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from the resultant tragic personal consequences, - p, in war will be jeopardized, because the fighting t° jtjeS be depleted irreversibly. On the other hand, if caS^er>s reach a level of care beyond that required, manpo depleted. That depletion is potentially reversibe, nonetheless it could jeopardize a combat operati°n'
C3 means command, control, and communications to the men manning the combat information center of this ship. But C3 also means combat casualty care for the wounded sailor or marine. Medical planners must meld the two different C3s so that the military can both save lives and win wars.
Within the Navy and Marine Corps, command, control, and communications (C3) for combat casualty care have not evolved much beyond the methods used in Korea and Vietnam.1 The U. S. Army is developing field-level computer-based systems for the processing of medical information (the Theater Army Medical Management Information System [TAMMIS]), but these systems will apply only to ground warfare, and it may not be possible to use them for the delivery of care in battles at sea or during amphibious landings. The Navy and Marine Corps are becoming increasingly interested in making casualty care a part of C3, but, as of now, there is no coherent program to incorporate it into new systems designed to integrate naval combat operations.
There are possible explanations for this. In the view of some military medical planners, casualty care belongs strictly to the province of clinical practice; it is an extension of hospital or emergency medical care. Parochialism is not unique to the medical side of the house. Line planners and commanders may not give sufficient consideration to the medical aspects of a mission in either the short term or the long. What is often not sufficiently recognized is that combat casualty care is an integral part of military operations. As much as fire support or logistics, it can determine the success or failure of a military operation. The converse is, of course, also true: the success or failure of the medical mission depends to a large extent on its interaction with tactical and logistic elements.
Another reason for the apparent lack of progress in medical C3 may be that most medical planners are not familiar with the subject. C3 can be difficult for anyone to understand. Its components and nature are hard to define,
continuum” whose stages are by-passed w*l£efal opportunity or need to do so arises. In general, $e subordinate units transfer casualties to the next & level unit. For example, a number of battalion aid s ^pi- may send injured combatants to the same medica ^ pany. The goal is to save lives and limbs by pr°vicl1 necessary level of surgical care at the appropriate e -z, in the chain of care. A major result is, of course, ma ing the fighting force.
If casualties do not reach the echelon of care nee to save life or limb, they will die or be crippled an
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standard procedures and issue appropriate comniJI1^ Finally, the flow of information, commands, and
tffly
iiers;
between the commander at sea and the commander land. Medical facilities, personnel, and supplies fa* jjj„
in the methods and technology of C3 or of war
Command, Control, and Communications: A ^ . s^Sand
The command process that has control over this situation is the evacuation policy. It states how long a casualty may remain at a given echelon of care before being either returned to duty or evacuated. During combat, policy is determined by the number of wounded, beds available, medical personnel lost, supplies used, etc.—i.e., estimates of demand balanced against estimates of resources. An important variable that is not as easily measured or anticipated is the tactical situation. When a battalion of marines decides suddenly to move, it cannot take its wounded with it. Therefore, the evacuation policy must be fluid; it must be governed by the combat situation integrated with a view of the entire care system, and it must take into account many variables that are not easily estimated. Moreover, the evacuation policy must be coordinated, but carried out separately at each level of care.
During combat, casualty care is commanded and controlled by medical regulating, and it is in this area that the impact of a medical C3 system can be most strongly felt.2 Medical regulating controls the movement of casualties within and beyond a theater of operations, and, in the process, it matches medical needs with medical resources. Overall control is exercised by a medical regulating center, which coordinates the flow of casualties in such a way as to optimize the delivery of care. To be effective, it must obtain from subordinate medical regulating units at various echelons of care information on available beds, casualty load, staffing, etc. The medical regulating center also needs information on available transport and other potentially important variables, such as tides, weather, ship movements, changes in the tactical situation, and supply. In other words, many variables can affect the decision making, the validity of which depends on the type, the quality, and the quantity of information available. Having been provided with adequate information, the medical regulating officer must exercise judgment in the context of
ties requires good communication, and this is not al available in battle. |
Medical regulating officers exert command pr'nia ^ via others, for example, air and boat traffic contro even communications rely on networks regulated by , ers. Casualty care, therefore, must be closely coordi with other support operations. Moreover, since c°nJj0n casualty care is viewed increasingly as a shared ft>nC of the Army, Navy, and Air Force, the integrah01^ medical departments for the provision of casualty must be possible.
