From cold call to critical care | Ep 92

Intro Voices

Coming to DARPA is like grabbing the nose cone of a rocket and holding on for dear life.

DARPA is a place where if you don't invent the internet, you only get a “B.”

A DARPA program manager quite literally invents tomorrow.

Coming to work every day and being humbled by that.

DARPA is not one person or one place. It's a collection of people that are excited about moving technology forward.

Stacey Wierzba:
Welcome to voices from DARPA. My name is Stacy Wierzba, and I'll be your host. Lieutenant Colonel Adam Millis, MD, joined DARPA in July 2023 as a program manager in the Biological Technologies Office. His research interests include biomechanics of brain injury, neuro ergonomics of operational tasks, and critical care medicine. He stopped by the studio to share his insights on the importance of cold calls, leaning in, looking at problems from multiple perspectives, and maintaining childlike curiosity.

Here's Doctor Willis.

Adam Willis:
Early on, started at university, Notre Dame, was in the ROTC program, Reserve Officer Training Corps, for Air Force, was a physics major and during physics, I really, you know, I love the math of the physics, but I really was always looking for how could this be applied to help people? And that's where the idea came of, well, you could do a combined degree and start thinking about a combined degree where you'd do more math and physics, like going on a PhD program, but also go to medical school. So that had a lot of appeal to me. So I applied to do that and was at least selected for the PhD portion of this and started to do that at University of Illinois, Urbana-Champaign.

And while I was there, I kept looking for opportunities to go to medical school and looking for, basically how does this get done? It was sort unclear how to, you know, convince the Air Force that this was a good use of my time. And then one day I had an opportunity to go to a bioengineering conference up in Chicago.

And there they had a demonstration of the Revolutionizing Prosthetics program. I saw Jesse, I think, was the name of the patient who had that robotic arm. And it was fascinating. I'm like, well, this is cool.  I would absolutely love to do this.

Stacey Wierzba:
That moment, seeing engineering and medicine merged to restore human function was a turning point for Willis, moving from abstract physics to helping people. And it was a path that led straight to an organization he'd heard of but didn't yet fully understand: DARPA.

Adam Willis:
And then I started to just Google “brain computer interface.” And one of the names that came up was this Colonel Geoff Ling, MD, PhD. I'm like, well, he's in the military, and he got a PhD and an MD, so maybe I'll just talk with him to see what's going on. And so I cold called him, and the first thing he said to me is, “You want to be here. You want to come to DARPA.”

Stacey Wierzba:
At the time, Geoff Ling was a program manager, but he'd later go on to be the first director of DARPA's Biological Technologies Office.

Adam Willis:
Then he gave me advice of maybe how to make a compelling case to get to go to medical school, which eventually worked. But that landed this vision of, you know, how can you take science and really make changes to really change the world? And following that, I went to medical school. I was interested in neurology because it's sort of like an engineering-like approach to medicine. It's circuits really. And then I realized in neurology, I like critical care just because of how fast things move. Went to do neuro critical care, but also started to build a lab and traumatic brain injury just because of some research opportunities that were given to me while I was still a resident at the 59th  Medical Wing. And that started to evolve into getting the opportunity to go to flight surgery course.

And that was just opened my eyes to so many operational considerations. But then I also, after I finished a fellowship in Critical Care, had the opportunity to go to what's called critical care advanced transport training, where you are trained to run an ICU in the back of an aircraft, which is an amazing opportunity, but it sort of just opened my eyes again to all the operational concerns and how medicine can play sort of as a direct contributor to our sort of the war fighting effort.

And I just had a couple more opportunities popped up to use my skill set in my training to help other issues where energy might affect a brain or affect a body. And I raise my hand and that's sort of just opened up a whole bunch of doors that led me to here.

And it's interesting, the more you talk with people who've done awesome things, a lot of it's cold calls just taking the initiative, right? And just saying, hey, I want to learn from you. I have some questions. It's shocking, the opportunities that happen.

Stacey Wierzba:
One of those opportunities was DARPA's Service Chiefs Fellowship Program, which we discussed in episode 88.

