Combat Casualty Care on the Technology Curve
The implementation of a theater trauma system demonstrated numerous opportunities to improve the outcome of soldiers wounded on the battlefield. Medical equipment standardization in a maturing combat theater is essential. By Lieutenant Colonel Bruce C. Syvinski and Chief Warrant Officer,
W-4, John R. Elliott
Operational Environment
Counterinsurgency operations in the Iraqi theater has shown the lethality and destructiveness of the improvised explosive device, explosively formed projectile, suicide vest and indirect fire. The resulting casualties have generated the reengineering of tactical combat casualty care. Operation Iraqi Freedom represents the first protracted, large-scale, armed conflict since the advent of civilian trauma systems. Collaborative efforts between the joint military forces of the United States initiated development of a theater trauma system in May 2004. The implementation of a theater trauma system demonstrated numerous opportunities to improve the outcome of soldiers wounded on the battlefield. To date there have been over 29,911 wounded-in-action servicemembers. The medical task force in theater covenant is to provide the highest level and quality of health care to these that transit the continuum of care in Iraq. The objective is to ensure that the theater has the right clinician, at the right place, with the right equipment to conserve life and prevent suffering.
Medical forces during Desert Shield/Desert Storm were 14 percent of total forces, 3 percent in Operation Enduring Freedom and 4 percent in OIF during 2004. The small medical footprint demands that we not only provide efficacious and efficient health service support, but also demands that we synchronize our medical forces in a collaborative effort to resolve issues. Through the collective efforts of the Military Health System-Forward and use of state-of-the-art technology, conditions are set for a continual increase in hostile survivability as seen from 78.3 percent in 1991 to 90 percent in 2007.
The “fleet” of computed tomography (CT scanner) is the tool most used in OIF by doctors and clinicians to fully assess trauma injuries. Trauma surgeons, neurosurgeons, vascular surgeons, thoracic surgeons, ophthalmologists and many other specialists require modern diagnostic equipment such as the CT scanner to diagnose and treat battle injuries. Army combat support hospitals and the Air Force theater hospitals average 20 to 28 CT examinations per day when the systems are fully operational. A dual slice CT scanner exists at each facility, and 16 slice CT scanners are scheduled for final delivery by August 2008. The 16 slice can acquire images 10 times faster than the dual slice units. These units are an excellent tool where quickness and accuracy is vital for diagnosis and treatment of traumatic injuries. In the ITO, the CT enhances the capabilities of the Level III medical treatment facilities to rapidly diagnose and treat combat casualties. U.S. casualties often transit Level I care to Level IV definitive care within in 72 hours versus the historical model of 15 days. The CT assists in the prevention of loss of life by expediting diagnosis and treatment, especially during MASCAL situations and when casualties present with severe trauma due to combat operations. They also eliminate unnecessary exploratory surgery ruling out internal organ damage or internal bleeding due to their advanced diagnostic capabilities, saving OR usage for those patients most severely injured and requiring immediate surgery.
Task Force 62
Combat Health Care Support Model
Historically the medical task force has focused almost exclusively on delivering a robust and accessible set of Level II and III care and force health protection support since operations began here five years ago. Immediately upon assuming the mission, Colonel Patrick Sargent, Commander of 62d Medical Brigade, noted the task force is charged to deliver three essential dimensions of combat health support 1) provide world-class warrior health care to U.S. and Coalition forces, 2) protect the health of the U.S. and Coalition forces, and 3) support self-reliant Iraqi Security Forces and government of Iraq health care and public health systems. Since the transfer of authority, he discovered two areas of great concern that compelled him to develop a more systematic approach to delivering world-class medical care to our warriors.
First, the high rate of turnover of units led to gaps or seams in our services. Each newly arrived unit essentially re-invented their approach to executing the mission that their predecessors had refined during their tours. This resulted in an unacceptably high degree of variance in the quality and accessibility of services across the battlespace.
Additionally, despite five years of stable positioning, security and infrastructure within our bases there were no discernable standardization of health care support, clinical quality or medical equipment beyond what the units chose to adopt.
Standardization
What is standardization? It is the process of developing concepts, doctrines, procedures and designs to achieve and maintain the most effective levels of compatibility, interoperability, interchangeability and commonality in the fields of operations, administration and materiel. While there are some areas for which total interchangeability is needed (such as ammunition), it is obvious that many other areas of concern do not need to be totally interchangeable. When operating in a multination operations there are three levels of standardization that should be considered:
Counterinsurgency operations in the Iraqi theater has shown the lethality and destructiveness of the improvised explosive device, explosively formed projectile, suicide vest and indirect fire. The resulting casualties have generated the reengineering of tactical combat casualty care. Operation Iraqi Freedom represents the first protracted, large-scale, armed conflict since the advent of civilian trauma systems. Collaborative efforts between the joint military forces of the United States initiated development of a theater trauma system in May 2004. The implementation of a theater trauma system demonstrated numerous opportunities to improve the outcome of soldiers wounded on the battlefield. To date there have been over 29,911 wounded-in-action servicemembers. The medical task force in theater covenant is to provide the highest level and quality of health care to these that transit the continuum of care in Iraq. The objective is to ensure that the theater has the right clinician, at the right place, with the right equipment to conserve life and prevent suffering.