An amphibious operation has particular need f°r ^ gration. There must be coordination within and amonf^ sea, and land elements. Lines of command are cf
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similar division of resources and command respond ties. For this and other reasons, amphibious operation* ^ inherently different from, and perhaps more coriT ^ than, most Army operations. This is even more tr battles at sea.
By today’s C3 standards, medical regulating PraC{oCe- are crude; one current medical regulating standard p ^ dure compares command and control of casualty care ^ the radio dispatch of taxicabs. Yet, current doctrine , for the continuation of these methods, with comma f tion by voice over nonsecure networks and by P ^ reports, decision making aided by status boards and s rules-of-thumb, and little or no attention paid to
te11]
is defined as “an arrangement of personnel, facility systems for information acquisition, processing, atl
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directi '°n emP'°yed by a decision maker in planning, js nied'"’ contr°b'n8 operations.”3 An example of C3 aianas re8ulating, in which command and control
recr,,,; , ^ow °f casualties and allocate medical Sources during combat.
mentTn ni-!JOr ^orces drive the great interest and invest- the em ™ ltar^ U3: t*le changing tactical environment, Comm„er§enCe information science, and advances in culmin n'catlons technology. The past 20 or so years, Elands3 h*^ 'n example of the war in the Falkland strike a ' Seen emergence of weapons that can accuracy Tk ’ ^ten w'1^ little warning, and with great *n the d S'tuat'on has resulted in dramatic increases
father a^f 1^ t^le.war> one aspect of which is the need to ate deci"' '^CSt inf°rmation quickly, make the appropri- g°als AS1°n’ an<^ react in sufficient time to achieve set Nation jeCOn(^ asPect is that defense against the above- of force6 WeaPons may be best achieved by the dispersal d'nate d’ ma^'n8 i* more difficult to command and coor- the paceerS|°nn(d and resources during combat. Changes in t° affect ° War anc^ distribution of resources are likely Admiral ij°m)?at casualty care. As pointed out by Rear Siirgerv • ei3 Eiseman, U. S. Naval Reserve, Professor of y at the University of Colorado’s Medical Center:
and^i?1^ combinations of conventional bombs, shells, radar *1 ClS Can now infallibly be guided to targets by facts a 3S?’ ^Cat’ infrared, and other rays .... The fare h at Suc^ advances in the technology of wartary ave- suddenly changed the entire format of mili-
imrnnn6 u'Cf* Planning. No longer can we rely on nne helicopter pickup ....
°n land^ tr°^f> nor medical facility concentration, be it Concent°r • °at’ w'" be immune from missile attack, niilitarv f311011 .^orces’ a fundamental Napoleonic ably have*161 efficiency and effectiveness, will prob- guided 6t0 ■,6 sacrificed as providing too tempting a ashore i^81 e target. Dispersion, both afloat and rable dicnl^ inefficient’^ an unwanted, but inexo- \yhii Um W^6n °ffensive weapons dominate.”4
accurate conc'usions are unfortunately likely to be extremel'v PffSC • WeaPons are not infallible. Though ■ fhe seen fC|'Ve.’ have limitations.5 'aforniation'1 .riving force for C3 is the emergence of afrhne sche ,SC!ence and its associated technology. From S*s> comput U m^ t0- medical recordkeeping and diagno- aPpropriate ?rS Provide information that is timely, is in facilitate therno'mts, and is processed in such a way as to techniqUes , making of good decisions. Decision-aiding dynamic prQUC as. linear and nonlinear programming, techniqUes ^ramming, queueing, inventory, and search Military andre usec* increasingly in business, and in °f success 6 r^eiCa* applications, with different degrees PerUieatini; , ecisl°n'suPPort systems, for good or ill, are stratc » e n)1‘Utary, an extreme example being the factical dccis'C ^ense system.7 However, systems for PUcemcnt r.10ns’ such as maneuver control or the best evdoped r 3 IUC^° transmitter, either exist or are being *ven the existence of such systems, it is relatively easy to think of their application to combat casualty care: getting casualties to the appropriate level and type of care, optimal use of available transportation for the movement of casualties, inventory management, and resupply of field medical units (e.g., for blood), and deciding which are the best places to set up aid stations and field hospitals.