Adam Willis:
Because of having raised my hand a couple times to be more operation relevant than normally, say, a neurologist would have been, I was able to apply for the Service Chiefs Fellowship Program, but I just also want to put a shout out to. I wouldn't have known about the program, except for I had a really good NCO that raised his hand and said, hey sir, you might want to look into this. And then I had a mentor who basically helped drive me through the application process to do this, and I was selected for the Service Chiefs Fellowship Program, and it's a great opportunity.

It's three months TDY of Choose Your Own Adventure. You land at DARPA and you're told do what you can to contribute to any programs. You want to learn something and have fun and start to build those connections between DARPA and your home units.

And that was unreal. Not only did I get to learn about, you know, sort of some medical programs, but I was just immersed with, you know, people who are electronic warfare officers, submarine officers, people from the intelligence community, and just a whole larger spectrum of different considerations to sort of the overall fight. So it was really eye opening experience.

And while I was in this program, I raised my hand again and told everybody, I would love to stay here. What can I do to stay here? And so I applied. And, that led to the opportunity to come back here as a program manager.

Stacey Wierzba:
Becoming a program manager at DARPA wasn't just about his medical expertise or his military experience. It was about his unique ability to see problems from different perspectives. We asked him how that early training in theoretical physics shapes his approach to the complexities of human biology.

Adam Willis:
From the theoretical and applied mechanics approaches, where we just come up, with what are the fundamental ways you can model fluids and solids, and really starting from core foundations to understand the different principles. What that has allowed me to do within medicine is take a look at a problem and say, let's break it down to what are the fundamental questions. Maybe the physics that is going on relates to that pathology. 

Where it actually came into play with one of my programs is, say, GOLDEVAC. So I'll talk a little bit more about GOLDEVAC. But one of the problems is getting a lot of fluid flow, let's say blood flow through a small tube. And we were hoping to get a large amount of flow through a tube less than five millimeters in diameter.

And at the time there were people there saying, well, that's impossible. Violates physics. But actually what's interesting is just having this background, I knew it didn't. You just have to redo your assumptions. So one of the ways to do this is rather than having a small tube, maybe it starts with a small tube and then expands once you're ready to flow blood through it. Or maybe you can do something to the inside of that tube so that the blood doesn't really flow like a normal pipe, but actually slides through it without all that viscous loss. And so that's one of the ways it comes up, is you're able to really have the opportunity to learn about a lot of principles so that we can maybe readdress a problem in a more fundamental way.

But I think probably most importantly is I trained with a whole bunch of people who are now physicists, engineers, and I have colleagues that I can now talk with about medicine, and we try and turn it into, say, fluid, mechanical and solid mechanical problems. And it's really taught me how to be a bit of a Rosetta Stone between the medical community and, say, the engineering community.

And that's just been a just a joy to do. If you get someone in a room who their entire life has been, say, in this case, thinking about fluid mechanics, they have a very different way of thought than I do thinking about neurology. But then you just start talking. I explain my problem. They can cast it into a problem that they are familiar with. And sometimes, like in fluid mechanics, you might have a 100 year old solution. Just classic fluid mechanics. You just have to cast it in that light. And the things that break through the seams, and really defining the problem and harnessing the tools, all the tools that exist through different disciplines is really where I think a lot of exciting things are getting done right now.

Stacey Wierzba:
That ability to act as a Rosetta Stone, translating between the worlds of engineering and medicine, is the foundation of Adam's portfolio. He's tackling some of the most daunting challenges in military medicine. Let's start with the MASH program, or Medics Autonomously Stopping Hemorrhage.

Adam Willis:
MASH is focused on really the big problem of saving lives on the battlefield. Like the number one cause of preventable death in the battlefield is bleeding, and it's actually bleeding internally. The way you stop internal bleeding is surgery.

We know future conflicts or even current theaters where you're far away from surgeons, you may not get someone to a surgeon in time.

So the question that this program aimed at was, could we get existing medical robots and medical devices that could somehow get into the abdomen, find the bleed, and just stop the bleed? That's all we're asking is just stop the bleed.

Sort of like applying a tourniquet to an arm. How can we apply a tourniquet or somehow get something in there just to stop the bleeding? Buy yourself time so that you can get to that next level of care. 

And when we looked at that problem, we saw that there are two key challenges. The first challenge is sort of the more technical aspect is where, of course, we're going to limit ourselves to existing robots because we didn't want to say create new robots. We want to make existing robots smart. 

