When the Alarm Can't Sound

By Captain Arthur Smith, Medical Corps, U.S. Naval Reserve

Reviewers from both the General Accounting Office and the DoD Inspector General have concluded that medical communication shortfalls during Desert Shield and Desert Storm degraded the casualty receiving mission in all services. Many deficiencies were related to divergent communications capabilities and limitations on both an intraservice and interservice level. Medical communications in the Central Command area of responsibility, for example, were limited by the medical community's almost total dependence on the geographic location and support capabilities of each service. The Army used tactical telephone systems, the Marine Corps used an extensive trunk/switch system, and the Navy relied on commercial lines. The Air Force Air Transportable Hospitals were dependent on whatever communication assets existed at their individual deployment sites. High-frequency capability was the only system that spanned the Central and European Commands' areas of responsibility, but medical units did not have the high-frequency systems.

For many years the military services have acquired different communication equipment that is not interoperable. As a result, communications between medical units and between the different levels of care (e.g., from aeromedical evacuation units to field hospitals) was difficult. Without a single system that all medical forces could use on a continuing basis, the reliability of information delivery never was certain. What impact these inconsistencies and shortfalls had on the casualty response mission is difficult to determine.

The Critical Interconnect

During combat, a well-planned and promptly executed casualty evacuation capability is crucial to the saving of lives. An important ingredient in this process is known as "medical regulation." Personnel trained as medical regulators implement the overall evacuation plan by matching the specific medical requirements of the injured with reported capabilities at medical treatment facilities, and then directing ambulance conveyances to them. Their control of casualty distribution is contingent on an intact, functioning medical regulating communications network.

Through continued communication with casualty receiving facilities, medical regulators ensure that individual facilities are not over- or underutilized. Logically, this entails ongoing communications with all casualty conveyance vehicles as well. Information collected by medical regulators includes the condition of the injured and their location, the capacity of treatment facilities to accept new patients, and the availability of specialized capabilities at specific treatment sites. Medical regulators also must appreciate the impact of casualty density and the effects of casualty surge rates on the capabilities of treatment facilities. When numerous geographically dispersed treatment facilities, some with variable workloads, are available, orderly medical regulation is essential.

Regrettably, during Desert Storm and Shield, the casualty regulating systems did not provide effective oversight of the evacuation and disposition of casualties. Communications problems were the greatest limitation. Troops on the battlefields, for example, could not communicate with ambulances. The radios used by medical regulators had an operating range of only 15 miles, whereas the corps area was about 250 miles deep and 100 miles wide. Evacuation ambulance units were operating with similar equipment, and because of distances, could not communicate with most regulators or hospitals. As a consequence, ambulance crews often took patients only to those hospitals whose locations they knew. Unfortunately, they were not always the ones best suited to the ailments of the patients. One air ambulance crew reported flying over enemy tanks and infantry while en route to a hospital. If it had been a "shooting war," the company might have lost all of its aircraft and crews, primarily because they were unable to receive directions for flying over friendly territory. Increased production of global positioning system (GPS) receivers allowed almost every type of weapon, platform, and vehicle access to GPS data, but delivery of this equipment to medical units was delayed, sporadic, and often incomplete.

To overcome the lack of effective communications equipment, the VII and XVIII Corps directed air ambulances to make only repeated round trip shuttle runs between a designated forward collection point and a dropoff point in the rear, adjacent to hospitals. A Navy medical officer with a Marine tank battalion described his situation: "The locations of higher echelon medical facilities were not even available at the battalion or division level." He also noted that "at the outset, medical evacuation communications procedures were unclear to the tank battalion and division communications officers, as well as to Collecting and Clearing Company command personnel."

While moving forward into Iraq, some Army field hospitals were left for several days with no method of communication with either combat or evacuation units. The chief nurse of the Army 12th Evacuation Hospital reported that communication was nonexistent in Saudi Arabia helicopters had FM radios with a range of only 20 miles; field hospitals had AM radios that could not be used near a battlefield because they gave off traceable signals; and combat and command units had satellite equipment. These deficiencies prevented command units from communicating effectively with medical units, and incompatible radio systems prevented effective communications between helicopters and field hospitals.

Because there was no single system that all medical forces could use on a continuing basis, the reliability of information delivery was uncertain. Without communication capability, Army field hospitals and some Air Force facilities frequently had no warning of the quantity or type of casualties they were to receive. Obviously, this precluded planning for immediate patient care needs.

The lead service for joint theater medical regulating during Desert Shield and Desert Storm, the Air Force stated in a lessons learned report that communications problems resulted in 43% of the patients arriving at the wrong airports. Automated medical regulating systems were not standardized, interoperable, or available in all theaters. Each service had its own specifically designed computer systems, and their incompatibility severely limited the services' ability to communicate with each other during the war. Consequently, to coordinate patient regulating between the various theaters, each service had to rely on message traffic and stubby pencils-a process that quickly would become overwhelmed by a large number of casualties. If the projected numbers of casualties had occurred, the inability of medical regulators to manage the evacuation of patients could have led to the underuse of some hospitals and the overwhelming of others-a potentially tragic situation.

