COMBAT Seeks to Solve Military's Clinical Challenges, Translate Science for Civilian Communities

This episode of CU Anschutz 360 focuses on the Center for Combat and Battlefield Research at the University of Colorado Anschutz Medical Campus. Launched in January 2019, the COMBAT Center conducts research that impacts clinical patient care, battlefield casualty and trauma care, and critical, large-scale societal issues including mental health. Using multidisciplinary and collaborative teams, the center conducts clinically relevant, translational research to get newly discovered treatments and devices into the hands of first responders and clinicians. The COMBAT Center is directed by Dr. Vik Bebarta, a colonel in the US Air Force Reserve and a researcher on the forefront of the toughest clinical challenges for civilian and military care. Thomas Flaig, MD, vice chancellor for research, co-hosts the discussion.

Transcript

Chris Casey:

My name is Chris Casey, and I'm the Director of Digital Storytelling here in the Office of Communications at CU Anschutz.

Thomas Flaig:

I'm Thomas Flaig. I'm the Vice Chancellor for Research here at the CU Anschutz Medical Campus. Delighted to be here today to talk about this topic.

Vik Bebarta:

And I'm Vik Bebarta. I'm professor of Emergency Medicine and Toxicology here at University of Colorado, and Vice Chair for Strategy and Growth for Emergency Medicine. And I direct the Center for Combat Medicine and Battlefield Research, or the Center for COMBAT Research, here.

Chris Casey:

The University of Colorado Anschutz Medical Campus, we have multiple research centers here. But I would say that the COMBAT Research Center, or, I'll use the full name, the Center for Combat and Battlefield Research, is probably one of the more unique ones. Could you explain what your center does, how it came about, and where you stand on the national stage in terms of this kind of research?

Vik Bebarta:

Absolutely. Thanks for asking about that. So as a little bit of background, I was an Air Force Academy graduate and was 14 years active duty and six years now in the reserve. And even in my current role at University of Colorado, I'm a reservist colonel for the Air Force. And when we were doing research in active duty and we were deployed, we realized that there's a lot of talent at different universities like the University of Colorado that can be applied to the military to solve their problems.

After coming here, about two years later, we decided to start the center here. And the goal of the center, our vision, is to solve the US military's toughest clinical challenges and improve our civilian communities. What we do is we take the top talent from the University of Colorado across the campus from all departments and schools. We channel (our campus’s) talents to the military’s capability gaps to find solutions for our United States military that ultimately end up being used in our civilian communities, including Aurora and Colorado.

Thomas Flaig:

And Vik, I've watched your work, your great leadership over the last couple years. I think what's been remarkable is, and I think you're quite modest about it there, how this program is developed, how quickly it's grown across different departments. Can you talk a little about the size of the program, the center, how many people are involved, and then how quickly this has happened in just over a few years?

Vik Bebarta:

Sure. We started the center in the fall of 2018, really January of 2019. And we started off with sort of one and a half FTEs, one and a half people, with the promise to, with support from the university and the school, to bring in about five research grants and probably about $3 million in three to four years. We ended up bringing in about $3 million in three months. We ended up ultimately having about 65 research grants, research awards over the last four years, far exceeding the five grants we had proposed to have. So now, from one and a half people, we're about at 17 people total, about 100 investigators, and really making an impact at the highest levels in the country for the military and also getting some support and interest from Congress and across the University of Colorado, the four campuses.

Thomas Flaig:

Do you want to talk about the general focus of the research you do and maybe give a couple of prime examples of those areas of focus?

Vik Bebarta:

We sort of target from the DOD's perspective, their acute care or their emergency care needs, and that is targeted around deploying. So before they deploy, there's a lot of interest in interpersonal violence, so there's some domestic abuse and child abuse. But at the same time before they deployed, there's a lot of folks around working with the team training to take care of critically ill patients. And then when they deploy, there are areas around pre-hospital care, brain injury, burns, infection, sepsis, those types of things. And then when they come back there are issues around mental health, PTSD, substance abuse and pain, hearing loss, those types of things. So that's how we cover those areas of research in that way.

We try to leverage all the assets on the campus, including our expertise in AI and machine learning, and engineering and clinical trials and then address those, and then they directly benefit our communities here. So when we address issues around mass shootings and how that's done and the examples given in Las Vegas, the way they respond to that was based on the principles in the military they have used and learned to take care of those patients. And the same thing here, when we have shootings here, when we have brain injury, when we address suicide in our civilian communities, we leverage the expertise and studies that the Combat Center's doing with our experts and our investigators.