But then if we're talking about trying to find the bleed in the abdomen, you can't really just use cameras to do it because it's a dark place. And if it's filled with blood, you can't see anything. So you might have to use new sensors, and there's a whole bunch of sensors to figure out what's bleeding. But also, what are you looking at and where are you in anatomy? But then how do you move through that space? Right. It's a very filled space. And do you have to push things out of the way? Do you have to go around obstacles? And that is going to be a hard problem for, say, an AI system to figure out. But there are ways through it. One is you could use a lot of animal training data. That's one way, but we think the more elegant solution that we really want to lean in on is what about simulating the environment, simulating what these robots would do, inside really fast computers so that you could train these robots in computers to really deal with all the possible permutations of, you know, injury patterns or where you are locating where you need to go.

And then once you say get to the location of where the bleed is, we actually view, we could harness existing devices that have been built for minimally invasive surgery to stop the bleed, whether it's just stuffing gauze, spraying some foam, or using electricity to stop the bleed or maybe even focused ultrasound. So like, I think it's knowing where you are and getting to where you want to be is really the hard part.

Stacey Wierzba:
The MASH program aims to bring advanced capabilities to the patient, but for decades, military medicine has been defined by a different logic a race against the clock known as the golden hour. On the modern battlefield, that hour is no longer guaranteed, and Adam is working to fundamentally redefine that timeline.

Adam Willis:
The golden hour concept was in, this came out of the global war on terrorism, and it was mandated that after someone got injured, you had an hour to get them to a surgeon to usually stop non compressible torso hemorrhage that Mash is addressing. You know, it's not going to get done in an hour.

Another way to think about it is we don't necessarily need to evacuate people. What we really need to do is create solutions for the problems that that individual is going to have. We call it the physiology. And if you can bring those solutions farther forward to address the physiology that you'd want to solve earlier on, then maybe you don't need to evacuate people. And that reduces the constraints of how you'd have to move people in places.

Stacey Wierzba:
So if you can't get the patient to a surgeon within an hour, the logic has to flip. You have to bring the lifesaving capabilities to the patient. That fundamental shift in thinking is the core of another of Adam's programs, one designed to literally put an ICU physician in a box called GOLDEVAC.

Adam Willis:
So GOLDEVAC is, at its highest level, trying to replace what I do as an intensive care physician. Put it in a box so then it could be started much closer to the point of injury. You know, we envision that perhaps if you could get a box that fits into a backpack and you have an IV that can go into one of the veins in the groin that a medic could place, that IV hooked the box up, press go, and it starts to deliver the medicines, starts to deliver the blood if you have it, but also controls what we call gas exchange, how much oxygen to give, how much CO2 to pull off to really keep someone's physiology or sort of health as good as possible, just to buy time to get them to that next step. GOLDEVAC is part of a solution that if we can apply early damage control resuscitation - that's the technical word for giving the right medicines and giving the blood - you can keep someone longer before they sort of get into a bad spot where surgeries couldn't save them. So it's just a way to literally buy time. 

But also, let's think about after, say, surgery has been accomplished, there's still critical care needs, and critical care needs is a key bottleneck in how we take care of injured casualties. GOLDEVAC could allow you to increase your holding capacity to do critical care, while waiting to move someone, but then augment your ability to transport more critically injured casualties in the back of aircraft to really increase how many injured casualties you can move and keep them sort of managed at a high level of care.

Stacey Wierzba:
Programs like MASH and GOLDEVAC aren't standalone solutions. They're critical links in a much larger, more ambitious vision for revolutionizing battlefield care, a concept the agency calls the Live Chain: the critical steps of tactical combat casualty care that bridged the gap between injury on the battlefield and arrival at surgical care.

Adam Willis:
So the Live Chain construct is trying to break down, what are the steps that need to occur in order for someone to survive? Maybe we can collapse some of those interventions that normally you have to get evacuated for, push those farther forward so that maybe you don't have to evacuate as many people, or you can do a longer hold of people in a single spot and just take a vehicle opportunity to evacuate to higher levels of care.

