Medically Ready or Medically Not Ready? That is the Question

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Medically Ready or Medically Not
Ready? That is the Question

COL Eric T. Lund, MD, MPH, FACPM
Preventive Medicine Consultant,
Office of the Command Surgeon,
U.S. Army Forces Command

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Shakespeare’s play, UNCLASSIFIED

SURG

The Tragedy of Hamlet,

Prince of Denmark (1599-1601)

Frontispiece of the 1605 Act I, scene ii. The queen
printing of Hamlet attempts to console Hamlet.
1834. Delacroix
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SURG Agenda

• Introduction
• Objectives
• Authoritative Documents
• Medical Waiver Process
• Practical Exercise
• Way Ahead

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SURG Introduction

• Medical Readiness of deploying FORSCOM

forces is the top medical priority of the

FORSCOM CG and Corps/Div CGs
• Significant Medically Not Ready

(MNR)/Medically Non-Deployable (MND)

population in FORSCOM formations,

challenging our ability to fill BCTs to DA-

required strength at LAD (latest arrival date)

• In 2009-2010, deploying BCTs averaged 4.2-

5.8% MND Soldiers at LAD

– 1/3 MND for reasons of Permanent Profile/MEB/PEB/
MMRB

– 2/3 MND for Temporary Profile/Deployment Limiting
Medical Conditions

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SURG ..but know, thou noble youth,
The serpent that did sting thy Fathers life
Now weares his crown. — KING HAMLET
(GHOST)

Act I, scene iv. Hamlet sees the Act I, scene v. The ghost and
ghost of his father. 1835. Hamlet on the battlement. 1843.

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Objectives

• Gain familiarity with the major authoritative
documents governing medical readiness
determination for deployments

• Practice a process for navigating the
documents to determine the answer to the
question of which Soldiers and Civilians are
Medically Ready or Medically Not Ready for
deployment

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Authoritative Documents

• AR 40-501, Standards of Medical Fitness, 14
Sep 07, RAR 10 Sep 08

• DA Personnel Policy Guidance (PPG), 14 Jul
10

• CENTCOM MOD 10, 5 Mar 10

• DoDI 6490.07, Deployment-Limiting Medical
Conditions for Service Members and DoD
Civilian Employees, 5 Feb 10

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To Be, Or Not To Be (Spoken
by Hamlet, Act III, Scene 1)

To be or not to be– that is the
question:

Whether 'tis nobler in the mind to
suffer

The slings and arrows of
outrageous fortune,

Or to take arms against a sea of
troubles

And, by opposing, end them.

- HAMLET

UNCLASSIFIED Act III, scene i. Hamlet
reproaches Ophelia. No date.

FORSCOM

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AR 40-501
14 Sep 07, RAR 10 Sep 08

• Provides information on medical fitness
standards

• Applies to all service-connected personnel

• Chapter 3: Medical Fitness Standards for
Retention and Separation, Including
Retirement

• Chapter 5-14: Medical fitness standards for
deployment and certain geographical areas

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DA Personnel Policy Guidance
(PPG), last updated 14 Jul 10

• Chapter 2:

- 2-6: Soldier Readiness Processing (SRP)
policy, including use of electronic SRP (e-SRP)
- 2-7: Non-Deployable Criteria

• Chapter 7 discusses medical and dental
requirements for personnel mobilizing and/or
deploying

• RC responsible for medically screening their
forces prior to mobilization

- Soldiers who fail to meet medical deployment
standards should not mobilize

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CENTCOM MOD 10, 5 Mar 10

• USCENTCOM MOD 10 depicts additional
medical and dental requirements

• Areas where only limited medical and dental
care exist

• Medical waiver approval authority-Combatant
Command Surgeon

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Key Changes from CENTCOM MOD 9,