A final reason for the intense interest in C3 is the burgeoning field of communications, where two important developments are taking place: the use of communications satellites and the use of digital signal-processing. Communications satellites are a major factor because they make possible the use of line-of-sight communications for the transfer of information worldwide. The advantages are that higher frequencies (VHF and above) can be used, providing faster rates of data-transmission and more resistance to electronic warfare measures. Moreover, transmission for line-of-sight communications requires smaller and less stable antennas, even for communication via satellite: for example, the AN/URC 100 and 101 are said to provide ‘‘portable C3” in a manpack/portable radio that has satellite, line-of-sight, UHF/VHF, and AM/FM transmission for voice and data over 8,360 separate channels. Thus, data can be rapidly transmitted via satellite from field medical facilities, such as battalion aid stations and medical companies, to medical regulating centers.
The processing of information by digital computers in communication networks offers several advantages: the improved signal/noise range can reduce transmitting- power requirements; the rate of information transfer can be increased enormously; the virtually automatic encoding of information ensures secure communications; and transmissions employing synchronous, computer-controlled skipping between several frequencies can be used, which enhances the security of communications.
Another major advantage of digital communications is bussing, whereby many users, even if their functions are ostensibly different, can use the same network. In the ideal case, this occurs synchronously and so rapidly that a shared network is functionally a dedicated one. It should be noted that information from many sources passes on a single net and can be readily recoded for distribution to a variety of users. This could have important implications for combat casualty care. For example, certain tactical, logistic, and medical subcommands using the same network might exchange little information, yet a need to share information could arise: tactical users might want to estimate the number of casualties in a given area based on information from medical sources; medical users might want tactical updates on which to anticipate where casualties will be heaviest, or they might want to know when and where troop or supply transport vehicles would be available to carry casualties. Such redistribution gives a decision maker access to the information he needs, when he needs it. Through use of time-shared, bussed networks this can, at least technically, be easily accomplished. The crunch comes in designing the system in the first place. Questions as to who gets what information and when are often very difficult to answer.
There are some further issues with regard to C3 which
roc<*din„
November 1983
69
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movement of injured be controlled by an individua ^ scene (who might have more precise information) ^
superior far from the combat zone (who might have r natim
Funct,c
mander and his staff. This procedure, however, carefully examined; it might invite a superior to m in ways that are not appropriate.
. . ftheeffeCt
The essence of control is the determination 01 of command and the use of that information in apP ^yl-
Current medical regulating practices depend on communication by voice over nonsecure networks. If today’s sophisticated C3 were integrated into a combat casualty care plan, it could mean the difference between life and death. The wounded marine being evacuated from the front line then could bypass triage, facing page, and be sent directly to the proper medical facility.
