FUNDAMENTALS OF MILITARY MEDICINE

The Coat of Arms
1818
Medical Department of the Army

A 1976 etching by Vassil Ekimov of an
original color print that appeared in
The Military Surgeon, Vol XLI, No 2, 1917

Textbooks of Military Medicine

Published by the

Office of The Surgeon General
Borden Institute
US Army Medical Department Center and School Health
Readiness Center of Excellence
Fort Sam Houston, Texas

Edward A. Lindeke
Colonel (Retired), MS, US Army
Director, Borden Institute

The TMM Series

Published Textbooks

Medical Consequences of Nuclear Warfare (1989)

Conventional Warfare: Ballistic, Blast, and Burn Injuries (1991)

Occupational Health: The Soldier and the Industrial Base (1993)

Military Dermatology (1994)

Military Psychiatry: Preparing in Peace for War (1994)

Anesthesia and Perioperative Care of the Combat Casualty (1995)

War Psychiatry (1995)

Medical Aspects of Chemical and Biological Warfare (1997)

Rehabilitation of the Injured Soldier, Volume 1 (1998)

Rehabilitation of the Injured Soldier, Volume 2 (1999)

Medical Aspects of Harsh Environments, Volume 1 (2002)

Medical Aspects of Harsh Environments, Volume 2 (2002)

Ophthalmic Care of the Combat Casualty (2003)

Military Medical Ethics, Volume 1 (2003)

Military Medical Ethics, Volume 2 (2003)

Military Preventive Medicine, Volume 1 (2003)

Military Preventive Medicine, Volume 2 (2005)

Recruit Medicine (2006)

Medical Aspects of Biological Warfare (2007)

Medical Aspects of Chemical Warfare (2008)

Care of the Combat Amputee (2009)

Combat and Operational Behavioral Health (2011)

Military Quantitative Physiology: Problems and Concepts in Military Operational Medicine (2012)

Medical Consequences of Radiological and Nuclear Weapons (2013)

Forensic and Ethical Issues in Military Behavioral Health (2014)

Combat Anesthesia: The First 24 Hours (2015)

Otolaryngology/Head and Neck Surgery Combat Casualty Care in Operation Iraqi Freedom and Operation Enduring Freedom (2015)

Medical Aspects of Biological Warfare (2018)

Military Veterinary Services (2019)

Occupational Health and the Service Member (2019)

Fundamentals of Military Medicine (2019)

A US Air Force HH-60G Pave Hawk, assigned to the 33rd Expeditionary Rescue Squadron, on the flightline before a training mission with a Guardian Angel team assigned to the 308th Expeditionary Rescue Squadron, Kandahar Airfield, Afghanistan, in support of Operations Freedom’s Sentinel and Resolute Support, March 13, 2018. The HH-60G is tasked to perform military operations, including civil search and rescue, medical evacuation, disaster response, and humanitarian assistance. US Air Force Photo by Tech. Sgt. Gregory Brook.

Reproduced from: https://www.dvidshub.net/image/4233511/33rd-expeditionary-rescue-squadron-conducts-training-mission-afghanistan.

FUNDAMENTALS OF MILITARY MEDICINE

Senior Editors

FRANCIS G. O’CONNOR, MD, MPH
Colonel (Retired), Medical Corps, US Army
Professor, Department of Military and Emergency Medicine
Formerly, Chairman and Professor of Military Science, Department of Military and Emergency Medicine
Uniformed Services University of the Health Sciences

ERIC B. SCHOOMAKER, MD, PHD
Lieutenant General (Retired), Medical Corps, US Army
Professor, Department of Military and Emergency Medicine
Uniformed Services University of the Health Sciences
Formerly, Surgeon General, US Army, and Commanding General, US Army Medical Command

DALE C. SMITH, PHD
Professor of Military Medicine and History
Uniformed Services University of the Health Sciences

Office of The Surgeon General
Borden Institute
US Army Medical Department Center and School
Health Readiness Center of Excellence
Fort Sam Houston, Texas

2019

Editorial Staff:

Joan Redding
Senior Production Editor

Lisa O’Brien
Volume Editor

Douglas Wise
Senior Layout Editor

Venetia Valiga
Illustrator

Robert Dredden
Layout Editor and Illustrator

This volume was prepared for military medical educational use. The focus of the information is to foster discussion that may form the basis of doctrine and policy. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Dosage Selection:

The authors and publisher have made every effort to ensure the accuracy of dosages cited herein. However, it is the responsibility of every practitioner to consult appropriate information sources to ascertain correct dosages for each clinical situation, especially for new or unfamiliar drugs and procedures. The authors, editors, publisher, and the Department of Defense cannot be held responsible for any errors found in this book.

Use of Trade or Brand Names:

Use of trade or brand names in this publication is for illustrative purposes only and does not imply endorsement by the Department of Defense.

Neutral Language:

Unless this publication states otherwise, masculine nouns and pronouns do not refer exclusively to men.

CERTAIN PARTS OF THIS PUBLICATION PERTAIN TO COPYRIGHT RESTRICTIONS. ALL RIGHTS RESERVED.

NO COPYRIGHTED PARTS OF THIS PUBLICATION MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM OR BY ANY MEANS, ELECTRONIC OR MECHANICAL (INCLUDING PHOTOCOPY, RECORDING, OR ANY INFORMATION STORAGE AND RETRIEVAL SYSTEM), WITHOUT PERMISSION IN WRITING FROM THE PUBLISHER OR COPYRIGHT OWNER.

Published by the Office of The Surgeon General

Borden Institute

US Army Medical Department Center and School

Health Readiness Center of Excellence

Fort Sam Houston, Texas

Library of Congress Cataloging-in-Publication Data

Names: O’Connor, Francis G., editor. | Schoomaker, Eric B., editor. | Smith, Dale C., editor. | Borden Institute (U.S.), issuing body.

Title: Fundamentals of military medicine / senior editors, Francis G. O’Connor, MD, MPH Colonel (Retired), Medical Corps, US Army Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences ; Eric B. Schoomaker, MD, PhD, Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, formerly, Surgeon General, US Army, and Commanding General, US Army Medical Command ; Dale C. Smith, PhD, Professor of Military Medicine and History Uniformed Services University of the Health Sciences, Office of The Surgeon General ; Borden Institute, US Army Medical Department Center and School Health Readiness Center of Excellence, Fort Sam Houston, Texas.

