As a military medical student in my final year at the Uniformed Services University, it is humbling to reflect on the knowledge and skills I have earned, the professional relationships I have made, and the challenges that lay ahead in military medicine and naval health service support (NHSS) to operating forces. I have learned from medical providers who shaped landmark medical capabilities in Iraq, Afghanistan, Syria, and at sea. Learning from their experience and perspective, I better understand the more pressing operational medical gaps and needed solutions in supporting distributed maritime operations (DMO).
NHSS is challenged by DMO’s anticipated demands. The biggest gaps include suboptimal clinical skill opportunities for forward-deployed providers in care relevant to expeditionary operations, and new solutions for blood supply and medical logistics different from the linear lines of supply seen in Afghanistan and Iraq.
There are many ongoing efforts to close these gaps. To bolster these efforts, solutions may include the following: For providers who will be forward deployed, establish regular in-garrison rotations at civilian level-1 trauma medical centers to build and maintain experience treating trauma, burns, and providing critical care; second, engage in recurrent multiechelon exercises to improve blood supply and logistic solutions in DMO. Without these changes, Navy Medicine may risk deploying teams without proper clinical skills or contingent logistic solutions for adequate combat casualty care.
Expeditionary Provider Clinical Readiness
Like any other military occupational specialty, medical providers require a working knowledge of their craft. However, as the nation’s recent conflicts fade further into the past, numerous studies have shown a significant decrease in clinical experiences at military treatment facilities (MTFs) relevant to combat casualty and expeditionary medical care. Just as in the Pacific during World War II, in a large-scale conflict forward-deployed providers must care for large volumes of casualties. In the majority of the current MTFs, providers are not exposed to the clinical skills that will be needed at this level of casualty burden.
This clinical readiness gap, coupled with the attrition of experienced combat casualty care providers, is common during every interwar period but costs lives at the outset of a new war. Navy Medicine is trying to mitigate this problem gap by piloting embedding surgical teams into busy civilian level-1 trauma centers through military-civilian partnerships (MCP). It also aims to elevate the MTF trauma centers’ accreditation to receive more civilian patients with injuries relevant to combat casualty care (such as gunshot wounds). These efforts are positive but take considerable time to mature. Ideally, forward-deployed medical providers and critical wartime specialty personnel would be prioritized to rotate regularly at MCPs during their home garrison cycle. However, requirements to staff MTFs without established and funded rotations at MCPs significantly limits naval providers’ ability to consistently participate and maintain a working knowledge of clinical care relevant to expeditionary NHSS.
While this need applies to all expeditionary providers, independent duty corpsmen (IDC) receive limited clinical skill opportunities but are often the fleet providers at the tip of the spear leading medical departments on subsurface and smaller surface vessels. It is encouraging to see so many recent publications identifying IDCs as important to DMO. However, if IDCs are to succeed in recently proposed concepts, they need the right training and tools to do so.
A recent review of Navy combat and non-combat related maritime mass casualty events found that of 11 incidents, 7 were on naval vessels with an IDC as the most senior medical provider. In each maritime mass casualty incident, the majority of injured were evacuated to a higher level of care within hours, the two longest being within 36 hours. In a future DMO conflict, casualty holding times could be up to 96 hours or longer.
Blood Supply and Logistics in DMO
There are ongoing efforts focused on closing gaps in combat casualty care and logistics. They range from point-of-injury, such as the Marine Corps’ Valkyrie Emergency Whole Blood Transfusion program, to advanced damage control and definitive care through training and assessment of critical wartime specialties in the Clinical Readiness Program. However, most of these efforts are focused on a single isolated role of care at best (i.e., from point of injury to initial damage-control resuscitation) and do not account for the full constraints of DMO in rehearsal.
Concept development through recurrent exercises and experimentation is a promising way forward. Effective innovation should minimize fictitious elements whenever safe and possible, decentralize testing for diversity of ideas, and encourage risk and failure early and often within the mission’s intent. Stanford University Engineering and Product Design validates these ideas through studies and practice of rapid prototyping and testing for iterative improvement. The iterative nature lends to a lean, practical, and targeted solution to a problem. So, what does this look like when applied to NHSS armed with robust principles but challenged by today’s new technology and evolving combat operational constructs? How does the Navy develop real data for evidence-based solutions to blood supply and medical logistics across the Pacific?
Operation Firebreak was a first-of-its-kind three-day exercise in spring 2022 and recurs at the Naval Expeditionary Medical Training Institute (NEMTI) compound in Camp Pendleton, California. The exercise modeled an expeditionary advanced base operation (EABO) scenario. 2nd Battalion, 4th Marines practiced point-of-injury tactical combat casualty care and whole blood transfusion prior to transfer via ground evacuation to Role-I Combat Logistics Battalion 13 for damage-control resuscitation. This was followed by MV-22 Osprey simulator evacuation for damage-control surgery by the Role-II Fleet Surgical Team 3 on board a ship simulator. Final medical evacuation was executed to the Juliet Role-III expeditionary medical facility for in-theater critical care stabilization of post-surgical patients.
This exercise provides an early template of what “right” might look like for an iterative-based development and testing platform dedicated to NHSS challenges for EABO/DMO. This was a local grass-roots effort made possible through the persistence of NEMTI and regional leaders. Fictitious components were minimized, and all in-theater echelons of medical care were integrated. Realistic recommendations were made for what did and did not work in this EABO scenario.
These exercises can also identify new gaps and opportunities not easily determined from wargaming alone. For example, gaps associated with using unmanned technology in patient transport, or, for austere surgical or resuscitative teams, opportunities to be leaner and expand regenerative capabilities to decrease the operational footprint. While austere surgical teams are routinely deployed during crisis and contingency operations, these questions have yet to be adequately addressed through iterative process.
Providing NHSS for DMO is a substantial challenge. While intelligent and resourceful teams are working hard to make and keep Navy Medicine ready, leaders and medical planners should expand opportunities and establish precedent for regular provider rotations at level-1 trauma centers with MCPs during home garrison cycles. Regardless of how MTFs evolve as a source of clinical readiness in the future, MCPs are critical for combat-ready medical force.
Navy Medicine should also build on exercises such as Operation Firebreak to answer difficult prioritization questions, including how to optimally facilitate blood supply and other class-VIII logistics to distant and distributed units. Convening technologic experts, logisticians, clinicians, and appropriate unrestricted line personnel at these events would improve awareness of emerging capabilities. These actions can increase the number of ready expeditionary medical personnel and ensure they have a viable system for combat casualty care and logistics in EABO/DMO.