Thomas Flaig:

I think that's such an important point. It's one thing I've learned in talking with you over the last couple years that the work that's being done, you give a great outline of that really driven by the DOD needs and the soldiers’ needs, very clearly translates to the civilian community. Whether it's learning how to deal with these terrible mass shootings and tragedies, and your physicians on the civilian side using this and so forth. I think it's really remarkable. And would you say that a lot of the membership within the Combat Center then, do they have a military background they bring to that or are they non-military background people? How does that group come together for this?

Vik Bebarta:

That's a great question. Our center is made up of both folks who had military and non-military experience, some that were active duty before. So Brigadier General retired Kathleen Flarity is our deputy director, Colonel Sean Keenan, he's retired Colonel Army with special forces. But the rest of our staff and many of them are civilians who've worked with the government, who've worked in research. And the principle is they bring their talents and their ability to solve problems to the center. And so we always say we deliver science, but more importantly we deliver solutions to our communities.

And what's interesting, and to go back to your earlier point, is that about 90% of what the DOD, the military funds for medical research, translates to civilian practice. It goes back to World War II where we learned about whole blood transfusions, Vietnam, where we understand it was the birth of emergency medicine and trauma surgery and actually all the pre-hospital systems now, and even over Iraq and Afghanistan, how we use tourniquets, how we respond to mass shootings, how we deal with TBI and suicide and mental health and substance abuse – all those were military funded efforts that are now used in civilian hospitals including UCHealth across the system … including our communities. We do outreach in Aurora. All those were born out of DOD sponsorship and funding.

Chris Casey:

You mentioned some of the wars and conflicts of the past in the 20th century, Vik. I'm wondering that unfortunately now we still have the conflict in Ukraine and the Russian invasion there. Some parts of this conflict may not be exactly what we would've expected in the 21st century. Does this type of conflict – what's happening in Ukraine – change our research and educational focus to support battlefield research?

Vik Bebarta:

Absolutely. It's interesting that we have this future national defense strategy that the Secretary of Defense puts together and a small part of that is medical. But a few years ago, they anticipated this type of warfare. And then in fact, it's potentially a look into what the United States may engage in the future. It's called multi-domain operations or large-scale combat operations in a setting very much like Ukraine where we would have these injuries where they may not be able to evacuate them quickly. We would have first responders or medics dealing with high-stress situations, who may not have reach back to get the support that they need, and they actually may have trauma and some unconventional attacks as well. For example, the threat of chemical or radiation with trauma.

And so we actually see what's going on in Ukraine as a potential future that the United States may engage in. And the center as well as all the Department of Defense and Defense Health Agency are leaning into this to try and make sure that we're addressing Ukraine's needs which will ultimately benefit our communities as well on the military and civilian side.

Thomas Flaig:

I guess the way you approach this is pretty adaptable then. Those are current events for last year. I guess again from the bystander point of view, I wouldn't have expected this type of conflict, trenches and artillery and so forth. But is it that dynamic, the kind of work you're doing and the direction you're getting to it to adjust to these things that are happening almost real time?

Vik Bebarta:

One of the strengths of the center is we want to focus on the future battlespace, and we want to focus on the future combat casualty care operations. It's kind of come full circle from this national defense strategy, which is the campus is on Fitzsimons. Years ago, when there was World War II and Pearl Harbor, those thousands of casualties came to this hospital. And over time, we've reduced casualties in warfare, which has been great. However, we see the future of warfare as potentially very similar to what we had in World War II and to some extent with their experience in Ukraine, which is lots of casualties overwhelming the local resources that we have, so we may not be able to fly patients out immediately. And the center tries to stay at the tip of the spear from that perspective. To understand and partner with the DOD and where they see the future is going, and we can skate to that puck and make sure we're doing the research that's beneficial to them.

For example, the future, this is public information, is around dealing with casualties in a cold environment, arctic environment. So we now have with our investigators, Dr. Lemery and team, four fairly large funded research grants, studying that (topic) here in Colorado in our community on campus. How do we respond to casualties who are exposed to cold, how do we train medics in that area and first responders, which has good applicability to our civilian medics here in the mountains in high altitude as well? That's one example of several.

Thomas Flaig:

How about an unconventional sort of chemical biologic? Is that sort of the mix? Is that something you can speak to at all?