Description: First edition. | Fort Sam Houston, Tex. : Office of The Surgeon General, Borden Institute, [2019] | Series: Textbooks of military medicine | Includes bibliographical references and index.

Identifiers: LCCN 2018058475 (print) | LCCN 2018059277 (ebook) | ISBN 9780160949944 (eb) | ISBN 9780160949951 (eb) | ISBN 9780160949968 (eb) | ISBN 9780160949609 (print)

Subjects: LCSH: Medicine, Military--United States--Textbooks. | United States--Armed Forces--Medical personnel--Handbooks, manuals, etc.

Classification: LCC RC971 (ebook) | LCC RC971 .F86 2019 (print) | DDC 616.9/8023--dc23

LC record available at https://lccn.loc.gov/2018058475

PRINTED IN THE UNITED STATES OF AMERICA

26, 25, 24, 23, 22, 21, 20, 19            5 4 3 2 1

Contents

Copyright

Contributors

Foreword

Preface

Introduction

Section I.    Military Leadership, Science, and Ethics

1.   The History of the Military Medical Officer
Dale C. Smith

2.   Roles and Responsibilities of the Military Medical Officer
Justin Woodson

3.   Officership and the Profession of Arms in the 21st Century
Isaiah Wilson III and Michael J. Meese

4.   Military Medical Leadership
Charles W. Callahan and Neil E. Grunberg

5.   Military Law and Ethics
Samuel J. Smith Jr

6.   The Law of Armed Conflict and Military Medicine
Michael H. Hoffman

7.   The National Security Structure
Jonathan Woodson

8.   The Medical Officer on the Commander’s Staff
Justin Woodson and Samual Sauer

9.   Military Medicine in the Operational and Strategic Context
Eric B. Schoomaker

10.   Tactical Field Skills for the Military Physician
Sean Mulvaney and Tony S. Kim

11.   Military Communication
Angela M. Yarnell, Cindy Dullea, and Neil E. Grunberg

12.   Enlisted Service Members
Althea Green

13.   Combined Health Services Support Operations
Martin C. Bricknell

Section II.   Operational Health Service Support

14.   Introduction to Health Service Support
James F. Schwartz, Megan C. Muller, and Conrad R. Wilmoski

15.   Health Information Systems
Michael J. Stone

16.   Force Health Protection
Mary T. Brueggemeyer

17.   Medical Logistics
David Sloniker and James F. Schwartz

18.   Joint Health Services Support: Operational Planning
James F. Schwartz, Megan C. Muller, and Conrad R. Wilmoski

Section III. Human Performance Optimization

19.   The Evolution of Human Performance Optimization and Total Force Fitness
Patricia A. Deuster, Francis G. O’Connor, and Travis K. Lunasco

20.   Physical Fitness: The Necessary Foundation
Brian R. Kupchak, Dana R. Nguyen, and Mark B. Stephens

21.   Performance Nutrition
Patricia A. Deuster and Jonathan Scott

22.   Environmental Extremes: Heat and Cold
Francis G. O’Connor, Richard A. Scheuring, and Patricia A. Deuster

23.   Environmental Extremes: Alternobaric
Richard A. Scheuring, William Rainey Johnson, Geoffrey E. Ciarlone, David Keyser, Naili Chen, and Francis G. O’Connor

24.   Environmental Extremes: Space
Richard A. Scheuring, Josef F. Schmid, and J.D. Polk

25.   Psychological Well-Being
Angela M. Yarnell, Erin S. Barry, and Neil E. Grunberg

26.   Sleep, Rest, and Recovery
Angela M. Yarnell, Matthew L. Lopresti, Omotola O. Lanlokun, and Thomas J. Balkin

27.   Musculoskeletal Injury Prevention
Timothy C. Gribbin, Kathryn Beutler; and Sarah J. de la Motte

28.   Spiritual Fitness and Performance
Matthew T. Stevens and Jeffrey E. Rhodes

29.   Family Readiness
Adam K. Saperstein, Teresa Combs, Ryan Landoll, and Regina P. Owen

30.   Medical Readiness
Christopher W. Bunt and Bonnie Sanchez

31.   Rehabilitation and Reintegration
Oluwaseyi Gbade-Alabi and Paul Pasquina

Section IV. Tactical Military Medicine in the Operational Environment

32.   Approach to the Emergency Patient
Tress Goodwin, Katherine Ellis, and Craig Goolsby

33.   Tactical Medicine
Lanny F. Littlejohn and Brendon G. Drew

34.   Mass Casualty Preparedness and Response
Gerard DeMers and John Wightman

35.   Chemical, Biological, Radiological, Nuclear, and Explosive Threats
Edward Lucci and Melissa Givens

36.   Acute Pain Management in the Deployed Environment
Chester “Trip” Buckenmaier III

37.   Combat and Operational Stress Control
James C. West and Christopher H. Warner

38.   Traumatic Brain Injury in the Military
Renee Pazdan, Theresa Lattimore, Edward Whitt, and Jamie Grimes

39.   Casualty Transport and Evacuation
Chetan U. Kharod, Brenna M. Shackelford, and Robert L. Mabry

40.   Preventive Medicine in the Deployed Environment
Lucas A. Johnson and Shawn M. Garcia

Epilogue

Abbreviations and Acronyms

Index

Contributors

THOMAS J. BALKIN, PHD

Fellow, ORISE Knowledge Preservation Program, Behavioral Biology Branch, Center for Military Psychiatry & Neuroscience, Walter Reed Army Institute of Research, Forest Glen, Maryland

ERIN S. BARRY, MS

Research Assistant Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

KATHRYN BEUTLER, BS

Research Assistant, Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland

MARTIN C. BRICKNELL, MD, PHD

Lieutenant General, Surgeon General, Headquarters Joint Medical Group, Coltman House, Defence Medical Services (Whittington), Tamworth Road, Lichfield, Staffordshire; Professor of Conflict and Health, Conflict and Health Research Group, King’s Centre for Global Health, Kings College, London, United Kingdom

MARY T. BRUEGGEMEYER, MD, MPH

Colonel, Medical Corps, US Air Force; Assistant Professor of Preventive Medicine and Biostatistics and Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

CHESTER “TRIP” BUCKENMAIER III, MD

Colonel (Retired), Medical Corps, US Army; Professor of Anesthesiology, Department of Military and Emergency Medicine, Uniformed Services University, Rockville, Maryland

CHRISTOPHER W. BUNT, MD

Lieutenant Colonel, US Air Force Reserves, Medical Corps, Associate Professor, Department of Family Medicine, Medical University of South Carolina, Charleston, South Carolina

