MADIGAN ARMY MEDICAL CENTER, Joint Base Lewis-McChord- If you visit Madigan Army Medical Center on Joint Base Lewis-McChord you may see more than the hospital's iconic swans, Madi and Lewi. You may also meet up with the mellowest black Lab in the facility dog business.

Earl, or, Capt. Earl as he can now be called since his commissioning ceremony in July, is a three-year-old black Lab trained specifically for service in a military treatment facility.

His work here is nothing new.

In Florence Nightingale's seminal work, Notes on Nursing, first published in the U.S. in 1860, she stated, "A small pet animal is often an excellent companion for the sick, for long chronic cases especially."

While managing nursing at Scutari Hospital in Turkey during the Crimean War, she introduced a tortoise named Jimmy as a pet for the wounded soldiers.

The Florence Nightingale Museum in London has resources reflecting Nightingale's support of animal therapy, noting that she understood the joy and calming effect animals could bring people.

Research is proving Nightingale was onto something.

"Dogs have been shown to reduce stress, anxiety and depression on a molecular level in those that participate in HAB (Human-Animal Bond) programs," said Lt. Col. Todd French, the Army Veterinary Corps Department of Defense advisor on the human-animal bond and deputy commander of Public Health Activity Hood in Fort Hood, Texas. "Studies show that HAB program participants have statistically significant lower stress hormones (cortisol) after even just a brief (as little as five-minute) interaction with a dog. Novel research into the effects of HAB also shows that participants have a dramatic increase (up to 300%) of the bonding/love hormone (oxytocin) during dog-human interactions. As you would expect, a beneficial hormone profile helps promote positive mental health and anxiety reduction."

The benefits of animals and humans relating appear to be universal. Patients, providers and the animals are all positively affected by these interactions.

"A recent study out of an Edmonton, Canada university emergency department showed that patients had clinically significant improvements in not only anxiety, depression and well-being, but a decrease in pain after only a 10-minute interaction with a handler-dog team," elaborated French.

People are generally fairly aware of how animals can aid people, as service dogs are quite commonplace. But, there is likely not considerable thought given to the influence a dog can have on the care team.

"Additionally, dogs are scientifically proven to be really good at promoting pro-social behavior. This is extremely beneficial in facility and therapeutic support dog programs as these dogs and their handlers are specifically trained to recognize and address individuals that are withdrawn due to stress. This is also a big win for the healthcare team who also experience the demands of a high expectation job coupled with the potential compassion fatigue of patient care," added French, whose career passion is the human-animal bond.

Luckily, these gains in physiological well-being have been noted in the animals as well.

What was apparent to the mother of modern nursing is also clear to one nurse at Madigan Army Medical Center on Joint Base Lewis-McChord.

Tracy Baker, co-chair of the Peer Support Advisory Council and a retired Army nurse and colonel, is now Earl's handler.

In accordance with DoD policy, Madigan has a Healthcare Resolutions Program (HRP) that deals with disclosure of adverse events to family and facilitates the patient's right to be heard in any quality assurance program review of the quality of care. The Peer Support Program (PSP) is one of the responsibilities of this program.

Peer support

According to a Defense Health Agency procedural instruction for the HRP, the PSP is separate from any investigation of an event. The peer supporter does not review medical records nor do they get involved or become knowledgeable on these aspects of any event in question. Instead, "The Peer Support Program is intended to provide psychological first aid and assist with restoring clinical confidence."

A brochure promoting the program describes it thusly, "The purpose of the Madigan Peer Support Program is to provide emotional support for healthcare providers following unanticipated outcomes of care, adverse outcomes or medical errors, and any situation resulting in concern for a clinician's wellness and fatigue/burnout." It also notes that peer support is available to all staff.

The HRP is focused on adverse events and clinical practice that can be revised to improve patient safety and clinical outcomes. The PSP certainly captures the segment of the healthcare professionals' population dealing with these situations, but it casts a wider net.

It may also be that the outcome was not unexpected, but the impact is still intense for a provider. Or, burnout is pressing heavily on a provider or care team. Peer support can be profoundly helpful in these situations as well.