10 Sep 08, to CENTCOM MOD 10, 5 Mar 10

• Women’s Health requirements changed to meet PPG

• Adds medical waiver appeal to CENTCOM CoS

• Adds pre-deployment HIV lab test and result to LAD-

120 days; Civilian testing per HN/SOFA

• Requires Automated Neuropsychological Assessment

Metric (ANAM) within LAD-12 mos

• Requires Behavioral Health training and assessment

prior to deployment

• Specifies medical conditions for which ―No Medical

Waivers‖ will be granted

• Requires calculation of cardiovascular heart disease

risk for civilians = or > 40 y.o.; further evaluation if

CHD risk is >=15%

• Requires waiver for DA Civilian with latent TB

infection FORSCOM

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Department of Defense

Instruction 6490.07, 5 Feb 10

• DoDI 6490.07, ―Deployment-Limiting Medical
Conditions for Service members and DoD
Civilian Employees‖

- Applies to all deployed or deploying DoD
military and Civilian personnel; Does not apply
to contingency contractor personnel, who must
comply with DoDI 3020.41
- For civilian employee covered by The
Rehabilitation Act of 1973, must have
individualized assessment including reasonable
accommodation without causing undue hardship

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Give him heedful note
For I mine eyes will rivet

to his face;
And after, we will both our

judgments join
In censure of his seeming.

- HAMLET says to Act III, scene ii. The play-scene.
HORATIO, concerning 1838.
CLAUDIUS, King of
Denmark

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One Standard, Multiple Levels

AR 40-501:
Chapter 3

Theater Specific CENTCOM PACOM AR 40-501:
Guidelines MOD 10 Instruction Chapter 5
6200.2
DoDI 6490.07 USEUCOM DA Personnel
Directive 67-9 Policy Guidance
UNCLASSIFIED (PPG)
AFRICOM NORTHCOM
FHP Guidance NNCI 44-163 FORSCOM

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Medical Waiver Process
(1 of 4)

• Authority/Approval

- DoDI 6490.07: Combatant Commander
- CENTCOM and AFRICOM: waiver authority is

delegated to CENTCOM/AFRICOM Surgeon, who
have further delegated all conditions except
behavioral health to component surgeons, i.e.,
ARCENT and US Army Africa, respectively, for
non-SOF Army personnel

- CENTCOM: Appeal authority retained at
CENTCOM CoS

- For SOF Personnel, may be delegated by
Combatant Cdr to CDRUSSOCOM or SOC unit in
theater, e.g., SOCCENT in CENTCOM

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Medical Waiver Process
(2 of 4)

• Medical personnel inform command and
Soldier of the waiver process

• Unit medical provider forwards waiver
request form at request of the Soldier's
commander/supervisor or representative

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Medical Waiver Process

CENTCOM (3 of 4)

AFRICOM

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SURG Medical Waiver Process (4 of 4)

Potential
Deployment Limiting

Condition ID’ed

Meet Standards of Yes Meet Standards Yes Meet Retention No Further medical
COCOM Med of AR 40-501/PPG? Standards or administrative
action required.
Guidance/DoDI No of AR 40-501? No Waiver at this
6490.07?
time

Deploy Yes No Eligible Yes Submit request to
COCOM Surgeon or
for Waiver?
designee

No

Non Deploy Approval?

Yes No
Signed waiver Signed waiver

returned returned

Place waiver in Place waiver in
medical record-Deploy medical record

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FORSCOM

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One Standard, Multiple Layers

• There is one standard with multiple layers for
medical fitness standards

• More specific guidelines depend upon the
Area or Operation

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SURG UNCLASSIFIED

Act III, scene iii. Hamlet comes HAMLET
upon the king at prayer. 1843. Now might I do it pat,

UNCLASSIFIED now he is praying;
And now I'll do't. And so

he goes to heaven;
And so am I revenged.
That would be scann'd:
A villain kills my father; and for

that,
I, his sole son, do this same

villain send
To heaven. …
No!

KING
My words fly up, my thoughts

remain below:
Words without thoughts never

to heaven go.

FORSCOM

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Determination of Medical
Fitness Practical Exercise

• Methodology:

1. Utilize AR 40-501, DA PPG, Combatant
Command Medical Guidance, and DoDI
6490.07

2. Utilize commander’s input

3. Determine medical deployability of
Soldier

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Does the Soldier meet medical

readiness requirements?

• 1LT Robin Sage is pending deployment to

Afghanistan. Has a permanent P2 profile for

exercise induced asthma.