CHARLES W. CALLAHAN, DO

Colonel (Retired), Medical Corps, US Army; Professor of Pediatrics, Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Vice President, Population Health, University of Maryland Medical Center, Baltimore, Maryland

NAILI CHEN, DO, MPH, MASC

Colonel, Medical Corps, US Air Force; Assistant Professor, Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

GEOFFREY E. CIARLONE, PHD

Lieutenant, Medical Service Corps, US Navy; Research Physiologist, Undersea Medicine Department, Naval Medical Research Center, Silver Spring, Maryland

TERESA COMBS, PHD

Assistant Professor, Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland

SARAH J. DE LA MOTTE, PHD, MPH

Assistant Professor and Scientific Director, Injury Prevention Research Laboratory, Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland

GERARD DEMERS, DO, DHSC, MPH

Captain, Medical Corps, US Navy; Navy Medicine East EMS/Disaster, Medical Director, Prehospital and Disaster Medicine Specialty Leader, Department of Emergency Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland; Associate Professor, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

PATRICIA A. DEUSTER, PHD, MPH

Professor and Director, Consortium for Health and Military Performance (CHAMP), Uniformed Services University of the Health Sciences, Bethesda, Maryland

BRENDON G. DREW, DO

Commander, Medical Corps, US Navy; Chairman of Emergency Medicine, Naval Medical Center San Diego, San Diego, California

CINDY DULLEA, RN, MBA

Rear Admiral (Retired), Nurse Corps, US Navy Reserve; Chief Marketing Officer, Experian Health Inc, Franklin, Tennessee

KATHERINE ELLIS, MD

Major, Medical Corps, US Air Force; Medical Director, Malcolm Grow Medical Clinic Emergent Care Center, Joint Base Andrews, Maryland

SHAWN M. GARCIA, MD, MPH

Lieutenant Commander, Medical Corps, US Navy; Assistant Professor of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland

OLUWASEYI GBADE-ALABI, MD

Major, Medical Corps, US Army; Chief, Inpatient Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland

MELISSA GIVENS, MD, MPH

Colonel, Medical Corps, US Army; Associate Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

TRESS GOODWIN, MD

Assistant Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Attending Physician, Children’s National Health System, Washington, DC

CRAIG GOOLSBY, MD, MED

Associate Professor and Vice Chair, Education, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

ALTHEA GREEN, PHD

Command Sergeant Major, US Army (Retired); Director, Recruitment and Outreach, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

TIMOTHY C. GRIBBIN, MED

Research Associate, Injury Prevention Research Laboratory, Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland

JAMIE GRIMES, MD

Colonel, Medical Corps, US Army; Chair, Neurology Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland

NEIL E. GRUNBERG, PHD

Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

MICHAEL H. HOFFMAN, JD

Associate Professor, US Army Command and General Staff College; Assistant Professor, Uniformed Services University of the Health Science; Barden Education Center, Ft Belvoir, Virginia

LUCAS A. JOHNSON, MD, MTM&H

Lieutenant Commander, Medical Corps, US Navy; Assistant Professor of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland

WILLIAM RAINEY JOHNSON, MD

Lieutenant, Medical Corps, US Navy; Undersea Medical Officer, Undersea Medicine Department, Naval Medical Research Center, Silver Spring, Maryland

SHAWN F. KANE, MD

Colonel (Retired), Medical Corps, US Army; Dive Medical Officer, Master Flight Surgeon, former Commander, Special Warfare Medical Group (Airborne); Dean, Joint Special Operations Medical Training Center, Fort Bragg, North Carolina; Associate Professor, Department of Family Medicine, Uniformed Services University of the Health Sciences

ARTHUR L. KELLERMANN, MD, MPH

Dean, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

DAVID KEYSER, PHD

Program Director, Traumatic Injury Research Program; Assistant Professor, Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

CHETAN U. KHAROD, MD, MPH

Colonel (Retired), US Air Force, Medical Corps, Senior Flight Surgeon; Program Director, Military EMS & Disaster Medicine Fellowship, San Antonio Military Medical Center, Joint Base San Antonio–Fort Sam Houston, Texas

TONY S. KIM, MD

Colonel, Medical Corps, US Air Force; Assistant Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

BRIAN R. KUPCHAK, PHD

Lieutenant, Medical Service Corps, US Navy; Assistant Professor, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

RYAN LANDOLL, PHD

Major, United States Air Force, Biomedical Sciences Corps; and Assistant Professor, Department of Family Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

OMOTOLA O. LANLOKUN, BS

Research Intern, ORISE, Behavioral Biology Branch, Center for Military Psychiatry & Neuroscience, Walter Reed Army Institute of Research, Forest Glen, Maryland

THERESA LATTIMORE, MSN

Director, Army Traumatic Brain Injury Program, US Army Office of The Surgeon General, Falls Church, Virginia

MATTHEW L. LOPRESTI, PHD

Major, Medical Service Corps, US Army; Deputy Director, US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, Washington

LANNY F. LITTLEJOHN, MD

Commander, Medical Corps, US Navy; Command Surgeon, Naval Special Warfare Development Group, Dam Neck, Virginia Beach, Virginia

EDWARD LUCCI, MD

Colonel (Retired), Medical Corps, US Army; Chief, Department of Emergency Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland

TRAVIS K. LUNASCO, PSYD

Senior Operational Psychologist, Consortium for Health and Military Performance (CHAMP), Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

ROBERT L. MABRY, MD

Colonel, Medical Corps, US Army; Command Surgeon, Joint Special Operations Command, Fort Bragg, North Carolina

MICHAEL J. MEESE, PHD

Brigadier General (Retired), Professor, US Military Academy, US Army; Executive Vice President of American Armed Forces Mutual Aid Association, Fort Myer, Virginia

MEGAN C. MULLER

Major, Medical Service Corps, US Army; Executive Officer, 264th Medical Battalion, 32nd Medical Brigade, Joint Base San Antonio-Fort Sam Houston, Texas

SEAN MULVANEY, MD

Colonel (Retired), Medical Corps, US Army; Associate Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

DANA R. NGUYEN, MD

Lieutenant Colonel, Medical Corps, US Army; Assistant Professor, Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

FRANCIS G. O’CONNOR, MD, MPH

Colonel (Retired), Medical Corps, US Army; Professor and former Department Chair, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

REGINA P. OWEN, DNP

Major, Medical Corps, US Air Force; Mental Health Clinic Officer in Charge, Dover Air Force Base, Delaware