Medical forces during Desert Shield/Desert Storm were 14 percent of total forces, 3 percent in Operation Enduring Freedom and 4 percent in OIF during 2004. The small medical footprint demands that we not only provide efficacious and efficient health service support, but also demands that we synchronize our medical forces in a collaborative effort to resolve issues. Through the collective efforts of the Military Health System-Forward and use of state-of-the-art technology, conditions are set for a continual increase in hostile survivability as seen from 78.3 percent in 1991 to 90 percent in 2007.
The “fleet” of computed tomography (CT scanner) is the tool most used in OIF by doctors and clinicians to fully assess trauma injuries. Trauma surgeons, neurosurgeons, vascular surgeons, thoracic surgeons, ophthalmologists and many other specialists require modern diagnostic equipment such as the CT scanner to diagnose and treat battle injuries. Army combat support hospitals and the Air Force theater hospitals average 20 to 28 CT examinations per day when the systems are fully operational. A dual slice CT scanner exists at each facility, and 16 slice CT scanners are scheduled for final delivery by August 2008. The 16 slice can acquire images 10 times faster than the dual slice units. These units are an excellent tool where quickness and accuracy is vital for diagnosis and treatment of traumatic injuries. In the ITO, the CT enhances the capabilities of the Level III medical treatment facilities to rapidly diagnose and treat combat casualties. U.S. casualties often transit Level I care to Level IV definitive care within in 72 hours versus the historical model of 15 days. The CT assists in the prevention of loss of life by expediting diagnosis and treatment, especially during MASCAL situations and when casualties present with severe trauma due to combat operations. They also eliminate unnecessary exploratory surgery ruling out internal organ damage or internal bleeding due to their advanced diagnostic capabilities, saving OR usage for those patients most severely injured and requiring immediate surgery.
Task Force 62
Combat Health Care Support Model
Historically the medical task force has focused almost exclusively on delivering a robust and accessible set of Level II and III care and force health protection support since operations began here five years ago. Immediately upon assuming the mission, Colonel Patrick Sargent, Commander of 62d Medical Brigade, noted the task force is charged to deliver three essential dimensions of combat health support 1) provide world-class warrior health care to U.S. and Coalition forces, 2) protect the health of the U.S. and Coalition forces, and 3) support self-reliant Iraqi Security Forces and government of Iraq health care and public health systems. Since the transfer of authority, he discovered two areas of great concern that compelled him to develop a more systematic approach to delivering world-class medical care to our warriors.
First, the high rate of turnover of units led to gaps or seams in our services. Each newly arrived unit essentially re-invented their approach to executing the mission that their predecessors had refined during their tours. This resulted in an unacceptably high degree of variance in the quality and accessibility of services across the battlespace.
Additionally, despite five years of stable positioning, security and infrastructure within our bases there were no discernable standardization of health care support, clinical quality or medical equipment beyond what the units chose to adopt.
Standardization
What is standardization? It is the process of developing concepts, doctrines, procedures and designs to achieve and maintain the most effective levels of compatibility, interoperability, interchangeability and commonality in the fields of operations, administration and materiel. While there are some areas for which total interchangeability is needed (such as ammunition), it is obvious that many other areas of concern do not need to be totally interchangeable. When operating in a multination operations there are three levels of standardization that should be considered:
- Compatibility: The suitability of products, processes or services for use together under specific conditions to fulfill relevant requirements without causing unacceptable interaction.
- Interoperability: The ability of one product, process or service to be used in place of another to fulfill the same requirements.
- Commonality: The utilization of the same doctrine, procedures or equipment.
It is important to understand that for a piece of equipment, or for a force structure to operate effectively, different elements may need to be at differing levels of standardization. To achieve cost effectiveness it is important, when defining a requirement, to establish the minimum level which will achieve the aim. For example doctrine, terminology and legal aspects should be on the level of commonality, ammunition on the level of interchangeability, with communication and weapon systems on the interoperability level.
Medical Equipment Standardization
Management Tools
Joint Medical Technology Assessment Review Team (JMTART). As the USCENTCOM theater has matured and evolved in its combat sustainment operations, a large part of the medical mission has transitioned from expeditionary facilities into hardened temporary facilities. The baseline service medical assemblages and equipment items are not ideally suited to optimally support the bulk of the current patient caseload within theater. The extended length of theater operations and exposure to the harsh environmental conditions has also led to increased medical maintenance demands and a shortened life expectancy for some medical equipment. Individual and piece-meal service and unit replacement efforts, while bringing needed and enhanced medical care capabilities, have brought some new medical equipment items into the theater with incomplete or partial logistical support tails. This has resulted in equipment being non-mission capable for significant periods of time due to maintenance and repair parts challenges and placed unnecessary stress on the supply chain for emergency purchase of consumables for patient care.
USCENTCOM established a theater medical equipment life cycle management strategy June 28, 2007. This strategy outlined the requirement for each service component and JTF to establish complimentary life cycle equipment management programs to support ongoing theater Health Service Support operations and for the service components to integrate these programs with their services for regeneration.
