Meeting an Important Need

In San Diego, the C5 center employs many innovations in helping service members severely injured in Iraq and Afghanistan recover and readjust.

By Tom Imerito

Along the harbor in San Diego, California, I walk into the NAVFAC Southwest offices and meet with three engineers. I ask them about the challenges of the project. I expect to hear something about the technical aspects of designing and constructing it, but Steve Wirsching, P.E., a commanding officer and civil engineer with NAVFAC Southwest, comes up with an unusual answer that foreshadows how unique this is. “During construction, everybody wanted to come out and tour the facility and see it because of the nature of the facility and its intent. There was a lot of national political interest — taking care of our wounded sailors and marines, wounded warriors.”

Wirsching is describing the Comprehensive Combat And Complex Casualty Care center located within the Naval Medical Center San Diego (NMCSD), one of the largest military medical facilities in the country. The new C5 center came about as a result of a $4.4 million design-build project overseen by NAVFAC Southwest and engineered and built by a private construction and engineering firm supported by a team of engineering firms and architects.

Occupying 28,000 square feet, C5 is a program of care that manages a severely injured or ill service member from medical evacuation through inpatient care, outpatient rehabilitation, and eventual return to active duty or transition from the military. It provides ambulatory care, occupational and physical therapy, vocational counseling, and advanced prosthetics support to combat-injured personnel returning from the wars in Iraq and Afghanistan and other locations the U.S. military serves.

This ranks as the first facility on the west coast for amputees. A high percentage of military amputees wounded in Iraq and Afghanistan are based on the West Coast. Many Marines come from California with its plethora of bases such as Camp Pendleton, Miramar Marine Corps Air Station, and the Marine Corps Air Ground Combat Center at Twentynine Palms. In the past, severely injured service members typically went to Walter Reed Hospital in Washington, D.C. or local Veterans Administration facilities.

Wirsching points out another reason for the timeliness of the C5 center. “On the battlefield, they’ve learned that the survival rate of our soldiers and marines getting injured is so much higher because of today’s technology. They’re saving people whose injuries are now much greater than they had in the past, so they’re learning how to deal with that.” Then he adds, “The stuff they’ve developed, I can’t wait for you to see it.”

First Hand Look
Venturing to hilly Balboa Park in San Diego just northwest of downtown, I come to visit the C5 center and meet with Jennifer Town, program director for the center. John Valente, community planner with NMCSD’s Facilities Management Department, and David Williams, an architect and senior project manager for NAVFAC Southwest, join us. Artwork along the hallways captures the spirit of the facility and patients, as paintings and photos show amputees engaged in active sports. Local disabled artists, including former patients, contributed these. Town says of the center, “This brings a new level of care.” She says they wanted to keep patient care in-house to save money and provide continuity, yielding better care.

The project to design and build the C5 center started in November 2006, and the facility opened in October 2007. Valente calls it one of their fastest, best-tracked projects. Williams recalls, “It was an amazing team approach.” They tell how in the design-build scenario, design work took place simultaneously with demolition and construction, resulting in timesavings.

A unit of the Naval Facilities Engineering Command, NAVFAC Southwest is one of 10 facilities engineering commands in the Navy. They do facilities engineering, construction, public works, and environmental support for the Navy, Marine Corps, and other Department of Defense and federal activities, covering the six most southwestern states. This includes support of Navy Medicine West, the command that includes NMCSD. They did the contract award and administration for the C5 facility. Wirsching relates, “We’re the equivalent of the owner’s rep. We handled the onsite quality assurance and safety and contracted with the private firm to do the work.” NAVFAC Southwest typically contracts with commercial businesses on engineering and construction for the military.