JAMES PALMA, MD, MPH

Commander, Medical Corps, US Navy; Associate Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

PAUL PASQUINA, MD

Professor and Chair, Department of Rehabilitation Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Chief, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland

RENEE PAZDAN, MD

Captain, US Public Health Service; Director of Traumatic Brain Injury, Warrior Recovery Center, Fort Carson, Colorado

J.D. POLK, DO

Chief Medical Officer, NASA Headquarters, Washington, DC

JEFFREY E. RHODES, MDIV, DMIN

Commander (Retired), US Navy; VA Mental Health and Chaplaincy Department, Durham, North Carolina

BONNIE SANCHEZ

Senior Master Sergeant, US Air Force; Air Force District of Washington Functional Manager, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, Maryland

ADAM K. SAPERSTEIN, MD

Commander, Medical Corps, United States Navy, and Associate Professor, Department of Family Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

SAMUAL SAUER, MD, MPH

Colonel (Retired), Medical Corps, US Army

RICHARD A. SCHEURING, DO, MS

Colonel, US Army Reserve Medical Corps; Associate Professor, Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

JOSEF F. SCHMID, MD

Major General, Medical Corps, US Air Force Reserve; NASA, Johnson Space Center, Houston, Texas

ERIC B. SCHOOMAKER, MD, PHD

Professor and Vice Chair, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; formerly, Surgeon General, US Army, and Commanding General, US Army Medical Command

JAMES F. SCHWARTZ, MHRM

Lieutenant Colonel (Retired), Medical Service Corps, US Army; Assistant Professor and Chief of Staff, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

JONATHAN M. SCOTT, PHD

Assistant Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Science, Bethesda, Maryland

BRENNA M. SHACKELFORD, MD

Consultant Emergency Physician, New Zealand

TRUEMAN W. SHARP, MD, MPH

Captain, Medical Corps, US Navy (Retired); Deputy Director, Office of Bioequivalence, Office of Generic Drugs, Center for Drug Evaluation and Research, Food and Drug Administration; past Chair, Department of Military and Emergency Medicine; Uniformed Services University of the Health Sciences, Bethesda, Maryland

DAVID SLONIKER, MSS, MBA

Colonel, Medical Service Corps, US Army; Commander, 6th Medical Logistics Management Center, Fort Detrick, Maryland

DALE C. SMITH, PHD

Professor of Military Medicine and History, Uniformed Services University of the Health Sciences, Bethesda, Maryland

SAMUEL J. SMITH JR, JD

Colonel (Retired), Judge Advocate General’s Corps, US Army; Deputy General Counsel, Uniformed Services University of the Health Sciences, Bethesda, Maryland

MARK B. STEPHENS, MD

Captain (Retired), US Navy; Professor of Family and Community Medicine, Penn State University, State College, Pennsylvania

MATTHEW T. STEVENS, MDIV

Commander, US Navy; Director, Pastoral Care Plans/Ops, Bureau of Medicine and Surgery, Falls Church, Virginia

MICHAEL J. STONE, MBA, MHA

Lieutenant Colonel, Medical Service Corps, US Air Force; Assistant Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

RICHARD W. THOMAS, MD, DDS

Major General (Retired), Medical Corps, US Army; President, Uniformed Services University of the Health Sciences, Bethesda, Maryland

CHRISTOPHER H. WARNER, MD

Colonel, US Army Medical Corps; Psychiatry Consultant to The US Army Surgeon General, USA MEDDAC-Fort Stewart, Fort Stewart, Georgia

JAMES C. WEST, MD

Captain, Medical Corps, US Navy; Assistant Professor of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland

EDWARD WHITT, MS

Master Sergeant (Retired), US Army; Senior Health Policy Analyst, Defense Health Agency, Falls Church, Virginia

JOHN WIGHTMAN, MD

Colonel, US Air Force, Medical Corps; formerly, Wing Surgeon, 24th Special Operations Wing, Air Force Special Operations Command, Hurlburt Field, Florida; Professor and Chair, Department of Military and Emergency Medicine, Uniformed Services University Bethesda, Maryland

CONRAD R. WILMOSKI, MHAP

Major, Medical Service Corps, US Army; Sustainment Branch, Concepts and Capabilities Division, Health Readiness Center of Excellence, Capability Development Integration Directorate, Joint Base San Antonio–Fort Sam Houston, Texas

ISAIAH WILSON III, PHD

Colonel (Retired), Aviation, US Army; Senior Lecturer of Global Affairs, Jackson Institute for Global Affairs, Yale University, New Haven, Connecticut

JONATHAN WOODSON, MD

Professor of Surgery, Department of Surgery, Boston University, Boston, Massachusetts; formerly, Assistant Secretary of Defense (Health Affairs)

JUSTIN WOODSON, MD, MPH

Colonel, Medical Corps, US Army; Associate Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland

ANGELA M. YARNELL, PHD

Major, Medical Service Corps, US Army; Research Psychologist, Behavioral Biology Branch, Center for Military Psychiatry Neuroscience Research, Walter Reed Army Institute of Research, Silver Spring, Maryland

Foreword

As he completed his final preparations to deploy the XVIIIth Airborne Corps headquarters to serve as the higher command in the latter part of Operation Iraqi Freedom, then-Lieutenant General Lloyd Austin was visited by the regional medical commander with responsibility for Fort Bragg, North Carolina, from which the corps was deploying. The regional commander had the combined responsibility for deploying some of his own medical soldiers to support the general’s units in Iraq; for ensuring that the XVIIIth Airborne Corps soldiers were medically and mentally fit to deploy; for caring for any deployed soldiers who were wounded, ill, or injured and evacuated back home; and for caring for XVIIIth Corps families left on installations and communities. They talked about many matters concerning his deploying soldiers and the families for which they shared many concerns. As they concluded their time together, the medical leader asked the warfighting general about what he, the medical leader, was responsible for that Lieutenant General Austin lost sleep over. The general, a thoughtful man of few words, destined later to become the Army Vice Chief of Staff and Commanding General, U.S. Central Command, paused and spoke slowly and eloquently:

The American fighting man and woman demonstrate extraordinary courage and complete dangerous tasks in defense of the nation. They kick down doors in the most dangerous neighborhoods in the world, prepared to confront an enemy intent on killing them. They do this because our warriors know that your medical soldiers are right behind them to save their lives, to safely carry them back to their homes, to give them the best chance of being restored to health and returning to their comrades or to life as a productive citizen. I worry that you medics will forget these responsibilities and the skills required to achieve this. If so, the warrior will pay the price.

