Rx for Contingency Medical Support

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We could lose the next war on the operat­ing table if we are unprepared to handle extensive combat casualties. Providing addi­tional medical equipment and better train­ing, such as this casualty-receiving exercise on board the Saipan (LHA-2), is part of the preventive medicine needed.

Combat casualty care is as integral to military opera­tions as fire support or logistics. It can determine the success or failure of any military undertaking. A military medical system dedicated to combat casualty support has two fundamental elements: patient manage­ment systems and facilities, and sources of trained contin­gency medical manpower.

Yet major gaps in contingency medical preparedness constitute today’s greatest challenge to military medicine— which historically has succeeded by mobilizing its re­sources well in advance of war. Whenever it did not antic­ipate approaching needs, it failed. Only once before have we faced the possibility of major conflict so ill-prepared. During the Civil War, the North and South together lost twice as many combatants (619,000) as we lost in World War II. The lack of medical preparation was certainly re­sponsible for the deaths of many who could have been saved.

In a 1983 speech (published in Military Medicine, April 1984, pp. 181-183), Dr. John F. Beary III, former Acting Assistant Secretary of Defense for Health Affairs, stated:

“Those ignorant of history are prone to assume that we need make no great effort in peacetime to achieve medical readiness; that we have always managed quite well by mobilizing our medical assets after conflict has begun. We know better. . . .

“We have predicted wartime requirements for seven thousand surgeons, of which only twenty-five hundred (35%) are now available. . . . The success of the war­time medical system is entirely dependent upon the capability to provide surgery very close to the place and time of wounding. Only then, after suitable stabiliza­tion, can evacuation safely be undertaken. . . . We are short 4,500 Reserve surgeons, which translates to 8 out of 10 soldiers not receiving surgical care in the combat zone.”

The Navy has undertaken initiatives to ensure the avail­ability of facilities for patient care, as well as a flexible system for integration of these assets, in ways responsive to both strategic and tactical needs. Yet, are we in a posi­tion to secure the manpower to operate the system? And can these personnel effectively carry out their mission?

Patient Management Systems/Facilities: In wartime, the systems and facilities for military patient care must be modified to respond to the demands of battle and to sup­port the operational mission. The ideal modification would be a single integrated system to provide, in the shortest possible time, the required care and treatment of the sick, wounded, and injured in a theater of operations.

A basic organizational characteristic of modern military medical service is the distribution of medical resources and capabilities in facilities at different locations for vari­ous functions. (See Figure 1.)

Dividing medical care into echelons is not a matter of rigid prescription. Any given echelon’s scope of function may be expanded or contracted, on sound indication. Varying types of wounds or illnesses may require bypass­ing some echelons for the sake of efficiency or expedi­ency. Aeromedical evacuation, when readily available, may allow bypassing various echelons. Certainly, the for­mal organizational structure may vary with regard to time, place, and the various requirements of different tactical situations.

The very nature of modern warfare may have an impact on traditional structure. Modem weaponry can strike quickly, often with little warning, and with great accu­racy. Concentrations of military and medical assets are no longer immune from guided-missile attack. The need for dispersion of forces and facilities may well change the classical patterns of health care, and the channels for evac­uation of the sick and wounded.

The combined nature of amphibious operations—using Navy and Marine Corps components—also requires an integration of their basic health care assets. (See Table 1.) Figure 2 shows the traditional method of integration, as determined by tactical requirements, transportation assets, and the ability of medical facilities to manage the volume of sick and wounded.

Strong attention was focused on the situation during a 1978 command post exercise, which revealed that there were no deployable Navy medical war reserve stocks available; that no hospital ships were available; and that no deployable full-care contingency hospitals existed in our strategic medical inventory. During World War II, in con­trast, 36 mobile, base, or fleet hospitals were deployed overseas. In addition, there were six permanent overseas hospitals, 12 hospital ships, and three hospital transports

in service. During the Korean War, two to four hospital ships were used in addition to fixed Communication Zone hospitals in Japan and Guam. In Vietnam, a 600-bed fleet hospital at Danang and two hospital ships were deployed, in addition to Communication Zone fixed facilities.

Increased emphasis on medical support and mobiliza­tion preparedness within the Navy has resulted in both short- and long-term projects dedicated to remedying these deficiencies. These encompass the Rapidly Deployable Medical Facility (RDMF) project, the upgrading of casu­alty receiving and treatment ships’ (CRTS) medical capa­bilities, hospital ship construction, and the fleet hospital project.

RDMF: It provides 1,000 beds with associated surgical and surgical support capabilities—an integral part of the U. S. Central Command’s deployment capability. During the first six months of 1983, the RDMF consisted of two 400-bed field hospitals and one 200-bed combat support hospital on loan from the Army. The Navy has now ac­quired equipment for four 250-bed reinforced hospital companies from the Marine Corps, in replacement. The RDMF-Navy is now in a prepositioned afloat depot.