DEPARTMENT OF DEFENSE
deserve examination. First, command has two major aspects: organization and direction. Organization defines the structure of command and identifies the principal decision makers; to a large extent, it defines the kind and amount of information that a given decision maker might need. Inadequate C3 can deprive decision makers of necessary information or provide them with more data than they can use. The latter is especially likely to be the case, given the large amounts of raw data handled at great speed by modem information-handling systems. Such problems are already cropping up in military C3 systems. Assistant Secretary of the Navy for Research, Engineering, and Systems Melvin Paisley notes:
“The most challenging command and control problem in the Navy today is managing information. Our ability to collect, process, and transport information at prodigious rates is great and continues to expand and already has exceeded our ability to assimilate and comprehend. . . . The commander [at sea] does not want and cannot
on1
or w;
ter overview of the situation)? Indeed, the very scope of control of casualty care may change. * - that were once dealt with in a piecemeal fashion ( ^3] regulating separate from supply, separate frorn. c0fi- care, etc.) may become integrated under a sing b1’
ways to make further command decisions. A key lS edge of what to measure and of how to use the & ^ ment obtained, and here lies perhaps the greatest 1 ^seful It is easy to generate information, but to general information is another matter. ^
“There is a danger in thinking that if we &at^aiyses more efficiently and are able to disseminate a
inhe ^1 Practlcaby instantaneous, we will have an -^better system- ^ the information we gather is all L ’ ^ ana|yses performed are ill-conceived,
fault 6 VC C*°ne 'S *enc^ weight °f technology to fied ^ reasonm8: the undesirable effects will be magni- Wart'rat"Cr l^an reduced. [Command], especially in
not may §° rapidly out of control. And we may not realize it.”9
of nreo631 obvious, is too often forgotten because
'^reasinT^'011w't*1 development of new and the Nav\f ^ P0Werful gadgetry. Recent discussions within ti°n svst ° 3 comPuter~based combat medical informa- are cases6™ a,K*’ Posslbly> the Army’s TAMMIS project and how ln ^°lnt' Attention to what we want to measure first prj0We Want t0 analyze information should be the Care of itselfS ^*e rnethod of measuring usually takes
Finals ^Srna" computers as part of “intelligent” C3 ter- decentraf8 SCVera* advantages that are realized through ScreeninpZatf0n contro'- One advantage is that, by Puters ca lrj.ormatlon before it enters the net, the com- thus imn11 •m*t t*le amount °f information transferred, advantaee°V,n^ eff"lciency of the system. Another because s h'S .'ncreased survivability of the system, control wh °rt^nate computers can be designed to assume en required. These factors, plus the recent availability of powerful, field-compatible microcomputers, have led to the adoption of microcomputers in C3. This trend is likely to continue, probably exponentially.
The time is not far off when such computers will be used in the field to gather information about casualties, then transmit it via satellite to other computers for such purposes as medical regulating, resupply of blood, tactical assessments, etc. Indeed, the Army is already testing a computer system that will enable personal “dog-tag” microchips, containing medical information, to be read and modified in the field. The information thus gathered will be used at the aid station for patient care and will be transmitted to other computers in a C3 network for other applications.
New communication links generate demand in much the same way that new highway systems encourage drivers to develop activities around the use of the highways.10 This has two consequences.
First, there is a need to define carefully which communications are part of C3. For example, administrative messages, unless vital to a mission, normally fall outside C3 and should be conveyed on a separate communications network. It is sometimes hard to decide in which category medical information belongs. In the past, lack of precision on this and related issues has relegated the medical department to the rear of most communications queues. This was
its associated technology. But is that movement
pub-
JCS
especially true in the Navy, where access is curtailed by the understandable precedence of tactical messages and by the limited availability of shipboard and field communication channels. However, it should be clear that information concerning numbers of combat casualties and messages related to providing them with definitive care are essential during a military operation.
Second, design and planning of C3 systems become difficult because communication networks that are adequate now may be overwhelmed in the near future. A “systems architecture” approach to development is required. This would allow planners to limit the demand for communications by structuring the relationship between communications and different command and control functions in the context of a “total system.” An obvious point is that the time to incorporate a new function is during a system’s design and development phase. Users added later may have difficulty in gaining access to the system, may need to adapt their methods to the system (rather than vice versa), and may not be added at all.
There is, of course, a negative viewpoint. Many people are justifiably concerned that, although useful in peacetime and in crises, modem C3 may not survive in actual combat. There are many potential vulnerabilities. Among these are the direct or electromagnetic pulse effects of nuclear blast, destruction by conventional weapons, destruction by sabotage or natural forces, and electronic warfare measures. As of now, the most vulnerable link is our satellite system, and the “hardening” of this link is a high priority in C3 programs.
An obvious question must be asked: If command and control become dependent on technology, what will happen if and when technology fails? There are few good answers to that question. Dependence on technology is not new. Had communications been lost, the methods of command and control for casualty care used in Korea and Vietnam would not have worked; nor would the current standard procedures. Other approaches are needed, and, clearly, not all our eggs should be put in the C3 basket. Nevertheless, an argument against applying C3 to casualty care based on fear of “technology dependence” is moot.