This book is intended to pass on these lessons and to “never leave a fallen comrade.” Four years in the making, this is a first-of-its-kind textbook. It leverages the extraordinary scholarship of leading academics while tapping into the experience of some of the most senior and accomplished medical officers and enlisted professionals to have ever worn the uniform. While anyone with an interest in military medicine can learn from this textbook, it is intended for the new medical officer from any service in any medical, surgical, dental, nursing, administrative, veterinary, or other discipline. A product of the Department of Military and Emergency Medicine at the F. Edward Hébert School of Medicine in the Uniformed Services University of the Health Sciences, it has become the principal textbook for their military medical practice and leadership offerings.

As Army Surgeon General and sponsor for the Borden Institute, the publisher of this and many other volumes in military medicine, I am particularly proud of this unique book. The support offered by the editors and director of the Institute throughout the book’s development have been invaluable. While one cannot be certain that lessons will not be lost and that future medical officers will not be sent in harm’s way without the education and training that they require, the authors, editors and publisher of The Fundamentals of Military Medicine and I have done all in our power to provide the doctrinal and experiential resources for highly effective, adaptable, and confident military medical leaders, planners, and practitioners. We strive to meet General Austin’s challenge by providing the most professional counsel to commanders in the field, fleet, and flight line and to extend to the next generation of warriors—on the ground, at sea and in the air—the protection and care they both expect and deserve.

Nadja Y. West, MD

Lieutenant General, U.S. Army

44th Army Surgeon General and Commanding General, U.S. Army Medical Command

Washington, DC

October 2018

Preface

Almost a half century ago, at the end of the Vietnam War, President Nixon and the US Congress agreed to end the draft and transition to an all-volunteer military and ready reserve. Compulsory service would be reserved for times when the nation’s survival was at risk. To achieve this goal, our military needed to make many changes. One significant change was the establishment of a “health professions scholarship program” to encourage medical students to commit to a minimum period of military service; another was the creation of a “Uniformed Services University of the Health Sciences” (USU) to serve as the leadership academy for military medicine. USU’s school of medicine, named for the visionary Louisiana congressman who worked for decades to create it, educates aspiring physicians in the unique aspects of military medical practice and leadership.

Today, the F. Edward Hébert School of Medicine at USU meets or exceeds every civilian standard for medical education. But “America’s medical school” does far more than educate doctors; it also prepares military medical officers for leadership and a career of national service. As the 21st century began, USU’s faculty, along with many others involved in American medical education, recognized that steady expansion of the knowledge base undergirding both the practice of medicine and techniques of adult education mandated a major overhaul of the curriculum. As a result, USU undertook a major redesign of the way we educate medical students to practice medicine and become high-performing military medical officers.

Today’s military medical practice and leadership curriculum relies heavily on self-directed and small-group-based learning. We continually reevaluate aspects of military medical practice to ensure our curriculum remains current with the latest lessons learned on battlefields and deployed settings abroad, and on bases and military treatment facilities inside the United States. Based on ongoing feedback from senior leadership of the armed services, military medical practitioners, and patients, four major themes of emphasis in the curriculum have emerged: (1) professionalism and leadership; (2) system of care (health service support) in the deployed environment; (3) the importance of force health protection (both physical and psycho-social) in deployed environments; and (4) the challenging nature of forward medical care.

Drawing on the insights and experience of hundreds of national faculty members as well as local members of USU’s Department of Military and Emergency Medicine, the authors of this textbook have developed and expanded these themes. The result is the first introductory English-language textbook in more than a century that compiles and codifies the knowledge required of military health professionals to support their unit commanders, protect the health of the force, and deliver high-quality care to those who go into harm’s way. Directors of military graduate medical education programs may also want to use this book to ensure their residents master the core concepts of military medical practice and leadership before they undertake their first deployment.

Modern medicine is a team sport, and military medicine is no exception. In deployed environments, effective healthcare requires more than physicians and surgeons. It needs the best efforts of physician assistants, advanced practice nurses, clinical psychologists, medics, corpsmen, medical technicians, and many others. For this reason, experts in a wide variety of military occupational specialties have contributed to this book. In addition to physicians and surgeons, they include nurses, lawyers, administrators, scientists, enlisted medical personnel, and line officers. This diversity is reflected in the growth of the USU’s mission since it was first chartered in 1972. At various points over the past 50 years, Congress has asked us to establish a graduate school of nursing to educate advanced practice nursing officers, a postgraduate dental college to strengthen dental readiness, and most recently, a college of allied health sciences to advance the education and career development of enlisted healthcare providers. As a result, USU has become more than the leadership academy for military medicine. USU is now a comprehensive hub for military health education and research; the topics covered in this textbook reflect this larger mission.

To remain current with evolving knowledge, this book will undoubtedly require future updates. However, military medicine also rests on enduring foundations. Many of the concepts outlined on this book’s pages are based on military traditions and principles devised by Major Jonathan Letterman during the American Civil War. Others can trace their origins to insights first described centuries, if not millennia, before.

We commend all who played a part in creating this remarkable book. The information it conveys will help military health professionals save lives, preserve fighting strength, and defend the national security of the United States.

Richard W. Thomas, MD, DDS

President, Uniformed Services University of the Health Sciences

Arthur L. Kellermann, MD, MPH

Dean, F. Edward Hébert School of Medicine—“America’s Medical School”
Uniformed Services University of the Health Sciences

Bethesda, Maryland

October 2018

Introduction

Historical Development of Military Medicine

Healthcare providers have been associated with armies (and later navies) for almost as long as there are historical records. In premodern times, these providers were usually trained in an apprentice system and cared for most patients in a society, both civilians and soldiers. It was a law of the state in ancient Egypt that medical care would be provided the soldier on campaign. During the Roman Empire, medici ordinarii accompanied legions across the known world. But in a very real way, military medicine, as it is understood in the 21st century, is a product of the wars of the 18th century and of the progress of medicine in the early modern era. Because 18th century leaders had armies and navies under different governmental organizations, military medicine (in the limited sense of land force) and naval medicine had related but distinct histories into the 20th century. With the development of air power, and with it aviation medicine, and the emergence of joint operations linking the military operations of ground, air, maritime, and space forces, military establishments began to be unified in a governmental and sometimes in a strategic sense. Since the Uniformed Services University’s first lectures on the subject in 1976, “military medicine” has had a joint meaning: it includes the knowledge, skills, and abilities needed to serve with the US military’s land forces, sea services, and aerospace components.