CRTS: Additional medical equipment and supplies, configured as Mobile Medical Augmentation Readiness Team (MMART) blocks have been prepositioned on board amphibious assault ships (LHAs) and helicopter amphibi­ous assault ships (LPHs). With the augmentation of pre­identified health care personnel (MMART component spe­cialty teams), the planned medical capability of both classes of ships can be maximized.

Hospital Ships: Initial operating capabilities for two ships are anticipated. When activated and augmented by medical personnel and their support teams, a hospital ship represents a surgically intensive self-sustaining medical support system that is fully capable of providing medical care upon arrival within an amphibious objective area. It is anticipated that each ship will contain 12 surgical suites and provide 1,000 beds.

Without this mix of in-theater capabilities, more long- haul strategic evacuation will be required, and an increas­ing number of personnel will be evacuated from the thea­ter for non-disabling wounds simply because there are no medical skills and facilities close by for rapid retum-to- duty treatment.

Fleet Hospital Program: This is the final and largest phase of long-term planning. An early objective of the system was the acquisition of an 11,250-bed system, dis­tributed within 23 hospitals, which would be preposi­tioned in 250-, 500-, 750-, and 1,000-bed units. These would be self-contained, readily transportable, relocat­able, and quickly erected modular hospital units.

The 250- to 500-bed Combat Zone Fleet Hospitals

could be erected by their organic staff and be ready to receive casualties within two to four days. They will be Prepositioned on board ships, ashore within the U. S. con­tinental limits (CONUS), or overseas, for rapid contin­gency employment to provide acute casualty care. Casual­ties requiring more definitive care—and those evacuated from hospital ships—would be received at the 500- to 1,000-bed Communication Zone Fleet Hospitals. (See Figure 3.)

The fleet hospitals will provide a comprehensive mix of medical resources to meet requirements ranging from ‘flow through” mobile facilities in the rear of the combat zone, to more fixed Communication Zone facilities pro­viding definitive and convalescent care. Their modular design provides a high degree of flexibility. Variations in size to meet differing requirements are accomplished by the selective deletion or addition of functional facilities (e.g., when used as convalescent hospitals, more ward beds would be added, and for support closer to the combat zone, more operating rooms would be included). The 19 Projected fleet hospitals will be procured prior to mobili­zation and assembled into functional components at desig­nated CONUS and overseas depots.

Surge demand for medical care may arise from the tem­porary overtaxing of local medical facilities by a casualty load of unusual proportions, or by a “mass casualty situa­tion” wherein locally available medical facilities are taxed beyond their ability to supply ordinary individualized treatment and evacuation. In either event, large numbers ^are fed into the treatment and evacuation system. Recog­nizing the potential limitation of Air Force Medevac assets jn casualty surge scenarios, there are now programs that jdentify potential maritime assets capable of providing intra- and inter-theater sealift evacuation of patients who require limited medical care.

The U. S. military hospital system currently totals 18,000 beds, including 2,000 located overseas. These beds, and their staffing, are scaled for the care of a rela­tively healthy peacetime population and are inadequate for contingency purposes. Upon mobilization, military hospi­tal treatment capacity cannot be augmented rapidly. In re­sponse, in 1980, the Department of Defense (DoD) estab­lished the Civilian-Military Contingency Hospital System (CMCHS) to provide a backup for DoD medical facilities.

CMCHS, with the assistance of the Veterans Administra­tion (which has offered the use of its 31,000 beds), has developed a cooperative venture with the civilian hospitals in the nation.

CMCHS ensures that combat casualties being returned to the United States from an overseas conventional war­fare situation will have the type and level of care to meet their specific medical requirements. CMCHS is coordi­nated locally by major federal hospitals in urban areas. Participating hospitals agree to accept DoD patients in military emergencies, and to take part in training for mass casualty care. By April 1985, CMCHS comprised more than 65,000 hospital beds in 812 participating civilian general hospitals. (CMCHS will soon be amalgamated with the National Disaster Medical System, a system re­sponding to domestic needs for rapid medical support.)

Other sources of contingency medical support for sick and injured U. S. personnel may possibly be found within the health care networks of Allied and friendly nations.

Contingency Medical Manpower: In peacetime, medi­cal personnel are assigned to the Fleet Marine Force (FMF) at levels below mobilization allowance. Similarly, health care resources of individual ships are designed and provided primarily to support ships’ complements. There are also medical specialists in the fleet, including surgeons and nurse anesthetists who are assigned to carriers on a routine basis. The limitations of smaller ships can be off­set by resources available on larger ships, when there is proper and timely coordination.