Vik Bebarta:

Public information, that has been a raised concern speaking with congressional leaders as well as DOD leaders publicly about that combined injury. So trauma with something else like chemical radiation, nuclear, is an important part of the future of the needs in military but also in the homeland and our civilian national security concerns as well. We're going to have to be able to treat those. And we uniquely have a program that evaluates those threats and builds on those so we can come up with modeling for the future what will those injuries look like, what are therapies we can repurpose that are available now to address those injuries in the military and, hopefully not, but potentially in our civilian homeland community as well.

Chris Casey:

Right. A lot of attention has been paid to the development of Narcan as a quick antidote to save people suffering from opioid overdose, for example. I'm wondering, Vik, if part of what your team looks into then is some sort of antidote type or just treatments of that nature that could be expediently applied in the battlefield to reverse perhaps a chemical agent or a biological agent. Do you go into territory like that with your research?

Vik Bebarta:

Absolutely. One of our programs that I actually lead is called TRIAD research, which is our Translational Research Antidote Innovation Development program that's primarily funded by NIH (National Institutes of Health) through NINDS (National Institute of Neurological Disorders and Stroke) and NIH, but also there's some military funding as well from the Department of Defense. And we're doing just that. We are trying to develop countermeasures against these things that can be used in the hands of untrained or minimally trained medics, maybe even bystanders. And we try to do research that can move things from the bench to the bedside to the bystanders or to the battlefield, as we say. And these are therapies that'd be FDA (Food and Drug Administration) approved and getting those approved in the process that's necessary for that. And that's where we've targeted: moving things from the molecule all the way from the military to the market with new therapies that can benefit the medics and sheriffs and cops and firefighters as well, whether it's Ukraine or whether it's in Aurora, Colorado, and rural parts of our state.

Thomas Flaig:

In thinking about some of the sponsors of the center, the work you do there, we've been talking about the DOD the Department of Defense for a bit. I think you just mentioned the NIH. Who are the kind of sponsors you partner with and the work you do?

Vik Bebarta:

We think it's really important to come at this from an inter-agency approach. And while this COMBAT Center is targeted toward the Department of Defense as the primary sponsor for some of this work, which we know then transitions quickly and that's one of the expertise that we have is transitioning them to civilian use, but it's across agencies. So working with NIH where it's relevant around trauma care, around these chemical countermeasure developments, around clinical trials, but also with BARDA (Biomedical Advanced Research and Development Authority) when it's relevant for mature products that can transition into clinical practice that are from companies or repurposed. But also we've partnered with some of our groups in NASA as well. If you think about it, one of the frames that we are concerned about and they're facing in Ukraine, but we know that's in the future for the United States potentially, is what we call prolonged casualty care, which means when someone's injured before they can get treated, could be hours or maybe a day or two, and that's really a paradigm for the military before they can be rescued.

The extreme version of that is someone in space. They're traveling to Mars or to the moon, and they have a version of that around prolonged care where they've got to take care of these folks with sometimes minimal medical knowledge. And so partnering with NASA, BARDA, including NIH and even some of our investigators, Dr. Betz and all partnering with the Veterans Affairs in areas around substance abuse, brain injury, mental health, firearm related suicide, and PTSD as well.

Thomas Flaig:

The NASA angle is really interesting in Colorado with our colleagues at University of Colorado Boulder doing a tremendous amount of NASA research and then our new medical school program, partnering with Boulder, where you can actually get an MD combined master's of science degree. So it's really a unique opportunity here in Colorado to work in that area as well.

Vik Bebarta:

Absolutely. And in fact, we're having a distinguished visitor come who's an astronaut, who graduated, Dr. Lindgren, who's coming in April, who's going to spend some time with the COMBAT Center as well as the space efforts here on campus to build that linkage with our team up in Boulder because there is a lot of relevance, a lot of engagement on how do we take care of these casualties, how do we innovate? Do we use decision support when they don't have direct access to a surgeon or a nephrologist? Do we use AI machine learning to deliver wearables and devices that they can wear the whole time that they're either in space or in our case that are under threat before they get evacuated? There's a lot of similarities there. And there's a lot of interaction between those two agencies and departments specifically. Makes us very unique.

Chris Casey:

I would imagine given that Doctors Without Borders is so active in serving these conflict areas around the globe, I'm curious if yourself or anybody on the COMBAT team advises or briefs physicians with Doctors Without Borders before they go into these extremely dangerous areas and what to look out for, how to protect both themselves and their patients?

