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II. Battlefield/Austere Environment Trauma Systems

Dr. Brandon Horne and Dr. Benjamin Kam, Lt Col, AF
A. Define levels of casualty care from point of injury to definitive care
I. Introduction
            A. Best example of levels of casualty care shown through military medical doctrine
                        1. levels established on system of echelons ranging from I (self and buddy care) to V (definitive and rehabilitative care)
                        2. progression through system allows patient access to progressively more advanced care, imaging, laboratory, blood bank, and rehabilitative capabilities
                        3. at each level there is opportunity to return to duty or transfer to higher level of care
            B. Military echelons should not be confused with American College of Surgeons hospital trauma level designations
II. Echelon I1
            A. Initial level of care – self-aid/buddy care/combat livesaver (injured fighter treats self or fellow soldier
            B. Includes combat medic and advanced capabilities of special forces medics, independent duty corpsmen, and pararescuemen
            C. May be a battalion aid station or United State Marine Corp (USMC) shock trauma platoon
                        1. at least one physician available to stabilize/treat and either evacuate or return patient to duty
                        2. no surgical capability
            D. In civilian sector, may be considered medical first responders or on-scene paramedics
III. Echelon II1
            A. Mobile facilities where enhanced care available
            B. Typically where first level of surgery available
            C. Blood products available (packed red blood cells or whole blood donation system from “walking blood bank”)
            D. Basic laboratory, X-ray, mental health, and dental services may be available
            E. Different branches all offer similar level II capability with variations/differences in manning, capacity, and nomenclature
                        1. Air Force – EMEDS (expeditionary medical support)
                        2. Army – Level II MTF (medical treatment facility/medical company)
                        3. Navy – CRTS (casualty receiving and treatment ships)
                        4. Navy – carrier battle group (typically support for the carrier and task force only; not designed to support ground operations)
                        5. USMC – surgical company
            F. Small, very portable surgical assets
                        1. Army FST (forward surgical team)
                                    a. 1 orthopedic surgeon and 3 general surgeons, anesthesia
                                    b. 2 operating room tables and maximum capability of 10 cases per day
                                    c. can be operational within 1 hour of arrival
                                    d. ground, rotary, or fixed wing portable
                                    e. doctrinally collocated with a medical company
                        2. Air Force MFST (mobile field surgical team)
                                    a. 5-person team to include orthopedic and general surgeon, anesthesia provider, emergency medicine physician, and OR nurse or technician
                                    b. capability includes 10 OR cases in 24-48 hours
                                    c. equipment portable in 5 backpacks
                                    d. typically collocated as part of EMEDS package
IV. Echelon III1
            A. Highest level of care within area of operations (AOR)
            B. Typical examples – hospitals in Balad in Iraq and Bagram in Afghanistan
            C. Hospitals (whether run by Army, Air Force or Navy) typically offer 25-1,000 beds (the latter in the case of Navy hospital ships)
                        1. full range of surgical, medical, laboratory, and radiology capability
                        2. blood banks offer multiple blood components with type-specific blood available
                        3. dental, physical therapy, mental health, as well as OB/Gyn and primary care available
V. Echelon IV1
            A. Encompasses definitive medical and surgical care outside combat zone or AOR, but not in continental United States (CONUS)
            B. Transition zone for patients with opportunity for convalescence and return to duty without redeployment to CONUS
            C. Typically, patients with severe injuries stop at this point for further stabilization prior to further evacuation to echelon V care
            D. Landstuhl Regional Medical Center is primary level IV facility during current conflict
VI. Echelon V1
            A. CONUS hospital with all resources typically expected at level 1 trauma center, including complete reconstructive and rehabilitative services
            B. In current conflict, time to transport to 5th level of care can be as soon as 24-48 hours from time of injury, depending on severity of injury and need for services not available in theater or at level IV facility
            C. Also cases of rapid transport (when resources available) for expectant patients in order to arrange for organ transplants and/or allow family to pay last respects prior to death (can also occur at level IV facility)
VII. see figure 12 
1. Emergency War Surgery, 3rd ed. Borden Institute, Walter Reed Army Medical Center. 2004.

