No Digging Required—Providers Access Digital Medical Record System for Injured Soldier
One inch ended MAJ Andy Ingalsbe’s service in theater. In September 2009, a sniper’s round struck him in the back, an inch below his Kevlar vest. The reservist and his civil affairs team had just completed a humanitarian mission in Afghanistan’s Paktika province.
The well-placed projectile did extensive damage. The bullet cracked two vertebrae, destroyed Ingalsbe’s right kidney, and wrecked his liver and digestive tract. Unable to brace himself for the fall, Ingalsbe also injured his neck when his head slammed against the ground.
Surgical teams treated him at Forward Operating Base Sharana and Bagram Airfield in Afghanistan. They also digitally documented Ingalsbe’s care in computer systems fielded and supported by the Army’s Medical Communications for Combat Casualty Care program. His digital medical history helped physicians at Walter Reed Army Medical Center, Washington, DC, piece together his traumatic story.
“I arrived at Walter Reed five days after my injury, but I regained consciousness on the 18th day,” Ingalsbe said. “The doctors told me about my injuries, and I required a lot of replumbing. Surgeons in Afghanistan removed a kidney and my right colon. The entire time I lived at Walter Reed, the doctors never asked me about any of my prior treatments. They had all of the information in my digital records. One doctor said that I looked better medically in person than what was documented in my chart.”
Voluntary Tour Cut Short
Ingalsbe was devastated by the timing of the injury. For 25 years, he had trained for combat as a military policeman. In 2005, he came out of retirement voluntarily to serve on the battlefield in civil affairs.
From 2005 to 2006, Ingalsbe led more than 80 missions throughout Iraq. His teams dug wells, repaired schools, and handed out food. However, the humanitarian experience came with a price. An improvised explosive device damaged his hearing. Ingalsbe remained committed to the mission. At the end of his tour, he retired for a second time.
In 2008, he returned to active duty and deployed in the same capacity, this time for one year in Afghanistan. While in theater, he decided to extend for a second year. Two days before he was set to begin another yearlong tour, the sniper’s bullet ended Ingalsbe’s service in theater.
Ingalsbe recuperated at Walter Reed for eight months. Digital medical history from the battlefield and home enabled MAJ Jane Dickler, Nurse Case Manager with the Warrior Transition Brigade at Walter Reed, to keep a close watch on Ingalsbe and others.
“I review the electronic records and treatment plan to make sure my patients receive the medical attention they require,” Dickler said. “Since the medical staff captures patient data electronically, it eliminates the need to hunt for paper forms. It also significantly reduces the possibility of losing patient information. My team also reviews appointment schedules so that patients are where they need to be at the correct times.”
Ingalsbe underwent a second surgery in March 2010. To repair the damage in his neck, a neurosurgeon inserted two titanium discs and a metal plate to hold them in place. Three months after the operation, Ingalsbe transferred to the Community-Based Warrior Transition Unit-Arkansas (CBWTU-AR). Ingalsbe continues his rehabilitation at outpatient facilities in his hometown of West Plains, MO.
“Patients such as Ingalsbe are able to receive medical care in their own communities,” said MAJ Barbara Schulz, Nurse Case Manager with the CBWTU-AR, who manages Ingalsbe’s care. “When Ingalsbe receives physical therapy at his local hospital or meets with his family physician, we receive documentation from the civilian providers. Ultimately, all of the records we collect will go to the Department of Veterans Affairs, allowing future providers to view his complete medical history.”
Continuing the Paper Trail
Ingalsbe still collects paper copies of every form from his appointments, although digital medical records have replaced paper forms. Since he was shot, the paper folder has been replaced by a plastic binder. He also has CD-ROMs and DVDs with the results of his radiology exams.
One doctor said that I looked better medically in person than what was documented in my chart.
“The military is much different today than when I began my career 30 years ago,” Ingalsbe said. “For most of my career, service members kept paper copies of their medical records to protect against a clinic misplacing months or years of medical information. Today, digital notes build upon older records like e-mail messages. I don’t have a medical background, but the digital records are pretty easy to follow.”
Periodically, Ingalsbe returns to Walter Reed for follow-up appointments, and he looks forward to the day when he receives medical clearance from both surgeries. When that happens, he will retire from the military for a third and final time. When the time comes for a medical review board to determine his future medical benefits, the board will be well-informed, Ingalsbe notes.
“Between my paper copies and the digital records in the military’s computer system, I have my medical history covered,” he said. “The medical board will have a complete medical picture of my military service.
“I have a lot of good memories from my military career. As a permanent reminder of my deployment to Afghanistan, I have a 12-inch scar on my abdomen and the sniper’s round mounted on my wall with my Purple Heart.”
- BILL SNETHEN provides Medical Communications for Combat Casualty Care Program public relations support. He holds a B.A. in communications from William Paterson University. Snethen has more than 15 years of public relations experience.