Vik Bebarta:

It's a good question. I think that the bigger question is around sort of global health and going in for humanitarian crises and the work that the COMBAT Center does, and there are a lot of similarities between those two groups as well. They're dealing in austere situations often under threat or care under fire as we say, maybe had the delayed evacuations, and then the folks who practice may not do this routinely or regularly in some of these opportunities. And so we actually work closely with our folks in global health. Dr. Mould-Millman is another example. He's one of our prominent COMBAT investigators who does a lot of work in global health and in austere settings. South Africa is one example. And so we work together. It's a very similar example as we see what the military needs where they're delivering care under fire, where they're in austere settings, where there may be language differences, language barriers, where there's a high volume of trauma.

And they may not have world-class treatment right away. It may be hours or days later. So we actually engage with our global health groups and are actually working with the National Guard as well with our global health group to understand how we can work with other countries such as Slovenia and Jordan as well because what they face is similar to what the military may face. And actually both those groups, both US military and these global health groups who respond to humanitarian crises, are also working together in Ukraine as another great example.

Thomas Flaig:

Shifting gears just a little bit, one of the real challenges in healthcare right now is mental health. And I think we certainly saw that manifest in the pandemic, but certainly before and after. And there's a significant impact in the veteran community and the soldier community, but the civilian community. Do you want to talk about any of the work that your center's doing in mental health, firearm safety, suicide prevention in any of those areas?

Vik Bebarta:

That particular topic is growing across the country, military and civilian. And the investments the DOD has made are almost $200 million a year in this topic. It quickly moves, and we help that from the active duty population to the veterans to the non-military associated population as well in our communities. Several of our lead investigators, Dr. Betz, and we recruited one of the new faculty, Dr. Ian Stanley, and their teams are addressing these topics head on. So looking at firearm suicide specifically, Colorado, especially our military bases here have one of the highest rates of military suicide, and most of that is with firearm. Our combat medics as well as our first responders face PTSD and issues with resiliency during and post COVID, but it's been there longstanding and wasn't addressed. So Dr. Betz is going after firearm suicide in our military and veteran and civilian populations both with DOD and NIH funding.

And we learned today we got another award with her as an investigator to the center to lead additional efforts in this way. Dr. Stanley does that work as well and also in PTSD for our first responders. And trying to help understand how we can reduce their burnout rates and address those needs has otherwise been unaddressed, military and civilian. In addition, we're expanding beyond that into resiliency generally. So that's with our workforce in healthcare, but also with our frontline docs, nurses and medics. And so Dr. Flarity, retired General Flarity, that's her work in resiliency both for civilian and military units, how to improve that. And she's been a national resource in nursing and medics and the military on techniques to improve the resiliency of that group and hopefully reduce some of their burnout, which is creating quite a bit of a burden on our ability to deliver care across the country.

Thomas Flaig:

So glad you brought up Dr. Betz and her great work. Again, I've seen several examples of that and what a great national leader representing Colorado on the national platform, so to speak.

Vik Bebarta:

And very focused on doing high-quality, rigorous research and delivering solutions that we can implement to our communities right away. That's sort of our target. Early on what makes us special is that yes, we have some amazing investigators, Dr. Betz, Dr. Mould-Millman, Dr. Ginde and others. But what really makes the center unique is we have the ability then to transition that research and to practice, implement it on the DOD, but also implement it and transition into our civilian communities, which is what everybody wants on both sides. And that's where I think we've been able to have a lot of success in the last couple of years.

Chris Casey:

It's really amazing just listening to you describe your work with the Center for COMBAT Research, Vik, and just how dynamic your operation is in reaching out to all these corners of not just societal problems, but mental health, suicide, warfare, NASA. It's phenomenal, all these areas and then drill down even to just the patient level clinical care in the field. How do you as a team and you as the director of COMBAT drill down and decide – this is such a massive kind of spectrum of areas you research – how do you prioritize?

Vik Bebarta:

One, I would say our team's remarkable. And I think a lot of folks have commented on that from our many visits to (Washington) D.C. and to the Pentagon and even our leaders in our community. Our group is purpose driven, mission focused, and operationally efficient. They want to target these solutions and again, not just deliver science, but also implement solutions in the community. We have focus. We sort of bucket these areas that we go after into three areas. One would be on point-of-injury or prolong casualty care, so it's pre-hospital care and acute trauma in those spaces. The second is critical injury and illness. So that would be around emergency care, trauma, surgery, resuscitation, TBI, critical care.

