Battlefield Hospitals Reinvisioned
Written by Joan Michel
MMT 2009 Volume: 13 Issue: 8 (December)
Replacing the MASH unites of old are
forward surgical teams that use advanced
technology to capitalize on every second
of the crucial "golden hour."
Today, military planners are still committed to placing expert care near or in the area of combat operations, but over the past eight years, the change in military operations has rendered the mobile Army surgical hospital (MASH) medical response model obsolete. Today’s multifront and multidimensional conflict demands a new medical response.
“The MASH concept is pretty arcane compared to where we are today and where we are going in the future,” said Colonel Daniel Chapa, chief of the Medical Materiel & System Division at the U.S. Army Medical Department Center and School. “This [MASH] is not an example of what hospitalization is in the Army today. The last eight years of conflict have led us to realize we need to develop more modular and flexible hospitalization.”
Chapa said flexibility is needed so that a mobile hospital can shift focus quickly from combat operations support, which may involve treating severely injured patients, to stability operations support, which may involve more preventive care for civilian populations. Modularity, on the other hand, allows combat commanders to move specialized medical treatment and expertise closer to the casualty. Lessons learned from Iraq and Afghanistan operations are causing military leaders to rethink the fundamental medical care strategy that has been in place since World War II of providing basic yet highly mobile medical resources at the front lines of conflict and concentrating higher-fidelity medical expertise and equipment further away from combat operations.
In the medical community, the hour after injury is known as the “golden hour,” and it refers to the idea that a casualty’s survival is dependent on the care that he or she gets during the first 60 minutes after trauma. In the cases of severe trauma, such as that caused by explosive devices, early surgical intervention has been found to save lives. This idea is causing military planners to rethink traditional medical operations and to find ways to move specialized capability as close to the point of injury as possible.
FORWARD SURGICAL TEAMS
Under the older MASH model, a casualty was first tended by the battalion aide station then transported for more extensive care to a MASH unit. To get more surgical expertise to a patient sooner, the Army replaced the MASH model with a forward surgical team (FST), which consists of several surgeons performing field-expedient surgery to stabilize and prepare the patient for evacuation to a combat support hospital (CSH), where specialized medical care can take place. The patient is then returned to service or sent to a fixed hospital facility out of theater—in Germany, Spain or the United States—for further care and rehabilitation.
“The idea of hospitalization and use of surgical capability on the battlefield is driven by the ‘magic hour’ and being able to get patients to some type of surgical intervention early,” said Chapa. “Either we evacuate or we go to the patients.”
Chapa said the forward surgical teams, which can set up an operating room in one hour, are embedded within combat brigades and designed to work in concert with medical companies. According to Chapa, FSTs provide 72 hours of capability and can treat 10 to 12 surgical patients. If additional capability is needed at the FST level, personnel can rotate from a nearby combat support hospital.
At the same time that the Army deployed its first forward surgical team, the Navy and Marine Corps also developed a similar mobile surgical unit, the forward resuscitative surgical system (FRSS). This eight-person unit allowed 18 trauma patients to be treated over a 48-hour period within one hour of arrival at a location. Similar to the FSTs, patients are then transferred to a more comprehensive medical facility, such as a combat support hospital or a Navy fleet hospital that is a forwardly deployed mobile and modular medical facility. The Navy’s expeditionary medical facility is a smaller, more mobile version of a fleet hospital.
There are 26 combat support hospitals deployed now in Iraq and Afghanistan, each supported by approximately 300 personnel. Most CSHs use a 248-bed design, but, Chapa said, the types of trauma that medical personnel are seeing on the battlefield today are dictating a greater need for more intensive care on the front end, and the Army is continuing to refine its CSH design.
Chapa said the Army is planning greater use of the augmentation team concept as it evolves its combat medical strategy. In this model, specialized surgeons with specialized equipment provide added support as needed. A neurosurgeon and an oral maxillofacial surgeon are both examples of specific capabilities that may augment either FSTs or CSHs at times.
“There is tremendous flexibility and capability available in modular form,” said Chapa. “We need the right equipment and the right people assigned as we re-engineer our combat support hospital. We are finding that we need more intensive care capability and less intermediate care for combat injuries. We found that given the type of injuries, everyone needs a full-body CT scan when they come through, so now all CSHs are equipped with CT scanners.”