The process of tracking individual patients during evacuation also was flawed. As the tank battalion medical officer noted, "Our patients' locations could not be ascertained after their entry into the MEDEVAC system." Not only was this deficiency embarrassing, but it also gave the appearance of disorganization and poor management.

Most in-theater moves between two Army or two Navy facilities were made without informing the joint regulators; they only found out about patient movements by reading the daily bed count reports. As a result, the regulators were getting information after the fact, rather than controlling the movements. In essence, the joint regulators only regulated patients who were evacuated by Air Force fixed-wing aircraft.

Unfortunately, communications problems for combat and support units, including issues of interoperability and availability, are not new. They were identified during the Urgent Fury invasion of Grenada in 1983, during the 1990 Operation Just Cause contingency in Panama, and during previous joint staff exercises. Although DoD and the military services have made attempts to field interoperative and reliable equipment for combat units, no comparable effort has been made in support of medical units.

In 1986, the Secretary of Defense issued a policy for equipping the first to fight (deploy), regardless of component. The Army XVIII and VII Corps fit the first-to-fight criteria, but those medical units were not equipped with adequate communications equipment. In fact, when Desert Shield began in August 1990, adequate medical communication still was not available. The military services had not identified the need for such equipment, and when the requirements finally were identified, did not resource them. The tables of organization and equipment for Army contingency hospitals, for example, cite the need for AM and FM radios, but hospitals only infrequently received FM radios because combat units took priority.

Communications . . . from the Sea

Any future joint crisis-response strategy must take into account the multifaceted capability of sea-based forces. A Navy/Marine amphibious ready force may be employed to secure initial entry into an area, and to seize ports and airfields needed for follow-on forces. These types of opposed overwater assaults have the highest rates of wounding. During World War II, it was seven times the average rate for a division in combat, and more than twice the average rate for all other types of action, such as offensive breakthrough operations, assaults on fortified lines, or river crossings. Casualty rates as high as 25% of landing force personnel have been reported in certain actions. The requirement for a functional casualty regulating communications network in this setting should be self-evident.

In 1993, Navy Fleet Surgical Team Six attached for a six-month deployment with the USS Wasp (LHD-1) amphibious ready group, which conducted two separate operations within the littorals of Somalia. The team's final after-action report indicated that "communication over the designated UHF medical regulating frequencies was inadequate for the communication of patient status." During training and workups, intensive work had been done in an attempt to use the medical regulating channels for exercising communications concerning patient status within the amphibious ready group. Unfortunately, the report noted, the only ships capable of using the frequencies were the Wasp and the Nashville (LPD-13). The El Paso (LKA-117) and Barnstable County (LST-1179) did not have the proper equipment. The report continued, "On occasion, the Nashville had to come down from the circuit so the radio circuit could be utilized by the forces ashore. When the circuit was up between Wasp and Nashville, even with fine tuning the information passed was broken, garbled or distorted." In addition, the report noted, "The Marines, when deployed ashore with a radio tuned to the MED REG frequencies, were unable to establish communication with the primary casualty receiving ship."

The same report noted that communications between the Army field hospitals in Mogadishu and the Wasp "relied upon the presence of a forward command element located with the Combined Joint Task Force command headquarters.... Despite vigorous and intense work by the PHIBRON communications staff, direct communication was infrequent at best." To guarantee immediate and constant communication, the report recommended that the forward command element be maintained in Mogadishu with both a working frequency and an encryption compatible radio provided from the ship.

During Operation Tandem Thrust, a Pacific Command amphibious landing exercise conducted in March 1997, a secure unclassified web site was created, allowing field medical units rapidly to input medical casualty data, as well as patient locations in the evacuation chain. This provided up-to-the-minute data to any authorized internet access site around the world, but the operational security of this concept in wartime remains invalidated.

The Ultimate Reality

Historically, policies for developing a medical communications network management capability have foundered on the reef of military indifference, and problems will continue to surface until the Department of Defense and the services make a commitment to a joint, interoperable system that includes medical units. The words of a distinguished former Navy Surgeon General still ring true today: "A well-prepared, ready, and able military medical system conveys four powerful messages. It tells the American people that its leaders have prepared means to care for their sons and daughters who may be sent in harm's way; it tells our adversaries that we have a credible, sustainable fighting force; it tells our military commanders that we will sustain their forces; it tells our troops that we care. The last is most vital: in the absence of medical readiness we can have no assurance that our troops, the flesh-and-blood elements of our weapon systems, will retain the will to fight, which is the crucial factor in the equation for victory."



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