-FEV1% = 65% despite appropriate therapy.

-No Hospitalizations.

-Regular use of short-acting bronchodilator prior to

exercise; no use of oral corticosteroids.

-Has had 1 ER visit for this condition, 9 months ago

-Runs outdoor APFT at a pace that meets the

standards for the 2-mile run. Performs all military

training and duties within standards.

- Profile has no restrictions on weapon or personal

protective equipment.

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1LT Robin Sage does meet

medical readiness requirements

• Does Meet Retention requirements with no need for MEB
referral per AR 40-501, Chap 3-27…able to perform all
military training and duty; no repetitive hospitalizations, no
repetitive ER visits, no excessive lost time from duty, no
repetitive use of oral steroids, is able to run 2-mile run
within time standards

• Does Meet medical fitness standards for deployment per
AR 40-501, Chap 5 para 14e(5),… Soldier can wear

protective gear, has not experienced recent emergency

room visits, and does not require repetitive use of oral

corticosteroids

• Deployable per Mod 10, Tab A, para 7.B.1.: FEV1% = 65%

which is > 50%; no Hosp in past 12 months, and no use of

daily systemic (not inhalational) steroids

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SURG Thou wretched, rash, intruding fool, farewell!
I took thee for thy better: take thy fortune;

Thou find'st to be too busy is some danger. – HAMLET to the
corpse of POLONIUS

Act III, scene iv. The murder of Act III, scene iv. Hamlet and the
Polonius. No date. body of Polonius. 1835.

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Does the Soldier meet medical

readiness requirements?

• SPC Rodriguez is pending deployment to

Iraq. Has a temporary profile from shoulder

arthroscopy for right shoulder pain (loose

tissue removed); the temporary U3 profile

expires 30 days after the unit is scheduled to

deploy.

-Soldiers has partially limited shoulder ROM:

forward elevation to 80 degrees, abduction to 80

degrees. Improving with physical therapy.

-Profile prohibits him from carrying and firing a

weapon and moving 40 lbs while wearing usual

protective gear (helmet, weapon, body armor and

LBE) at least 100 yds.

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SPC Rodriguez does not meet
medical readiness requirements

• Does Meet Retention requirements with no need for
MEB referral per AR 40-501, Chap 3-12 and 3-14

• Does Not Meet medical fitness standards for
deployment according to AR 40-501, Chap 5, para
14e(7): musculoskeletal injury that prevents firing a
weapon. Also does not meet fitness standards to
deploy per Chap 5, para 14e(16), still in rehab post
surgery with temp profile.

• Does Not Meet medical deployment standards

according to CENTCOM MOD 10 Tab A, para 7.G. ―Any

medical condition …for which surgery has been

performed and the patient requires ongoing…

rehabilitation…‖ FORSCOM

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SURG UNCLASSIFIED

HAMLET Act III, scene iv. Hamlet and
Gertrude. 1834.
I do repent: but heaven hath
pleased it so, FORSCOM

To punish me with this and this
with me,

That I must be their scourge
and minister.

I will bestow him, and will
answer well

The death I gave him. So, again,
good night.

I must be cruel, only to be kind:
Thus bad begins and worse

remains behind.

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Does the Soldier meet medical

readiness requirements?

• PV2 Anderson is pending deployment to
Afghanistan. Diagnosed with anxiety and
depression 7 months ago.

-He is treated with Zoloft and Xanax. He has been
stable on these meds for 4 months.
-No requirement for extended or recurrent
hospitalizations
-No limitation of duty or duty in a protected
environment
-No interference with effective military
performance.

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PV2 Anderson does meet
medical readiness requirements

• Does Meet Retention requirements with no need for MEB
referral per AR 40-501, Chap 3-32 (Mood Disorders) and 3-33
(Anxiety disorders).

• May or May Not Meet medical fitness standards for deployment
per AR 40-501, Chapter 5, para 14(8)(a), The recommendation of
deployability should rest with the clinical judgment of the
treating physician or other privileged provider, in consultation
with the unit commander.