Despite the importance of “jointness,” it is a fact that even in the navies and air forces of the world, most personnel spend most of their days on land. Armies are typically larger and sicker than the more technologically oriented weapons system services, so much of the knowledge related to keeping a force fit and healthy is derived from land force military medicine. Therefore, the editors of this book decided that the best organizing principle for a basic textbook of military medicine was to consider land force medicine as the default position and describe differences from it as they arise; this approach has the secondary virtue of reflecting how the knowledge was developed.

Historically, practitioners accompanied armies for a variety of reasons. The most common was a broad humanitarianism—the belief that a soldier, when injured, deserved care. Such concerns motivated Isabella of Castile to supply ambulances and barber surgeons for the wounded of the crusading wars retaking the Iberian Peninsula in the 15th century. That mercenary companies, from Renaissance through early modern Europe, employed surgeons to tend to their own wounded suggests some understanding of the worth of troops (at least to themselves) and the potential effect of the availability of medical care on morale. That 15th century barber surgeons were employed to accompany highly trained Welsh archers by Henry V also reflected these concerns of humanitas and morale. Perhaps there was, additionally, a growing understanding of the importance of returning valuable trained soldiers to duty (if a leader was concerned with the supply of arrows, the historian may presume a concern with the supply of archers, but logistics of arrows were also much easier to manage than logistics of archers). These were the social motivations of the early modern military physicians, men who increasingly recognized they were doing something different from other practitioners. As merchants, explorers, and finally navies began to sail out of sight of land, the value of surgeons going to sea was also acknowledged. As voyages grew longer in the 17th century, surgeons in sea service began to study the knowledge of contemporary physicians, recognizing that more and more of their practice was shaped by disease—both its prevention and its treatment.

Disease prevention received increasing attention as the impact of professional combatant skills became more evident and public health policies were developed. In the 18th century a clear understanding emerged of military medicine as a military technology—the idea of keeping soldiers and sailors healthy and fit to increase their ability to fight. This new understanding became increasingly important as time passed, particularly as armies and navies became increasingly complex social institutions. The reader will discover that this text considers prevention, prophylaxis, and optimization at least as important to military medical practice as diagnosis and treatment. Therefore, exactly what military medicine includes is a fair question to ask of the editors.

Military Medicine Today

Military medicine, at its simplest, is the application of medical art and science in a military setting for the benefit of the military organization through optimal care of the combatant. However, this relatively broad definition has included, in the last 300 years of Western history, a wide variety of activities. The understanding of care for the soldier and care for the organization is frequently described as the “utilitarian union”; its very nature introduces the potential for the practitioner to be placed in an ethical posture of “dual agency”: what do you do when the good of the many is in tension with the good of the individual?

For some, military medicine is simply the practice of medicine, or more properly in today’s multi-professional settings, the delivery of healthcare in the military. The military might be seen as simply another social and cultural context for healthcare, except that military medicine also includes key areas often neglected or inadequately addressed because they are uncommon in civilian medicine. For instance, the care of personnel in different disease and threat environments is important for the morale of troops, so is a vital part of our complex military medical system. Military medicine can thus be considered a subdivision of preventive or occupational medicine having to do with the unique risks and predominant health problems associated with a specific, unusual, and dangerous occupation; it is the preservation of the lives and health of soldiers, sailors, airmen, and marines. It is important for humanitarian reasons (and so recruitment), morale, and ultimately, readiness and the accomplishment of the mission. The commitment to mission is not a function of medical professionalism but a key component of officership, or military professionalism, and it is frequently where the potential dual agency becomes a real issue.

The remaining medical aspects include the management and treatment of trauma and mass casualties in frequently austere field and ship environments; the humane clearing of the battlefield; vaccines and protection against exotic global pathogens—both manmade and naturally occurring; the unique psychological stressors of war; biodefense against chemical and nuclear weapons; facilitating return to duty; and the eventual return and reintegration home of valuable human resources. These approaches, which detail medical tasks, look at military medicine from the medical, or iatrocentric, point of view.

Military medicine is frequently considered from a medical point of view in 21st-century America primarily because society is usually focused on the contribution of scientifically inspired technical innovations for the wounded. Historically, on the other hand, military medicine was a subdivision of military activity and was predominantly seen as such until the middle of the 20th century. These two points of view—iatrocentric and military—contribute to different priorities being assigned, depending on the priorities of the commentator, to activities engaged in by the military medical departments.

Peacetime Mission

Military medicine has both two missions and two masters. In peacetime (and to some degree in war), military medicine is part of large healthcare industrial organizations, private and public. It delivers care to the active duty forces (and sometimes their family members) and retirees. This peacetime mission is expensive in manpower and materiel. It is governed by medical standards from the civilian community (licensure, hospital accreditation, malpractice law, etc). These standards are matters of law and regulation as well as (most importantly) social expectation. In Western countries today this mission of military medicine is part of what historians view as the welfare state, the obligation of government by its policy and actions to take care of its citizens.

Thus, military medicine must serve its civilian medical standards master with a full-time healthcare provision mission. Because military physicians are primarily trained in civilian institutions and, even more significantly, they are trained to civilian medical standards, this is the common medical orientation in the military health system. It is the only military component so completely tied to civilian standards and expectations.[1] This standard is largely a function of the 20th century because only for about 100 years have common civilian standards been widely accepted in Western society or have physicians trained to a common standard even been the primary providers of healthcare. Additionally, during the last century, the Western cultural assumption of “the right to healthcare” has become increasingly accepted. This social contract evolved along with the necessity of offering high-quality employer-provided healthcare benefits in the competitive marketplace of the all-volunteer military, a wage compensation reality resulting from wage freezes in World War II and competition at home for employees who were not fighting abroad. In this context, military culture has no social choice in the decision to provide access to care as a benefit of employment.

Wartime Mission

At the same time, military medicine must, like all other military components, plan and train for war. The wartime mission is quite different from the peacetime mission. Different standards apply—the standards of the military master. But military medicine must also be considered from the military point of view even in peacetime. Professor Robert Joy suggests that military medicine should be defined in the same way that all military activity is defined, and in the United States this is as related to the levels of war: the tactical, the operational, and the strategic.[2] This modern understanding of warfare, originated by Russian military thinkers, has profoundly influenced American and allied doctrinal development in the last 50 years. It is principally a land-based understanding, although naval and air forces can use it. For medicine, it fits the medical support of land-based operations very well.