The strategy also outlined the role and function of the USCENTCOM senior bio-medical maintenance technician (SBMMT) for the theater. Lastly, the strategy identified that, when appropriate, the SBMMT would initiate a request to USCENTCOM requesting a joint technology assessment (e.g., JMTART) be done for the purpose of establishing a standardized theater medical equipment formulary. JMTART is a unique USCENTCOM AOR concept based on practices that each service medical logistics agency utilizes to support their CONUS MTF operations in upgrading medical technology under the Defense Health Program.
The Army and USAMMA’s Technology Assessment and Requirements Analysis Program (TARA). The TARA program originated with a 1992 tasking by the Corporate Information Management group (later designated the Medical Functional Information Management group) to evaluate commercial capabilities for technology assessment and capital equipment asset management. The TARA consists of four components:
1) assessment of clinical processes, 2) assessment of requirements, 3) assessment of operations, and 4) assessment of equipment.
Comparison of U.S. Army TARA and USCENTCOM JMTART
Department of Defense Inspector General. Audit of medical equipment used to support operations in Iraq and Afghanistan. Objective: evaluate the internal controls over medical equipment used to support operations in Southwest Asia. Specifically, determine whether controls are in place for acquiring mission-essential medical equipment and whether the recording and reporting of medical equipment maintenance and disposition are accurate and complete.
Medical Task Force Medical Equipment Validation Board (MEVB). The MEVB is a medical equipment standardization tool for the medical task force commander. Comprised of the deputy commander for clinical services, the Task Force S4 medical logistics officer, the TF medical maintenance officer and commensurate direct reporting unit representatives. This board is guided by the following principles of medical equipment validation and standardization:
- Equipment should support a capability which is appropriate to the mission and role in theater.
- Equipment should represent a clear advantage to the patient and/or the units we support.
- Equipment should be sustainable within theater without creating overwhelming support problems.
- Acquire equipment that will be used by subsequent rotations, not just to support a one-time special skill.
- Equipment should be standardized within theater to the greatest extent possible.
Letter of Justification (LOJ)
A letter of justification is a document used to justify an equipment requirement to replace shortages as a result of equipment becoming condition code “F” (unserviceable-repairable) or “H” (unserviceable/uneconomically repairable), loss of equipment, or to replace an existing shortage (IE: 4 authorized, 3 on hand). The condition code will be verified by a maintenance officer and the documentation will be part of the LOJ process.
Operational Need Statement (ONS)
An operational needs statement is a document to justify a request for equipment that exceeds the unit’s current authorization (either as a new capability or an addition/increase to authorized on-hand quantities) i.e. MTOE, MEEL, MTOE Plus Formula. Units submit an ONS into the equipment common operating picture (ECOP) system. It is a request to document the urgent need for a materiel solution to correct a deficiency, improve a capability, or request HQDA to procure a new/emerging capability that enhances mission accomplishment.
ECOP is a SIPR-based Army start-to-finish database for 1) determining initial equipment authorizations for a named operation, 2) creating, submitting and monitoring ONS, and 3) requesting sourcing of pre-validated and validated equipment requirements. Effective September 1, 2006, all ONS began being submitted by all units via ECOP.
Maintaining the Fleet
On a maintenance perspective, the CT devices currently in theater have been available only 72 percent of the time. Part of the problem has been “dirty power” fed to the CT scanners. One initiative has been to provide every Level III MTF with 16 slice capability, providing clearer, three-dimensional pictures faster while exposing the patient to less radiation. The CT scanner up-time has increased to 94 percent in the Philips MX8000 CT scanners since a power protection system that provides voltage regulation, frequency stabilization and surge suppression has been put into service on each unit. It contains a remote emergency power off cable and wall-mounted box. This system protects against power spikes, swells and sags that are currently contributing to extended non-mission capable (NMC) time in theater. Power spikes and swells are the sole contributing factor as to why the CT at one of the MTFs was NMC for over 32 days straight. A second initiative is the introduction of 16 slice CT scanners to provide faster cycle time between scans, allowing more expeditious diagnosis and treatment of trauma patients.
The long-term solution as advocated by USAMMA and OSTG is to standardize CT capability with the Philips Brillance 16. The single and dual slice CT scanners (PQS 2000 and MX8000s) had a total average readiness rate of 66 percent from January to April 2007. The life expectancy for the PQS2000 is approximately 8 years. but because of the environmental conditions in Iraq and the fact that the CT scanners are used far more often than its intended use, life expectancy dropped to five years. Over a three-month period the Philips MX8000 CT scanners had a 42 percent full mission capable (FMC) rate versus the Philips Brillance 16 FMC rate of 98 percent.
Recommendations
Medical equipment standardization needs to be worked into theater planning early on as a means to manage the quality of health care delivered and maintain the technology curve.
Commanders, clinicians and senior leaders should understand the tools available to ensure medical equipment life cycle management and standardization to maintain the fleet of state-of-the-art medical equipment in a maturing combat theater of operations.
An SBMMT at the medical task force headquarters and CENTCOM play a pivotal roll into creating, implementing and maintaining a theater medical equipment standardization strategy. ♦