If military contingencies require employment of Marine Corps units, FMF medical support requirements increase significantly. Similarly, to meet an anticipated increase in medical/dental support requirements for planned fleet op­erations or other developing contingencies, fleet medical/ dental resources may also require augmentation.

An important group of medical augmentation resources includes 68 surgical, surgical support, and other medical specialty teams, e.g., head and neck trauma teams, neuro-

Table 1 Basic Assets for Integrated Navy/Marine Corps Health Care in Combat

surgical teams, nursing teams, medical regulating teams, blood bank teams, preventive medicine teams, disaster relief teams, and special psychiatric rapid intervention teams. These rapid response teams—or MMARTs—and their equipment are available to augment existing medical facilities during peacetime or limited contingencies and are at all times prepared to assume their operational mis­sion in a smooth and orderly manner.

Surgical teams, surgical support teams, and specialty teams are trained and maintained in an available status, with their equipment and supplies, at various Navy hospi­tals and other Navy/Marine shore activities. Currently, surgical and surgical support teams are on board all under­way potential CRTSs (LHAs and LPHs). A number of surgical teams are continuously in a high-priority alert sta­tus (48 hours) in accordance with the declared overall mil­itary defense condition. Team members are designated from among the complement of medical/dental personnel of the sponsoring Navy hospitals. A contingency deploy­ment condition may well require MMART deployment, fleet medical augmentation, and large-scale FMF medical unit augmentation. Consequently, all active-duty medical department personnel must be available for immediate as­signment to operating forces.

Following large-scale contingency deployments, re­quirements for manpower at all levels of the Navy health care network increase significantly. This is especially true for anesthesiologists, general surgeons, orthopedic sur­geons, neurosurgeons, cardiothoracic surgeons, urological surgeons, oral surgeons, and general medical officers. Requirements for nurse anesthetists, operating room nurses, and enlisted operating room technicians are even more formidable. This strongly indicates that reserve as­sets should be included in total force planning, maximum mobilization and combat capability to support the global missions of the fleet and the Marine Corps.

There has been increased emphasis on the need to ex­pand, improve, and rely upon reserve assets—resulting in current, congressionally mandated growth in reserve strength, with substantial increases in the number of Se­lected Reserve billets. But can recruiters deliver the re­quested personnel? Creative and innovative recruiting mea­sures involve tasking recruiters by specialty. These recruiters must be able to appeal to modem professionals’ value systems that go beyond the usual financial incen­tives. Above all, health planners should give priority to providing an interesting, challenging, and pertinent re­serve military training program.

Another grave cpncem is the difficulty enlisted Selected Reservists have in getting enough training to qualify for Navy personnel subspecialty codes in hospital corps rates. Shortfalls in such ratings as operating room technician, laboratory technician (basic and advanced), x-ray techni­cian, pharmacy technician, preventive medicine techni-

cian, and medical service technician, call for creative and innovative action.

The Impact of Professional Training: Military medicine requires treatment of missile, chemical, radiation or other weapon injuries, or treatment for patients who are simply ill—often with tropical diseases no longer prevalent in this country. Although all patient care has its roots in the basic principles of regular medical and surgical practice, spe­cialized knowledge is required to adapt these principles to the varied requirements of the military. The importance of such knowledge for both health planners and practitioners is illustrated by the experiences of the military forces of the United Kingdom in the Persian Gulf between 1915 and 1918. British casualties included 28,621 deaths with a high proportion resulting from disease. Of the 15,000 evacuated to the United Kingdom, only 2,050 were wounded. Outbreaks of dysentery, cholera, malaria, and smallpox took a terrible toll, and high incidence of heat casualties at times almost became a decisive factor against the British Army.

The introduction of firearms into Europe in the 14th century presented a distinctly new problem to surgeons: the gunshot wound. The most noteworthy writings and innovations on this subject have come from military sur­geons. Until the mid- 19th century, the treatment of gun­shot wounds was largely restricted to wounds of the ex­tremities and to superficial wounds of the trunk, head, and neck. Wounds involving the body cavities and joints were regarded as inevitably fatal. During the early 19th century, amputation was the main treatment for gunshot wounds of the extremity. With the advent of the science of bacteriol­ogy, surgeons gained substantial control over wound in­fections. During the Korean and Vietnam wars, military surgeons developed great insights into the use of blood vessel grafts for preserving limbs.

Modern wars have seen increasing use of high-velocity small arms and automatic weapons, together with the re­introduction of the Claymore mine which, upon detona­tion, emits numerous spherical missiles at high velocity. Consequently, the number of high-velocity bullet wounds has dramatically increased. The high-velocity wound is totally different from the type of penetrating wounds that occur in the civilian environment. Experimentation has shown that the high-velocity missile energy is imparted along the track of the projectile. This disrupts tissues, rup­tures blood vessels and nerves, and may even fracture bones at distances removed from the missile’s path. The trained and alert military surgeon will realize that, al­though the wounds caused by large artillery, mortar, and mine fragments may appear to be more formidable, the energy imparted by smaller missiles of higher velocity may actually create far more serious and lethal injuries.

