-powered troubleshooters. Five-ten years ago, when I was fighting The War, this isn’t who I thought I’d be if/when I made it to Colonel.

The hospital couldn’t function without me (or at least it wouldn’t function nearly as well), but only because we have such a complex web of rules and obstacles to navigate that it takes an expert like me to do it. I have no regrets; I am, to some extent, a necessary evil. I recognize the need for people like me. What I rage against, is the fact that people like me are needed.

We spent a week and thousands of taxpayer dollars (because I get paid quite well, thank you) jumping through a hoop so that we can continue to do the exact same thing we’ve always done, except now it will magically not be illegal anymore. And that’s not counting the 2-star General and his staff, or his boss and final approver, the 3-star General and her staff. All of them are spending time and taxpayer money to generate a piece of paper that declares that something we do is not illegal.

Everyone—our hospital, DHA lawyers, my boss’ boss’ boss—all agreed that the end result (treating civilian hyperbarics patients) is desirable; that it has been happening, is still happening, and should continue to happen. We all knew that it was only a matter of time, will, and effort for us to jump through the hoop and make it legal. But we didn’t have the option of not jumping through that hoop and simply accepting things the way they were.

There’s a name for it when a part of the organism starts growing out of control, consuming an ever-growing amount of the organism’s resources, and often interfering with the normal function of its other tissues and organs. It’s called a tumor, or, in medicine’s quasi-Latin technobabble, an -oma (suffix applied to a root word; “carcinoma”, “melanoma”, “sarcoma”).

So I guess what I’m diagnosing here is a DHoma.

How does one treat a tumor, anyway?

1. https://www.congress.gov/114/plaws/publ328/PLAW-114publ328.pdf

Section 717 is on pp. 225-226 (out of 970).

2. In case you’re curious or want to nerd out on Air Force medical readiness, my specific reference is 48Rx CMRP Cat II, #2 (PHYSIOLOGIC INCIDENT RESPONSE AND ANALYSIS 048XX). The reasoning being that DCS or AGE is a “physiologic incident”.

3. I can’t prove it, but my strong impression is that this is the part DHA was really interested in. They knew perfectly well that we any halfway competent staff officer can prove a readiness requirement. What they actually wanted to know is whether or not it would cost them more money if we were to keep providing these treatments.