Chapa said they are moving to a 240-bed design and optimizing the level of care offered at CSHs in theater, which includes increasing the number of surgeons by 12 percent and bringing in new technology, both to improve the design and mobility of combat hospitals and to provide greater service to patients. A structural change they will make is to use airbeam technology in their tents. Airbeam technology uses air-filled tubes instead of conventional rigid frame structures as the skeleton for a tent. Currently with rigid-beam structure, a 32-foot section of tent takes 12 people 45 minutes to set up. Using airbeam technology, that same 32-foot tent will take four people 14 minutes, said Chapa.
SETTING UP SITES
Technology is also playing a major role in furthering the strategy to get more specialized and intensive care closer to the battlefield.
Steve Hawbecker, project manager for medical devices for the U.S. Army Medical Materiel Agency at Fort Detrick, Md., is working to bring new technologies into use in the military to improve trauma care. He cited the development of special surgical microscopes that can perform multiple studies, reducing the need for additional equipment, new operating room tools that can speed up the healing process, and noise-immune stethoscopes that cancel out background noise. One of the most encouraging technologies, and one that addresses the military’s objective to get intensive care to the injured faster, is “en route care,” currently an area of focus for Hawbecker’s organization.
Integrated Medical Systems (IMS), based in Signal Hill, Calif., developed the Life Support for Trauma and Transport (LSTAT) system. Essentially, IMS developed a stretcher with built-in intensive care equipment and capability. By integrating medical devices, data systems and utilities, medical personnel can support continuity of care while patients are being moved from one location to another.
Matthew Hanson, vice president of IMS and one of its cofounders, said that IMS’ “Star Trek” stretcher is in use throughout the services and has been adopted by 10 other countries. Built into the stretcher are a variety of state-of-the-art commercial medical devices from manufacturers, including a ventilator with on-board oxygen monitoring, suction unit, many types of physiological monitors and multiple infusion pumps, defibrillator and blood chemistry analysis capabilities, and a data and information management systems that allow patient data to be presented in a single display and transmitted over a network.
“This stretcher is for the 10 percent of patients who are really bad off, that is, trauma patients who need a wide variety of medical support,” Hanson said.
IMS was asked by the Defense Advanced Research Projects Agency to develop a suitcase or backpack version of the high-tech stretcher, which they recently delivered for testing by the Army. The Army Medical Department and the DoD’s Rapid Response Technology Office also contributed funding to the project. Called the LS-1, the FDA-cleared device has different intensive care capabilities compared to the LSTAT, and offers several improvements on the original design, including the ability to control all the devices from one monitor as well as remotely from a handheld device. Like the LSTAT, the LS-1 has the ability to store at least 72 hours of continuous data, which can be downloaded for patient care or medical research.
Hanson said the LS-1 device is designed for the “other 90 percent” of patients that do not need the complete capabilities of the LSTAT platform.
Another commercial firm has designed an interoperable series of stretchers and equipment focused on mobility, primarily for special events. North Coast Outfitters, based in Riverhead, N.Y., and headed by Charlie Darling, former consultant for the FRSS program, has developed a system of products and methods that allow a hospital facility to be erected and operational within one hour of arrival. The system, called the Medical Emergency Response Facility (MERF), is a 10-bed facility that includes the equipment needed to staff an operating room, ICU and triage/ treatment/holding facility. The MERF also comes with a protocol that allows for set-up by one person without specialized equipment. The MERF system is currently in testing, but company leaders see utilization by emergency responders in the civilian and military communities.
Power and water are both logistical issues for mobile hospitals. Hospital operations need to continue regardless of local resources. Pacific Technologies, based in Redmond, Wash., has developed the Coli-Analyzer: a mobile, self-contained water-quality test system that rapidly identifies bacterial contaminates of water resources in the field. Its primary function is to determine within eight to 10 hours that a water supply is clean and safe for use according to EPA regulatory guidelines.
It replaces a variety of current standard tests that require 18-48 hours. Moreover, when water is unsafe, the Coli-Analyzer can detect contamination earlier, potentially within minutes, and report the level of bacteria: the more severe the problem, the higher the risk, the faster the test. By providing a faster test that is conducted on-site, water purified in the field, or imported, can be qualified and released for hospital use sooner.
Finally, the Army teamed up last year with Florida International University to develop a mobile hospital that runs on solar power and can desalinate water for its own use. The program began last year with a $2.4 million grant and would result in technology, such as tent coverings made of sheets of solar cells, that could be used to power modern mobile hospitals for military and peacekeeping operations in remote parts of the world without access to reliable power and water. ♦