The modern military surgical team requires more pro­fessional skill and sound judgment than ever before. Ex­cluding the added problems of environmental adversity and debilitation from indigenous diseases which can affect Patients, such health care professionals must be trained to carry out lifesaving procedures upon blast, chemical, hum, cold, and missile injuries. They must overcome problems of hemorrhaging, shock, and severe infection to manage crush and blood vessel injuries, injuries of bones, joints, and peripheral nerves, as well as amputation inju­ries, and other life-threatening conditions.

The First United States Revision of the Emergency War Surgery NATO Handbook stated:

“Success in military medicine has been achieved de­spite the fact that, over the ages, many (sometimes most) of the lessons of the past, all learned by hard experience, ordinarily lie fallow between conflicts. Almost invariably they have had to be rediscovered, relearned by additional hard experience, and expanded and adapted by succeeding generations as new emer­gencies have arisen.”

The potential role of reserve health care personnel in providing medical support in combat zone health care may be both vital and significant. However, we cannot assume that these personnel, as well as portions of the active-duty community (which by its nature is being continually in­fused with new personnel), are fully trained and prepared to perform well in their roles.

Unfortunately, medical professionals from civilian training generally do not enter the reserve programs as fully trained combat surgical experts. Some health care personnel are trained in specialties that have little, if any, association with the treatment of trauma. Today, most health care personnel have never experienced combat, and have little or no experience with the injuries resulting from battle. Most general surgeons, anesthesiologists, and op­erating room nurses—trained in the civilian setting—are not experienced in immediate recognition of battlefield injuries. They are unaccustomed to treating heavily con­taminated battlefield injuries, or managing large numbers of casualties at one time. Certainly, there are some civilian trauma surgeons who treat gunshot wounds, stab wounds, and accident victims daily. Their preparedness for war is closer to the ideal. Nevertheless, few of these personnel are in reserve programs.

Commenting upon the qualifications of contemporary young surgeons to care for critically injured patients, a leading trauma expert wrote in the February 1985 Journal of Trauma (p. 176):

“Another study done by the American College of Sur­geons Committee on Trauma (unpublished) showed that 74.5% of the Chairmen of State and Provincial Committees on Trauma felt that surgeons recently ap­pointed to medical staffs were marginally trained in the care of trauma patients. What is the meaning of these studies? They imply that we are training a generation of surgeons who will be unfamiliar and unskilled in treat­ing the critically injured patient.”

In addressing the subject of preparation of civilian phy­sicians for combat casualty management, a former combat surgeon wrote in the February 1985 Journal of Trauma (pp. 156-159):

“Most such physicians are relatively untrained even in civilian trauma. If they have had surgical training, they might have rotated through a metropolitan trauma cen­ter for a few months, where the occasional ‘crunch’ consisted at most of three or four patients brought si­multaneously to a luxuriously staffed unit. Less than ten percent of such physicians would even have had this type of surgical background. . . . Military medical officers in a forward area may have to assume profes­sional responsibilities far beyond those to which they are accustomed in civilian practice. Many are not trained in traumatology. Others are accustomed to a civilian practice where specialists are available for crit­ical decisions. The military medical officer in a for­ward area is often on a semi-independent duty, where he must make clinical decisions far beyond his ordinary professional capacities. In some cases, this responsibil­ity critically erodes his effectiveness. He must be made aware of this potential problem in advance which, if appreciated, may sponsor intense professional study to meet these anticipated responsibilities.”

Proposal: A Tri-service Armed Forces Medical War College: There is a need for a major medical educational and training facility—operating at a postgraduate level— that is dedicated to the professional development of both the providers of health care and the managers of health services. A tri-service Armed Forces Medical War College is an answer. A curriculum in war wound management should occupy a major curricular segment in the Armed Forces Medical War College.

The current tri-service Combat Casualty Care Course (C4), though a reasonable and proper step in the right direction, is a most elementary and rudimentary introduc­tion to medical care in the combat setting. And although the civilian-oriented Advanced Trauma Life Support Course within the C4 curriculum is an excellent basic pre­paratory educational vehicle, it is hardly a qualifying mechanism for resolving management issues of battlefield maxillofacial (face and jaw) injuries, vascular (blood ves­sel) injuries, large-scale soft tissue and visceral (organ) injuries, as well as orthopedic (bone) and thoracic (chest) wounds.

The great repository of knowledge concerning the man­agement procedures in large-volume combat wounds lies with those surgeons who have previously functioned in a combat setting and learned the bitter lessons firsthand. Such surgeons should be recruited as special consultants to the Armed Forces Medical War College. Many of them