As a healthcare resolution specialist, Baker is in an ideal position to not only know which clinics and providers have experienced an adverse event or bad outcome, but also to engage peer support, now to include Earl.

Currently, the program concentrates on clinical staff - providers, nurses, technicians - who provide direct patient care. Some of this is due to the relatively small number of trained peer supporters. Some is the paramount concern for patient safety. Peer supporters are ready to talk to and support any staff member.

Training sessions are occurring for new peer supporters. The program hopes to match providers in need to support with someone in their own discipline. As Baker noted, "A surgeon talking to a surgeon helps a lot more to be relatable."

Baker will also place a call to peer supporters at other facilities to ensure that no provider is placed in a potentially uncomfortable situation such as talking with a subordinate in this capacity.

The PSP hones in on the provider and their coping strategies. Are they eating well? Are they getting enough sleep? Are they able to focus at work? A peer supporter will walk with them through these challenges to make sure they are not in a compromised situation where their mental health suffers or their clinical practice is not up to their usual standard.

Baker would address a provider dealing with a negative outcome or burnout by saying, "We just want you to know that you're not alone, and that somebody's here for you to talk to."

Where the PSP is tightly tailored to address event-based needs, Madigan Organization Leadership Development (MOLD), Staff Wellness Program (SWP), Employee Assistance Program and other programs are more appropriate to implement in cases of team discord, adverse personnel actions or personal behavioral health or performance challenges.

The SWP has created and maintains wellness rooms and the staff gym where staff members can relax, decompress or workout.

Earl currently visits with all in need of his positive presence, including patients.

Bringing Earl to Madigan

Earl came into the picture when Baker was talking with her counterpart at Brooke Army Medical Center in Fort Sam Houston, Texas, about what they were doing to enhance their program.

Brooke was in the process of obtaining Budd, their facility dog, from America's VetDogs, a non-profit organization in Smithtown, New York, that raises, trains and places service dogs for service members, veterans, first responders and military and Veterans Affairs hospitals.

Since Brooke was already engaged in the application process, it was easier to add Madigan to the mix, especially since America's VetDogs had previously done evaluations of its capacity to support a facility dog. The organization is well-versed in military treatment facility functionality as it has placed dogs at Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, both in Bethesda, Md.

The military is appreciative of this organization because it has developed an understanding of the needs of its personnel through its focus on service members and veterans. The organization notes this on its website saying, "We have been honored with the Secretary of the Army Public Service Award, the second-highest level award given to civilians ‘for exceptional service that makes a substantial contribution to the accomplishment of the Army's missions.'"

America's VetDogs is just one of many similar organizations that trains and places or facilitates service animals for those in need of such support. Like many, they do this free of charge, working on a donation basis to do their work.

From first engagement in early 2022 to Earl's arrival in May, Baker was busy drafting policy mirroring the Defense Health Agency's guidance, getting command approval and preparing herself, her home and her family to serve as his custodian.

Baker had to go through training to work with Earl and she is his caretaker. He is a part of her family, though he actually is still owned by America's VetDogs.

Get involved

Baker retired as a colonel from active duty in 2018 having spent her career as a nurse in a variety of areas including medical/surgical, emergency room and leadership positions. She saw the effect of providing a compassionate ear and recognized the benefit of hearing all aspects of conflict, knowing that one's perception is their reality.

While Baker is currently Earl's North Star, she is not his only handler, and there are opportunities for others.

Brad Baumgardner, the director of MOLD, is also a trained handler who shepherds Earl to his scheduled events and appointments. His involvement is logical as he is heavily involved in staff wellness efforts.

Just as the PSP is always on the lookout for new blood, Earl's dance card has some space that Baker intends to fill with staff who can accompany him in his duties. She expects to do this over time, and with intention. She also anticipates that Earl will interact more with patients when more handlers, in more areas around the facility, are trained.

"He's visited with L&D (Labor & Delivery), postpartum patients, and with oncology patients/palliative care patients already.