For this project, Stronghold Engineering, a general, civil, and electrical design-build construction company based in Riverside, California, served as the prime contractor. The company has done many projects at the hospital. Ravatt, Albrecht & Associates, an architecture and engineering firm in Santa Maria, California, was the architect and handled mechanical and plumbing engineering. Structural engineering work went to Cannon Associates, a multidiscipline engineering firm with several offices in California and one in Denver, Colorado. Dittmann Associates in Shell Beach, California handled electrical engineering.

As we stroll through the halls, Valente remarks, “This all had to be gutted.” The building previously housed an occupational therapy center. Demolition included remediation of unforeseen asbestos-laden floor tile mosaic. Stronghold also discovered damaged sewer piping, which required removal of the existing concrete slab and installation of new corrosion-resistant piping.

At the first stop, Town announces, “We’re in the gait lab now.” This featured panels on the floor and tracks overhead with several cameras mounted on them. As a patient walks on the panels, sensors in them monitor their gait, and the cameras send imagery to a computer screen that creates a simulation of the person walking. The motion-capture system digitally acquires, analyzes, and displays three-dimensional motion data. It provides quantitative documentation of walking or running ability and identifies any underlying cause for gait deviations.

Williams and Valente told me they worked on the project from the beginning, while Town came on about half way through. When she came onboard, she lobbied for extra funding for the courtyard and gait lab, which weren’t in the original plan.

Like a Fitness Center
Next came the physical therapy room, where Town notes, “This looks like a high-tech fitness room.” A guy ran on a treadmill that had a skirt around him to support him to reduce impact on his lower joints. It would allow him to only support 10 percent of his weight. A solo step system had a harness hung from the ceiling on a track for supporting a patient as they walked along the floor. Valente explains, “Structurally, the ceiling had to be reworked to handle the solo step system.”

Down the hall, in the prosthetics lab, Valente states, “This was the most unique, complicated area of the project.” Williams adds, “A tremendous amount of design went into this little space.” Here, composite fiber parts for artificial limbs for amputees are fabricated, a process that includes casting, fitting, and alignment by certified prosthetists and prosthetic technicians. The advanced patient casting room has a computer-aided design and manufacturing (CAD/CAM) system.

Why was the prosthetics lab so complex? It required specialized exhaust systems to ventilate chemicals used for limb fabrication. This required demolishing existing chase piping, drilling 20-inch holes for new ducting, installing rooftop utility fans and associated stainless steel ductwork, connecting to fume cabinets, and adding low-pressure air drops.

But while the prosthetics lab may have required the most engineering, the outdoor courtyard and climbing wall stand as the C5 center’s most visible signature. In essence, these involved converting a 3,500-square-foot outdoor courtyard to a multi-terrain obstacle course. The area contains ramps, stairs, and beams that allow patients to work on ambulation and balance. Sand, gravel, rock and brick terrains simulate surfaces encountered in everyday life. Walking surfaces have varying textures and slopes, including rubber matting, cobblestone, and obstacles such as cast-in-place boulders. As Town points out, “This is all about reintegration.”

The 30-by-9-foot climbing wall enables patients to work on agility, problem solving, and muscle strengthening. Town says, “It was a feat to get it in here.” As we examine it, Williams notes, “It has a huge foundation underneath it” to keep it from tipping over. It also required the relocation of 60 feet of storm drain.

In addition, a training apartment gives patients the opportunity to practice tasks in an environment they will encounter upon discharge. The suite has a full kitchen complete with a microwave, stove and oven, refrigerator, and dishwasher as well as a bedroom, living room, and bathroom with a tub/shower combination. The living room offers a computer workstation with a wide variety of computer assistive devices such as one-handed keyboards, print enlargers, and voice-activated technology.

With the C5 center in operation for a while now, its engineers and builders can reflect back on the project to see what they’ve accomplished. Perhaps Wirsching says it best. “It’s been a great facility. There was a huge need there, and that project has met that need. It was a great project from our perspective. It’s one that, at the end of the day, you feel good about what you’ve done because it was urgently needed, and it fills the gap to a pretty dang important group of people.”