So rather than having, say, that golden hour to get to a surgeon, perhaps we could have 48 hours or even longer to just patch someone up so that when an opportunity does arrive, you can get them out to the next level of care. The DARPA Triage Challenge sets the stage for where GOLDEVAC would go. You gotta do TCCC, which is tactical combat casualty care. You've got to do the life saving interventions. That is DTC almost identifying what who needs to get the basic stuff done. So then a subset of those will be identified. GOLDEVAC could carry from there. And this then aligns with well then how do we think about bringing in something like F-SHARP.

Stacey Wierzba:
The Fieldable Solutions for Hemorrhage with bio-Artificial Resuscitation Products or F-SHARP program aims to develop a deployable, shelf stable, universal whole blood substitute to sustain injured warfighters.

Adam Willis:
But you can view F-SHARP as maybe a part of a GOLDEVAC system. You know, we could utilize it if it was available and if it's been proven to work. So it's really been fun to try and plant yourself in this larger ecosystem, which we now call the Live Chain. And really having a clear narrative of how our investments are putting together the chain of events that need to occur to keep someone alive.

It's really been fun to bring other teams together for this really large picture, because a single person is not going to get this done, and addressing all the problems would be like boiling the ocean. How can we be strategic among the group of us in among the whole office, to really get the key things done so that we can accomplish that Live Chain?

Adam Willis:
Developing these ambitious, world changing programs is a full time job, and then some. But Adam's also a practicing neuro intensivist, still treating patients in the ICU. We were curious how and why he manages to keep a foot firmly planted in both worlds.

Adam Willis:
Certainly in critical care, it's not like riding a bike. One of the things I realized when I came here is just, I have to keep seeing patients, keep staying relevant, to just know how to deal with the problems that pop up so that I'm in the end, I'm still a physician within the Air Force that can contribute if I need to get pulled to work in the ICU, even if I get pulled back to do CCAT, etc. So that was a priority that I had to put on myself because, you know, DARPA wants as much as they can of you to build programs. But this was something that both the Air Force and myself realized was very, very important to keep going. And that's why it took a bit of paperwork. But in the end, that's why I really focus on getting that clinical practice back at Johns Hopkins. So I stayed sharp and till relevant in my original field.

There is things you learn from patients every day, the challenges that you see perhaps in the ICU that you can bring back as like, well, how can I solve them? How can I make that easier? And then how do I report the problems I see in an ICU even further forward? How would we manage these problems without all those resources I have in the ICU

Stacey Wierzba:
So that commitment to staying on the clinical frontlines isn't just about keeping a skill sharp, it's a direct source of inspiration, feeding real world problems from the ICU back into his search for battlefield solutions. But maintaining that dual identity as both a full time DARPA, PM and a practicing neuro intensivist is a massive logistical undertaking. It's a feat of scheduling and teamwork that relies on much more than just a packed calendar.

Adam Willis:
I see clinic about once a quarter. Bottom line is, it's teamwork. I sit in the midst of an amazing team that keeps the wheels running. So when I'm on clinical work, I basically have to focus all of the daytime hours to taking care of the patients because that's what is required. But there's actually some good long drives in there. And so I had usually a couple hour drive home, and that's the time where I can connect up with my team and see what needs to get done, what are the decision points, and sort of work through a lot of problems on my drives home. 

Then I had a team of great technical advisors for all of my programs, and they really keep things running and are able to reduce key decisions down to really clean decision points for me, and we can get that done on the drive home. 

But lastly, also the other trick is I'm blessed to have my wonderful wife who holds the house together because these are very, very busy weeks and I couldn't do it without her. And of course, actually my parents are in town to help also with taking care of the kids. So it's a team effort. Again, I'm just lucky to get to do it.

Stacey Wierzba:
Adam's emphasis on teamwork isn't just about managing a busy schedule. It's a core principle that has shaped his entire career. From his training at Brooke Army Medical Center to his current work at DARPA, his professional network is more than a list of contacts. It's a community built on shared experience and trust.

Adam Willis:
The advantage of having lived in this environment when I trained and then worked at Brooke Army Medical Center, and then having gone through the training for CCAT and then just being involved in that community, you've sort of been steeped in many of the operational problems you also have just along that front. I have a lot of colleagues who I can bounce ideas off of, and they can call me if some of my assumptions, my lofty DARPA-like assumptions, are just way off. If nothing else, it's a peer group. 