The human-animal bond

"The idea of Earl being part of the PSP is because he is a non-judgmental being who can just be present after a patient or staff member is going through some stressful time, an unanticipated outcome, bad outcome or medical error, where they feel the weight of the world on their shoulders," said Baker. "That's when Earl can be there for them. I can just leave him there, they can be in privacy and just sit there and pet him and just cry and let it out, whatever they need to."

Baker is dedicated to being attuned to the impact Earl's time supporting staff has on him. She's aware of his need for time and recovery from intense emotions.

"After an encounter, like one of those kind of really heartbreaking, intense encounters, he needs to debrief and have play time," she noted. "Because he does absorb all that."

Baker and others supporting Earl's presence feel it's important to protect him and ensure that he continues to enjoy coming to Madigan.

The impact of Earl and staff is a two-way street - one on the other, just as one would expect knowing the profound bond that humans and dogs have, as noted by the research.

The policy Baker has written for the Facility Dog Program outlines the extensive training Earl has had to perform both "animal-assisted activities" that enhance quality of life, as well as "animal-assisted therapy" to, "... be a goal-directed clinical intervention that incorporates the use of a dog into a patient's treatment regimen." Human-animal bond programs include both of these types of interactions.

All about Earl

Earl working a room is an impressive sight. Baker believes that America's VetDogs breeds their animals to have a calm temperament. Earl may be their star achiever when it comes to calm as it is entirely possible to be in a room with him for some time without even knowing he is there. He can quietly blend into a dark carpet. But, when it's time to work, he is up to the task.

Baker brings him to events of all sorts and visits staff throughout the facility regularly. During one, two-hour peer support training meeting, Earl alternated between being a furry lump under Baker's chair and a hands-on diplomat ensuring every person in the room received a check-in, as did their pockets for treats.

"Earl, he's happy to see you. But he's also very happy to have treats," attested Baker.

He also likes to smell people's feet, walk slowly, rise early and be just a bit goofy.

"He's a character; It makes a lot of people laugh," said Baker. "And of course, he cleans the floors everywhere he goes, he's part of our cleanup operation. But he throws that in for free."

Baker posts photos of Earl making the rounds on the staff Facebook group page periodically where it is clear to see that many enjoy their time with "Madigan's wellness pup". Earl can also be found on his own Instagram page at www.instagram.com/earl.thewellnesspup/.

Earl's support of his peers is evident to all in his social media posts, so is his crooked halo, as Baker likes to call it - his mischievous side.

"He's usually very well behaved, except he likes to eat my strawberries off my strawberry bush," Baker said. "He's taught little Blue, which is his little buddy, to eat my cherry tomatoes as well. So, yeah, so, he's a little naughty."

Expanding HAB programs

Earl is not the first dog to support Madigan, its patients and staff, nor is he alone now.

A social media post about Earl this summer garnered a comment that informed about Maj. Austin, a pointer that was a certified therapy dog that made weekly rounds visiting patients after duty hours with his physician assistant handler in the mid-1990's.

Upon his arrival at Madigan, Earl found Cooper, a golden retriever that works through the American Red Cross HAB program to visit patients. Now, Cinderella, a black Lab mix that is an emotional support dog of a new member of Madigan's staff has joined this canine crew. She also spends time with people throughout the facility, when possible.

The presence and support of dogs in military treatment facilities are increasing and becoming more formalized.

Walter Reed has seven facility dogs including Sully, a yellow Lab that was former President George H.W. Bush's service dog. Naval Medical Center San Diego has LC and Cork, a golden Lab and black Lab, respectively; and the California Air National Guard's 144th Fighter Wing has a facility therapy dog named Paige.

All of these animals are essentially focused on patient involvement. The program that is likely most similar to Madigan's current path with Earl is that of USUHS where two facility dogs are employed to help the students incorporate therapy animals in their day-to-day work and consider treatment from a holistic perspective.

French confirmed that the DoD is refining policy and standards for HAB programs as well, specifying training for both dog and handler.

It seems a safe bet that as the benefits of having trained dogs in healthcare facilities become more apparent, these programs will expand significantly over time.

Capt. Earl is ready to take his place in this evolution, especially if treats are involved.