The tactical level of military medicine is the hands-on application of medicine. It includes field sanitation, administration and inspection of preventive measures, direct point-of-injury care, and the evacuation of patients from the battlefield. The challenges of command and control of medical elements and personnel, implementation of tactical combat casualty care, deployment and execution of forward resuscitative surgery, and facilitation of return to duty typically occur at this level.

The operational level of military medicine, or operations above the division level, includes those functions in which medical department personnel offer highly specialized advice to the line command. It includes the planning and implementation of preventive medicine advice; the structure of medical logistics capability; and the determination of need for and placement of medical assets and resources, including forward surgical capability, blood products, and hospitals, given the battle plan and casualty estimates. It is usually described as the system of Health Service Support.

These medical matters are line responsibilities, and the advice of medical staff must be tailored to the overall theater plan. For example, modern medical science has developed vaccines against certain infectious diseases. The medical advisor can suggest that troops receive immunizations, but the decision to require immunization is a command decision. Similarly, for a given campaign, the application of modern medicine may require a certain number of hospitals and a particular mix of healthcare experts, but the decision to use limited lift capability to deploy medical assets is a command decision.

The operational level of military medicine, primarily the responsibility of line officers, requires a certain level of military medical knowledge on the part of all officers. Just as an infantry officer in command of a combined arms task force must know something of the capabilities and support requirements of artillery and armor, so must such a commander know something about military medicine. That being stated, line commanders at the operational level rely heavily on the advice and guidance of their special staff medical officers to assist in executing the medical plan in conjunction with the overall mission.

At the strategic level, military medicine is concerned with preparedness and joint coordination of care for casualties—combat wounded, as well as those with diseases and injuries other than those inflicted by the enemy. Issues of disease threat prediction, research and development of drugs and vaccines needed in the military, the national supply base for mobilization of health personnel, and planning to ensure medical industries can make available what the military might need in times of war all require advance thinking and activity. Again, some awareness of the military medical issues outside the medical establishment is essential because military medicine’s strategic resources come from the military resources of the nation, and care ultimately is transferred back to civilian or nonmilitary federal caregivers, such as the Veterans Health Administration.

The application of these land-based levels of war to naval and air forces and their medicine creates some peculiarities. In service with the fleet, command responsibility at a junior level is somewhat different. A company commander or platoon leader has command that, at least in the past times, has frequently been independent of his or her seniors. The department head or division head on a capital ship is not detached from the overall command in any significant way. Thus, in deployed activities, the front line medical support of naval forces at sea is more involved with the provision of advice, teaching, and inspection, and less involved with direct command responsibility of medical personnel than the regimental surgeon might be in service with Marines or the battalion and brigade surgeon with the Army.

For air forces, historically, most of the treated casualties and DNBI (disease and nonbattle injuries) patients were in forward bases and so fit the land model. Increasingly the technologies of air force weapon systems are allowing basing further from the fight. Like navies, air forces have fewer independent junior commands, which reduce tactical-level command experiences, but the unique role of the flight surgeon means there are more staff roles where medical findings (eg, not medically fit) are implemented by command authority (eg, do not fly).

Similarly, there are no straightforward equivalents to corps and above-corps activities in seagoing naval and aviation operations. The basic structure of task forces, battle groups, and fleets is much more flexible than the land-based system (although land doctrine is moving toward a more flexible capability).[3] The naval medical staff are, as a result, called upon to operate at a variety of levels, and in ocean-going naval operations, preserving the more traditional distinction of staff and command at all levels of medical activity is probably advantageous. However the service military medicine mission is described, it involves much more than providing excellent scientific care for a patient who comes to a fixed clinic or emergency room. No matter how capable the tactical expertise of individual physicians, nurses, or corpsmen, there are differences between the medicine practiced at Naval Medical Center, Portsmouth, and on the hospital ship Comfort, not to mention treatment facilities even more diverse.

The humanitarian motivation for democratic society’s provision of medical care impacts all three levels of military medical activity and its peacetime practices. However, this motivation is most obvious at the tactical and operational levels. At the tactical level, it demands good medicine in peace and war regardless of setting. At the operational level, it requires that those who go into harm’s way be protected from unnecessary risks, and that “the system” provides appropriate care to those who are injured. At least since the British public’s disgust over newspaper reports of conditions in the Crimea in 1854, military and political leaders have had to consider public expectations for the care of troops. Similarly, the issues of morale and return to duty are in the short run tactical and operational, but to be adequately staffed and prepared to address these issues requires strategic preparation. Force preservation efforts, medical logistics, casualty evacuation, en-route medical care, and other uniquely military concerns within military medicine are primarily seen at the operational and strategic levels. These issues are as much the concern of line officers as they are the province of the medical officer. They are seldom directly of concern to politicians and the public at large, unless, of course, they fail in execution; in this case they have profound impact on humanitarian and morale concerns.

Categories of Military Medical Activity

To understand the interrelations of these different missions and the roles of the different masters, it is possible to categorize military medical activity in yet another way: by what different personnel, at different times, need to know. In this approach, the activities of military medicine may be considered as (a) common military tasks, (b) medical science in a military setting, or (c) the military tasks requiring specialized medical knowledge. Common military tasks are those needed by all military personnel in a particular environment (field skills for the infantry, platform-specific knowledge such as damage control and fire-fighting on a naval vessel, etc). Military medicine is often practiced in unique and austere environments, and if practitioners cannot take care of themselves in such environments, they are virtually useless to the military unit.

The medical science in a military setting component is that portion of medical science and healthcare practice used exclusively or primarily in military deployments, whether on land, onboard ship, or on the flight line. It is a special part of peacetime medicine that is also a component of military medicine. For example, in Western society today, malaria is a disease seldom seen in civilian practice, yet it remains the most damaging disease in the world. When deployed, military personnel will possibly be exposed to infection, so knowledge about the prevention and treatment of malaria is an important medical skill for military physicians. Many other areas of prevention and treatment are also predominately of concern to the military, for example, high-velocity missile wounds, chemical casualties, and combat stress reactions. The medicine involved is part of the larger field of medical science, but the specifics are of little or no concern to civilian practitioners or even the drug and medical instrument industries.

Those parts of medicine included in military medicine vary with time and place depending on the changing nature of civilian practice. Malaria, to return to the original example, is an issue of military medicine for physicians in the US Army in the 21st century. It is not for a practitioner in today’s Indian army, and was not for the US Army in the mid-19th century; in these cases malaria is or was an integral part of civilian medicine. It is possible that, in this century, issues of biological attacks and chemical casualty treatment may move from the province of military medicine into general knowledge required by all civilian healthcare providers.