Another thing to say is many of the people who trained me are now senior leaders. Many of my contemporaries are now leaders in this space, and many of the people I've trained are now operationally active, doing these missions. And so it allows me to have a large network of both the stakeholders, but also the teams working on transition.

So these are many of them are friends or many people I've been running across at conferences for years. So that just helps, given that we all have a shared mental model of how we want to get what we need to get done for the patient. And so that really, really helps. More generally, I think this is going to go for almost everybody. The relationships, just having relationships with people that you can keep working with throughout a career, just makes it so much easier, right? If you have trust with someone, you're working and you've known someone and now you're working with them to get something done later on, it just helps. For example, my neighbor in San Antonio was in charge of the Medical Center of Excellence, some level of training in Texas.

It turns out when we were doing a technical interchange meeting, he's now working, I think, with PEO Soldier, working on transition. And so this is my neighbor, and we're going to be talking soon about how can we transition GOLDEVAC. How could you know something like PEO Soldier or some other Army command start to plan to grab GOLDEVAC technology and pull through.

So it's shocking that people you work with at the beginning of your career, you will keep seeing. And that's that's one of the fun. And I think the advantages of being active duty and going through DARPA.

Stacey Wierzba:
As we've noted before, DARPA, PMs all have an end date. That's by design, to foster a sense of urgency, ensure a constant influx of new, high risk ideas, and to prevent bureaucratic stagnation. Adam has just accepted a new opportunity as the chair of the Department of Neurology and Rehabilitation Medicine at the Uniformed Services University, also referred to as USUHS or USU.

Adam Willis:
I am always shocked by I get to do cool things and this is just another opportunity. I have to thank, of course, Dean Elster, who gave me the opportunity. But even Lieutenant-General Dugoes who helped me and Brigadier General Bogarde and Colonel Heaton, who are my current command, just allowing this opportunity to sort of step forward and happen.

So taking over this summer, June 1st, the Department of Neurology and Rehabilitation at USUHS.  And at some way, this is really sort of coming back sort of to a clinical environment. And I mean, I couldn't be happy because USHS has a rich history of working with DARPA. The rehabilitation program was working with the Revolutionizing Prosthetics program. Currently at USUHS, one of the neurologists is working with a DSO program on sleep optimization. So it's already a hotbed of innovation. 

And just to land there, I think it almost sort of comes full circle of bringing innovation, bringing the DARPA approach to military medicine. And I think what I'm most excited about is trying to address one of the challenges we always face at DARPA and face in medicine in general, is how do you determine if any intervention you gave is valuable?
Does it actually make a difference if we're dealing with, you know, say, cognitive optimization, sleep optimization, physical optimization, you're going to have to tie those interventions to making someone faster in an obstacle course or making someone fly better on a long duration mission. How do you test that? And the opportunity that I think we have as a department is there's a core faculty that exists that uses which is, again, the hotbed of really good research.

But there's also 200 faculty across the world that are affiliated with USHS. These are people who are now positioned in, you know, Japan and Europe who are taking care of the very pilots, special operators, service members all across the world for all these different mission sets. And I think this gives us a great opportunity to really build testbeds, to take care of these individuals, but also fold in interventions and then test if we're actually making them better with metrics that we can explain to senior leaders, but also have credibility to both the service members saying, hey, this is going to make me better, do my job better.

So I'm really excited about that opportunity of just the network and the richness already that exists within uses to really push that.

Stacey Wierzba:
This new role feels like a natural next step, a chance to embed the forward thinking, problem solving DARPA DNA directly into the institution that trains the next generation of military medical leaders.

Adam Willis:
And that's exactly what I want to do, is take the lessons I've learned through my career, but also the lessons at DARPA forward to the next generation. The Heilmeier questions are really key to almost addressing any problem. We use them here, but they're applicable to almost anything you want to do.