2. Office of the Surgeon General, Dept. of the Army, USA. Textbook of Military Medicine, Part I, Volume 5, 1991, p. vx.
B. Demonstrate the skills needed to evaluate the host nation’s capabilities and apply the levels of care (what can be accomplished at each level)
I. Introduction
            A. During conflict or disaster, careful assessment must be accomplished as medical response initiated
            B. Assessment often performed simultaneously with deployment of medical assets because situation is often dynamic and constant strategic reassessment must be performed
            C. Host nation capabilities at each level, or echelon, of care vary greatly and may vary with geography within country itself
II. Four Generalized Scenarios for Most Combat/Disaster Areas1
            A. Safe urban setting
                        1. urban, developed environment
                        2. single, isolated event
                        3. casualty numbers relatively small compared to population of city
                        4. infrastructure intact: roads, emergency vehicles
                        5. health infrastructure intact: sophisticated hospitals
                        6. short evacuation time: route is secure
                        7. good communications
                        8. personnel: adequate number and quality of trained health staff
                        9. materials adequate
                        10. environment good: weather, daytime
                        11. final destination of wounded known
            B. Unsafe urban setting
                        1. low-income country: under-developed or destroyed urban setting
                        2. continuing danger: street fighting and bombardment in city
                        3. continuing and unpredictable casualty flow including massive influx of wounded
                        4. poor infrastructure: potholed roads, debris in streets
                        5. disrupted health infrastructure: hospitals damaged or looted
                        6. availability and length of evacuation uncertain or unknown
                        7. no or poor communications
                        8. minimum health personnel available
                        9. material re-supply uncertain, irregular, or nonexistent
                        10. environment poor: cold, wet, dark
                        11. final destination of wounded not always obvious
            C. Unsafe rural setting
                        1. low-income country: under-developed rural area neglected in peacetime
                        2. constant danger: ongoing combat, landmines
                        3. continuing and unpredictable casualty flow
                        4. poor infrastructure: badly maintained or no roads
                        5. poor health infrastructure: few health posts, even fewer district hospitals
                        6. availability and length of evacuation uncertain, long, and arduous
                        7. no or poor communications
                        8. minimum health personnel available
                        9. material re-supply uncertain, irregular, or non-existent
                        10. environment poor: extreme cold or heat, rainy season and dry season
                        11. final destination of wounded not always obvious
            D. Safe but austere setting
                        1. low-income country
                        2. continuing danger: on-going low-intensity warfare
                        3. discontinuous casualty flow, includes irregular mass evacuations
                        4. poor infrastructure: few good roads and few vehicles
                        5. minimum of health infrastructure: some rural clinics or health centers, fewer district hospitals
                        6. evacuation predictable but long and arduous
                        7. poor to moderate communications
                        8. minimum to moderate number of health personnel available
                        9. minimum material re-supply
                        10. environment harsh
                        11. final destination of wounded: distant by known
III. Key Questions for Each Topic1
            A. Geography/logistics
                        1. where is fighting taking place/where is disaster zone?
                        2. what demarcates safe areas from dangerous areas?
                        3. military activity, natural disaster, or major accident? (is health infrastructure intact?)
                        4. urban or rural setting
                        5. industrially-developed or low-income country: recourses available?
                        6. how are wounded transported from point of wounding to hospital?
                                    a. private means
                                    b. public transportation
                                    c. ambulance service
                                    d. military services: air, land, etc.
                        7. assessment of efficiency of evacuation system
                        8. which hospitals receive the wounded?
            B. Echelon I – first aid/buddy care
                        1. trained paramedics?
                        2. combat medics?
                        3. civilian first responders?
            C. Echelon II – forward medical assets
                        1. local medical assets?
                                    a. capability assessment?
                                    b. re-supply assessment?
                        2. mobile medical/surgical teams?
                                    a. insertion capability?
                                    b. evacuation capability?
            D. Echelon III – hospitals in country
                        1. capability assessment
                        2. damage assessment
                        3. remaining trained staffing
                        4. logistics re-supply
                        5. water and power
            E. Echelon IV – hospitals in country or supporting nations
                        1. evacuation capability
                        2. diplomatic visa
                        3. repatriation
            F. Echelon V – hospitals in country or other fully industrialized nation
                        1. evacuation capability
                        2. diplomatic visa
                        3. repatriation
1. Giannou C. War Surgery, vol. 1. International Committee of the Red Cross, ICRC, May 2010, annex 6a, pp 146-150.
C. Describe the methods to document patient care
I. Introduction
            A. Documentation may run gamut from complex interconnected computer systems, where data entered is available in and out of theater of operations, to handwritten notes on bandages
            B. Despite fast pace and sometimes overwhelming nature of mass casualty situations, patient care documentation essential at all levels of combat/disaster care to convey critical information to next health care team to ensure continued comprehensive multisystem trauma care
            C. At levels of care where administrative and information system support may be limited or non-existent, practice of making notes directly on patient’s dressing may be employed to prevent information loss during evacuation and transfer of care
                        1. critical information may be written directly on patient’s dressings to detail nature of wound, treatment given, timing of recommended next intervention or treatment
                        2. this documentation critical in environment where paper records may be lost or separated from patient
                        3. allows accepting providers at higher levels of care to better assess and triage incoming wounded without having to remove dressings or submit patient to unnecessary repeat surgical trauma because of lack of patient information (see figure 2)
II. Current Medical Systems Employed in Operation Iraqi Freedom and Operation 
     Enduring Freedom
            A. JPTA/MC4 (joint patient tracking application/medical communications for combat casualty care)1 
                        1. integrates, fields, and supports comprehensive medical information system (see figure 3)
                        2. enables lifelong electronic medical records, streamlined medical logistics, and enhanced situational awareness for Army tactical forces
            B. AHLTA (armed forces health longitudinal technology application)
                        1. standard electronic medical record system utilized by Department of Defense for non-deployed forces
                        2. has been forward deployed to as low as level II and III facilities to facilitate documentation of medical care (see figure 4)
            C. Written notes
                        1. handwritten notes on standard and non-standard forms still serve important function throughout deployed military setting
                        2. resistant to failures of communications equipment but still susceptible to loss by misplacement, illegible writing, or damage (see figure 5 and figure 6)
            D. JTTR (joint theater trauma registry)2
                        1. system serves as data collection tool for combat-related casualties
                        2. system provides:
                                    a. ongoing improvement of battlefield and military trauma care, prevention, and follow-up care
                                    b. more timely, actionable medical knowledge by generating critical outcome data reports within hours
                                    c. enables for efficient and effective medical research in a resource-constrained environment
                                    d. advances battlefield and military trauma care process improvement and quality assurance (see figure 7 and figure 8)