A related issue is fear of a “cognitive dependence” on C3 if we allow decision-support systems to assume too predominant a role. This is a real and important concern, and one that is common to all such applications, including medicine. Although some C3 systems must be made automatic, this is clearly not so with casualty care. It is important to point out that here the subject is decision-support, not decision making. In this sense, C3 could assist the managers of combat care in much the same way that personal computers assist business managers. Data-base management, spread-sheets, and word-processing generally facilitate, rather than inhibit, thought. Managers who are in the habit of using such tools would clearly be able to carry out their jobs without them; on the other hand, most managers would not be willing to give up the advantages these tools provide.
Conclusion: There appears to be a growing movement to bring casualty care into the mainstream of combat and
takin?
place too late? Many of the developments described in article put C3 for casualty care on the threshold. Use m combat theater of digitalization, decision-support syste satellite communications, and the like is just begtn^^ Nonetheless, development and deployment of C sys' j are going on with or without the participation of t planners. Clearly, combat casualty care should be par the system, not an add-on with fragmentary supPort,((|
A concerted, coherent program must be develops accomplish this goal. As a first step, Navy medical p ners must learn about C3 and its important issues, must be able to speak knowledgeably with other mj planners, present well-considered arguments, and di ^ with them the need to view casualty care as an aspect o that is of vital importance to success in combat.
Finally, the development of combat casualty care terns cannot be left entirely to the Army, which ts cemed almost exclusively with ground combat. No ; the Navy and Marine Corps will be able to adapt rnu the Army’s work. However, they must have a C' sys^t. that will support the delivery of casualty care during ^ ties at sea and during amphibious landings. It responsibility of Navy and Marine Corps medical pUn to see that this happens.
• 6320'.
’Commander in Chief, Atlantic Fleet, U. S. Navy. CinCLant Instniction (1983); Commander Amphibious Group, Eastern Pacific, and 1 Marine ous Force. Medical Regulating Standard Procedure. ComPhibGruEastPac ^ ^ tion 6320.1 and 1 MAFO P6320.1 (1979); U. S. Marine Corps.
Dental Support. FMFM 4-5 (Washington, D.C.: U. S. Government Office, 1980).
2 Ibid.
3 Joint Chiefs of Staff, Dictionary of Military and Associated Terms, (Washington, D.C.: Department of Defense, 1973).
4B. Eiseman, “Planning for Combat Casualty Care,” Report of the ^ava |1opo!' Research and Development Command and Office of Naval Research Wot Combat Casualty Care, 1976, pp. 49-56. g0.
5J. F. Dunnigan, How to Make War (New York: Morrow Publishers,
6F. T. deDombal, “Computers and the Surgeon: A Matter of Decision, tenP Annual, Vol. 11, pp. 33—57; H.B. Teates, “The Role of Decision Supp01*^ in Command and Control,” Signal, September 1982, pp. 45-49; T. MR. A. Russell, Introduction to Management Science, 2nd ed. (Englow°
NJ: Prentice-Hall, 1981).
7D. Ball, Can Nuclear War Be Controlled? Adelphi Papers No. 169 (E°n International Institute for Strategic Studies, 1981). , ■ al< ^
8M. Paisley, “U. S. Navy Strategic and Tactical C3I for the 80’s,” S'$n tember 1982, pp. 15-25. gig*^
9J. V. Henderson, “The Importance of Operational Definitions in the V fystim Combat Casualty Medical Information System,” Journal of Medica ■ 1983, Vol. 7, pp. 413-426. ^
10A Guide to U. S. Navy Command, Control, and Communications, De nical Information Center, Technical Document 247 (Alexandria, VA- Logistics Agency, Cameron Station, 1979).
Commander Henderson entered the Navy in 1962, serving three y lit a member of Underwater Demolition Team 22. Following returned to college and attended medical school on a Navy sen After completing his internship at Bethesda Naval Hospital an ^ th£ as a Submarine and Diving Medical Officer, he was assigne ^ Naval Submarine Medical Research Laboratory at Submarine t> sys- London. There, he worked to develop a computer-aided diagn ^ tern (now undergoing seatrials) for use by hospital corpsmen 0cliC submarines. Under Navy sponsorship, Commander Henderson ^ rently attending Yale University, where he is completing medicine residency and pursuing a PhD in Epidemiology. His tion topic is combat casualty care.