And the third category is brain health. So that is around resiliency, firearm-related suicide, PTSD, even around substance abuse as well. So point-of-injury, prolong casualty care, critical injury and illness, and brain health. And those are our three categories that we've decided where we are strong at. And we'll focus on awards for other areas, but that captures the bulk of the work that we go after that benefits the communities that we serve. And there's a line with the leadership and the Department of Defense as well.

Thomas Flaig:

Vik, do you want to talk about the educational work that the center does and touch on that in addition to the research, and how those two things come together?

Vik Bebarta:

One of the things that we have sort of focused on or we think it's really important is impact, purpose, and legacy. Impact is what we talked a little bit about already, which is about how we want to change practice. We want people to do things differently and better, with less variance. Purpose is that we're all driven to solve our problems. Everyone's highly motivated in that area. The third part is around legacy, which is building the future researchers in this area, bringing talents from across the campus, across the university in our case, to apply them to these needs or capability gaps. So we have a couple of programs. One is our COMBAT Scholar Program, and I can tell you these students are just remarkable. They come from all walks of life. Their story to get into graduate school, medical school, their PhD, how they got here, has been just amazing. And it's so competitive.

But these students are so impressive. We have folks that were former enlisted, former fighter pilots, some that are MD PhDs, in school now, and we engage them on the needs and questions of the military from mental health and suicide to pediatric trauma to coagulation and TBI, and train them in what the military needs, how to seek those funding sources. And we hope with that legacy, they will be the future of the researchers in this space as well, whether they're here at University Colorado or otherwise. And then we also work with, we call COMBAT Fellows who are now past graduate school. They're in residency, they're in fellowship training, and they may or may not be in the military. And we help align them to also Department of Defense needs and research opportunities.

Chris Casey:

Your background, I know it's highly diverse, and you've worked in an array of hospital settings, I believe, from rural hospitals, county hospitals, municipal, and then also combat field hospitals. Can you just describe from a personal level how satisfying it is to do what you're doing now after having this wealth of personal experience that you've built up and also your military background? With your position directing the Center for COMBAT Research, is it just a nice way to just kind of dovetail all your experiences into one area?

Vik Bebarta:

Yeah, it's personal for me. When we take care of these patients and we try to solve these problems, these are colleagues of mine that are in harm's way that are being deployed and were deployed. These are patients I took care of when I was deployed as well. And so really making the best use of the government resources to solve these problems, support our war fighters and our combat medics is really important in my role as a reservist and a civilian practitioner and physician to make sure that these solutions get into the hands of our civilian medics, doctors, surgeons, internists as well, because I know that we can really push those solutions out.

And we haven't done a good job historically, but the center believes that we can actually do this. And there's a lot of stories you won't hear, a lot of letters you won't read about folks that have been injured over the years in the military and even in our communities. And we want to address those by saving their lives, reducing their morbidity, get them back with their families and reuniting them with their communities. That's where I think our purpose is coming from and where our impact is focused on.

Thomas Flaig:

So I'll say this, we're sitting here today in a pretty cold, a typically cold Colorado day in the winter. We're sitting in the Fitzsimons building here on the Anschutz medical campus. So this campus was formed in 1918 initially after soldiers returned from World War I, particularly those with chemical injuries and lung injuries related to chemical exposure. This building was opened in the early 1940s. It was the largest building in Colorado. And this campus has over a hundred-year history of serving military personnel and veterans. And do you see yourself, you ever think of that? I like history. Do you think of your center now as the extension of that history we have on this campus?

Vik Bebarta:

Absolutely. The legacy of this campus aligns perfectly with the folks of the center. And you can feel the patriotism, you can feel that everyone is aligned to address the needs of our military here more than probably anywhere else. This campus is based on significant breakthroughs in military medicine that have all passed on to civilian communities. We actually still have an Army unit on the campus, and that is an important part of Colorado. It's an important part of the future of medicine and really tied to our legacy as the COMBAT Center. And so we're really proud to be on this campus that serves veterans in a remarkable way and is actually recognized to do so, but also addressing our active duty needs, too, in all of those (areas) benefiting our Colorado communities as well.

Chris Casey:

Well, that's a great place to wrap up our conversation I think here today, Vik and Tom. And as Tom mentioned, what your center does, Vik, is a magnificent continuum to the history of the campus here. And the work you're doing is phenomenal, and we appreciate it. And also thank you for your service and your colleagues’ service. And thank you for the chat today. Very much enjoyed it.

Vik Bebarta:

Thank you. It's an honor, and I'm proud to be here.