1. Joint patient tracking application/medical communications for combat casualty care.

2. Joint theater trauma registry.

D. Understand medical logistic system
I. Introduction
            A. Medical logistic system of battlefield and austere environment must be responsive to rapid changes  
                        1. operational tempo with frequent and unpredictable change in rate of resource consumption
                        2. environment where transportation is unreliable and often limited in capacity
            B. Hallmarks of effective medical logistic management
                        1. frugal use of resources
                        2. accurate anticipation of future demands
                        3. creativity required, as resources may need to be obtained from unusual sources using nonstandard delivery methods
II. U.S. National Incident Management System (NIMS)1 (resource management in organized framework with cascade of steps following major disaster incident)
            A. Identification of requirements
                        1. involves accurate identification of what and how much needed, where and when needed, and who will be receiving/using it
                        2. important for medical response teams to focus on types of durables and disposable medical supplies and remain flexible regarding specifics
                        3. ideally, logisticians should be available to provide technical expertise to select, order, and deliver needed supplies expeditiously
            B. Ordering and acquisition
                        1. includes either local acquisition or standardized ordering processes to get needed supplies into area
                        2. allocation of scarce resources also need to be made in this step
            C. Mobilization
                        1. includes mobilization of staff resources
                        2. must be formal accountability of these vital resources, whether personnel or stock/supplies
            D. Tracking and reporting
                        1. without stable system, accountability and tracking cannot be performed and resources may be wasted
                        2. reporting by end users necessary to prevent sending too much of wrong thing or not enough of what is really needed
            E. Recovery and demobilization
                        1. involves final disposition of all resources
                        2. includes facilities at incident site
            F. Reimbursement
                        1. recouping funds expended for incident-specific activities
                        2. validating costs against scope of work
                        3. finalizing mutual aid or assistance agreements
            G. Inventory
                        1. includes identification and typing of resources to allow standardization across response teams
                        2. allows resupply and deployment of personnel without worry that teams will find training or equipment incompatible
                        3. includes verification of currency and credentialing of professional staff
III. Military’s Blood System2
            A. Well-established program where blood components transported within theater of operations on regular schedule
            B. Given time and environment sensitive nature of blood products, there is pre-set level of products to be pre-positioned at various levels of casualty care system
            C. History
                        1. first operational frozen blood bank established in 1956 at Chelsea Naval Hospital in Boston, in part to determine practicality of frozen blood usage aboard Navy ships
                        2. in 1966, under Department of Defense direction, Navy Bureau of Medicine and Surgery established first frozen blood bank in combat zone at Navy Station Hospital, DaNang, Republic of South Vietnam
                                    a. over 7-month period, 465 previously frozen packed red blood cell (pRBC) units transfused to severely injured casualties
                                    b. both solo in and in combination with liquid pRBCs
                        3. in 1985, Department of Defense, under each branch surgeon general’s FDA license, froze 68,000 pRBC units
                                    a. units were pre-positioned throughout several geographic combatant commands (COCOMs)
                                    b. distributed in direct support of current and future military medical expeditionary/contingency operations
            D. FDA-approved frozen and deglycerolized red blood cells may be used at levels III and IV medical treatment facilities within COCOM theater of operation
            E. More recent emphasis to push blood products to lower levels so their use may occur earlier in patient care
1. National Incident Management System Handbook. U.S. Department of Homeland Security. Dec 2008, pp 31-43.
2. Joint Theater Trauma System Clinical Practice Guideline. Frozen and deglycerolized red blood cells, Nov 12, 2008.

The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, Department of Defense or the U.S. Government.

Materials and support for The Disaster Preparedness Toolbox is provided by Lt Col. Ky Kobayashi, MD and Col. Benjamin Kam, MD.