And part of the Heilmeier questions is, let's envision the world that you want to live in and then ask, why aren't we there? What can we do to get ourselves there? And just that process of breaking down the problem and figuring out what do you need to focus on to get there is, I think, invaluable. And then having a very rigorous way by which you develop solutions that we do for the Heilmeier questions, I think is imperative for anybody who wants to institute change. But added on to that, how can you have the biggest impact? There's millions and millions of problems out there, but what problem can you focus on that will have the biggest impact and start there and then start to build out how do I want to tackle that? And I think looking for impact and looking for opportunity to have impact is just a great mindset for young people to think about. I can tackle any problem I want, but which one should I tackle to really have the biggest impact? 

The other things that pop out are get diversity of thought. Talk with people who have no similarity in background with you because they're thinking about problems differently. And if you can get to a point where you can explain a problem so that they understand it and they're able to analyze it in the way they think, you're going to find these rich solutions like these solutions that pop out at the edge.

And so that's absolutely living in this multidisciplinary world, because I think we all see the writing on the wall. Solutions aren't going to come from siloed groups. Solutions are going to come from new people coming together with new ideas, from rich histories being brought together. I wouldn't be here if it wasn't for people going out of their way to give me opportunities. And so, first of all, that should be passed forward. 

But secondly, I think this is important when you're starting your career, it's so easy to get self-conscious and worry about the people who are in charge of you and what they think of you. But I think the most important thing to remember is your bosses, your supervisors, your consultants in the military. They want you to succeed, and they're looking for reasons to give you an opportunity. So if you can justify what you want to do and why, it's good for the mission, opportunities are going to pop up. And so remember, the people who are in charge of you want you to succeed. And so don't be afraid to ask. And certainly don't be afraid to say, this is what I'd like to do, and I think this helps the mission.

Don't violate the principle of trying to achieve more than one consecutive miracle. Like choose one. Pick what you want to focus on. Get that done, and then tackle the next one. If you try and take on too many things that seem really, really hard, you will more likely fail. You need to focus on the one key thing you need to get done, and then move on in a sequential fashion

I think lastly, take professional risks. Raise your hand, say, I would like to try this, and I would say for my future students, you're in the military. Embrace that. Look for problems, how you can contribute that’s not only a physician but also a physician in the military. And by doing that, a lot of opportunities pop up.
And lastly, dream big and follow your dreams.

Stacey Wierzba:
From physics student to doctor to DARPA, PM and now department head, Adam's path has been one of increasing complexity and impact. To close, we wanted to rewind to the beginning and ask about the much simpler decision that started it all why he chose to join the military in the first place.

Adam Willis:
So growing up, my grandpa, who was an orphan, this is on my mom's side. He wasn't going to go to school unless he did ROTC. So he did ROTC in the Army and went to go through, I think he was an intelligence officer, and then served in World War Two. And that just opened my eyes of, okay, there's something out there.

And then we actually had a good family friend who was in the Air Force growing up, and he would just tell these amazing stories of just the things he got to experience. He was a master sergeant in the Air Force, working on a missile base. And like all just the cool things that were happening, so that sort of sparked it in my mind.
I've always enjoyed having a bigger picture or bigger mission than just yourself and being associated with sort of a larger effort, and the military had that option. And lastly, they also offered to pay for school, and that was really, really, really helpful. 

And what was funny is like when I applied to college, I also in parallel, applied to ROTC scholarships. And the Air Force asked, do you want to do physics, chemistry or biology? Physics sounds okay. Penciled that in as what I wanted to do. And then lo and behold the Air Force said, yeah, you got a scholarship for physics. And I'm like, okay, I'll go that way.

And it's just sort of been an adventure since. 

And while I was in ROTC, it just reaffirmed why I did that, because the mission's amazing. But the people are the best. I mean, really, all my colleagues from ROTC were the best friends that I still have now. So I think that really just keeps you in and allows me to keep saying, yeah, I'll raise my hand. I don't know, maybe, what the future holds, but it’s probably going to be amazing.

Stacey Wierzba:
Doctor Willis's journey is a powerful testament to the value of connecting disparate fields, driven by a relentless curiosity to solve life or death problems. His story serves as a reminder that the most profound innovations often begin with the simple courage to ask a question, and the willingness to pursue its answer, no matter where it leads

That's all for this episode of Voices from DARPA. For more information on Doctor Willis's portfolio and other Biological Technologies Office programs, visit darpa.mil. Check the show notes for links. As always, thanks for listening.