• Does Not Meet medical fitness standards for deployment per DA
PPG, para 7-9o(23): new diagnosis (< 1 year) of mood disorder
and anxiety

• Does Meet medical readiness requirements per CENTCOM MOD
10 Tab A, para 7.H, psychiatric disorder stable for > 3 months

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Act IV, scene v. Ophelia's OPHELIA
madness. 1834. (To King) There's fennel for you, and columbines.
(To Queen) There's rue for you; and here's some
UNCLASSIFIED for me: we may call it herb of grace a' Sundays.
You may wear your rue with a difference. There's
a daisy. I would give you some violets, but they
withered all when my father died. They say he
made a good end—

[Sings.]
"For bonny sweet Robin is all my joy.‖ …

―And will he not come again?
And will he not come again?
No, no, he is dead:
Go to thy death-bed:
He never will come again.‖

FORSCOM

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Does the Soldier meet medical

readiness requirements?

• SFC Angeletti is deploying to Djibouti
(AFRICOM). Has a permanent P3P for type II
DM and is on metformin.

-PEB found SFC Angeletti fit-for-duty with
current profile. Code H and Y in Block 2, DA
Form 3349
-Pt has no advanced findings of disease and has
good understanding of disease condition.
-HbA1C 6.8, at target for patient.

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SFC Angeletti does not meet
medical readiness requirements

• Does Meet Retention requirements per PEB IAW AR
40-501, Chap 3

• May or May Not Meet medical fitness standards for

deployment per AR 40-501, Chap 5 para 14e(2); see
table 5–1 for medical qualifications.

• Does Not Meet medical fitness standards for
deployment per DA PPG, para 7-9o(10): Type II
diabetes on pharmacological therapy

• Does Not Meet medical readiness requirements for

AFRICOM per DoDI 6490.07: Type II diabetes on oral

hypoglycemic agent FORSCOM

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SURG UNCLASSIFIED

Act IV, scene vii. The death of QUEEN speaking about
Ophelia. 1843. OPHELIA

UNCLASSIFIED Clambering to hang, an
envious sliver broke;

When down her weedy
trophies and herself

Fell in the weeping brook. Her
clothes spread wide;

And, mermaid-like, awhile they
bore her up:

Which time she chanted
snatches of old lauds;

As one incapable of her own
distress,

Or like a creature native and
indued

Unto that element: but long it
could not be

Till that her garments, heavy
with their drink,

Pull'd the poor wretch from her
melodious lay

To muddy death.

FORSCOM

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Does the Soldier meet medical

readiness requirements?

• SSG Montag is pending deployment to Iraq.

Has a permanent P3P profile for Obstructive

Sleep Apnea (OSA).

-Moderate OSA (apnea-hypopnea index (AHI)

25/hr), treated with continuous positive airway

pressure (CPAP)

-PEB found SSG Montag fit-for-duty within limits

of profile. DA 3349 lists code H (limitations on

duty where sudden loss of consciousness would

be dangerous to self or to others) and Y (Fit for
duty). In block #10 ―Must have access to

electricity for nighttime use of CPAP‖

-No functional activity limitations, no APFT

UNCLASSIFIED limitations. FORSCOM

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SURG

SSG Montag does meet medical

readiness requirements (1)

• Does Meet Retention requirements per PEB IAW
AR 40-501, Chap 3

• May or May Not Meet medical readiness
requirements per AR 40-501, Chap 5 para
14e(6),…criteria for the ability to use nasal
CPAP in the area of deployment include the
following: availability of a reliable power
source, absence of environmental factors that
would render electrical equipment inoperable
or unreliable, and the availability of a reliable
source of replacement supplies such as
masks, harnesses, and filters.

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SSG Montag does meet medical
readiness requirements (2)

• Does Not Meet medical fitness standards
for deployment per DA PPG, para 7-9o(31):
Requirement for medical devices using AC
power

• Does Meet medical readiness requirements
per CENTCOM MOD 10 Tab A, para 17.B.10.d.,
Treated (CPAP or otherwise) OSA with an AHI
< 30/hr does NOT require a waiver to deploy,
except to Afghanistan or Yemen

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