Finally, the military role that requires specialized knowledge is that which most often sets apart the military medical officer. It is the component used by the least number of medical practitioners at any given time; it is also the component that must be shared, at least to some extent, with line officers. This component includes the staff and command roles and operates at all levels of military activity—tactical, operational, and strategic. To illustrate the utilization of this component, we will consider again the strategic military medical effort to reduce malaria infection in troops. Most of those engaged in the study of malaria need to know nothing of the military. The knowledge they have of malaria as a disease is medical science in a military setting. The people responsible for initiating the project to reduce infection among troops (those who recognized the malaria threat as a threat to the military effectiveness of troops, a special staff function), and those individuals (often non-medical) who funded the research (a command decision), are a small initial group using a special knowledge for military purposes.

This group will commission a staff study on how malaria might be reduced. The staff will need to know a lot about malaria. It can presumably be treated more effectively than current therapy permits, so one arm of the program might be treatment research. Malaria is an infection, and at least theoretically a vaccine might be produced and administered to all troops at potential risk, so vaccine research may be another arm of the effort. Classically, the most effective prevention for malaria is drug-based prophylaxis, so new prophylactic drugs might be studied. If drug prophylaxis fails, then personal protection and mosquito (the vector of malaria) control are the best means of control, so new repellants and insecticides might be studied.

The research efforts on treatments, vaccines, and other means of prevention will all be based in medical knowledge that American civilian practitioners do not often need, but that can be acquired by skilled professionals. Therefore, the leadership will need to know how the Department of Defense can get this research done (contracts, internal laboratories, etc). They will probably need to be aware of several joint systems (eg, the Army Medical Research and Development Command, the Naval Medical Research Command, the Armed Forces Pest Management Board). Should a vaccine or other new prophylactic be developed, it will require personnel who understand the threat and can implement the new program. This will require both military and medical knowledge. Evaluating the program will require living with the troops in the field to develop a realistic and practical set of procedures, devices, and inspections, if nothing else, and this requires common military tasks on the part of some practitioners.

However, the staff might realize that the low-hanging fruit in malaria prevention is more systematic and effective use of the tools currently available. Improving current practices will require command influence on commanders in areas of risk. To determine how these practices can be strengthened, the staff will need to use both open source data from the World Health Organization (eg, what vectors and levels of resistance are seen in what areas of the world) and service-specific data from the National Center for Medical Intelligence (eg, what practices are most effective among deployed forces at risk).

This first edition of The Fundamentals of Military Medicine is the product of nearly 40 years of educational and curricular experience at the Uniformed Services University of the Health Sciences. We have assembled experts from across the world—active duty, retired military, and civilian authorities from all disciplines and services—to put down in print for the first time the core concepts that define military medicine for the emerging military medical provider. Our text will begin with a history of the military medical officer, and then examine issues of contemporary military practice of importance to the medical officer, as well as how to apply medical knowledge in a military setting.

The second section, which will describe issues in health service support or operational medicine, is the military medical practice equivalent of learning the role of the medical staff in the modern hospital, or how the hospital is staffed and organized to support practice. Section three is an orientation to some aspects of strategic military medical knowledge, addressing what is being done to improve the health of the force and assure that lessons of the recent wars are integrated in to the readiness of tomorrow’s units. The final section covers the actual care of patients, or tactical military medicine in the deployed or operational setting, addressing how deployment makes practice different from your accustomed practice setting.

It is the hope of the editors and our colleagues who made this book possible that it will help you provide care for those who go into harm’s way.

Notes

1.   This is not to say other activities are not tied to civilian standards. For example, logistics, aviation, and information technology (IT) have substantial overlaps, as evidenced by the revolving door between civilian and military logistics and IT realms. One case in point is the efforts of Army Staff’s senior logistics officer, General William “Gus” Pagonis, to revitalize Sears’s logistics supply chain management after he retired using principles and techniques of the Persian Gulf War. (William Pagonis. Wikipedia. https://en.wikipedia.org/wiki/William_Pagonis. Updated May 29, 2017. Accessed March 1, 2018.)

2.   Joy RJT. Armed forces of the USA: medical service. In: Walton J, Barondess JA, Lock, S, eds. The Oxford Medical Companion. New York, NY: Oxford University Press; 1994: 49–54.

3.   Contingency operations, especially since the end of the Cold War, including humanitarian missions and war in the Balkans, were marked by the development in the ground forces of smaller, tailored, multifunctional, even multicomponent (active duty, Reserve, and National Guard), joint and coalition medical units to protect and care for combatants in these unique missions. On the Cold War aspects, see Charles Wolf’s 1968 RAND Corporation study, Controlling Small Wars (https://www.rand.org/content/dam/rand/pubs/papers/2006/P3994.pdf); for more recent concerns see the US Marine Corps Small Wars Center website (http://www.mccdc.marines.mil/Units/SWCIWID/) or related material from other services.

Section I

MILITARY LEADERSHIP, SCIENCE, AND ETHICS

Section Editors:

MELISSA GIVENS, MD, MPH, AND SHAWN F. KANE, MD

“White Coat Ceremony,” fall 2018, for the Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine, in which the class of 2022 is symbolically awarded their white coats while in the uniform of their respective service—Army, Navy, Air Force, or Public Health Service—to signify their admission into the profession of medicine while serving as a professional uniformed officer. Photograph by Tom Balfour, Bio-Medical Photographer (Lead), Multimedia Design Division, Uniformed Services University of the Health Sciences.

Chapter 1

THE HISTORY OF THE MILITARY MEDICAL OFFICER

DALE C. SMITH, PHD*

INTRODUCTION

EMERGENCE OF THE ROLE OF OFFICER

MILITARY PHYSICIANS BEFORE BECOMING OFFICERS

The American Revolution

Military Medicine in the Early 19th Century

THE AMERICAN CIVIL WAR: MILITARY MEDICAL OFFICERS IN COMMAND

THE MODERN MILITARY MEDICAL OFFICER

The War With Spain

The Great War

The Second World War and the Emergence of Medical Specialization

CONCLUSION

*Professor of Military Medicine & History, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

The military medical officer is the person who most often practices the Fundamentals of Military Medicine and so the presumptive primary reader of this book. However, military medical practice antedates the role of military medical officer because the role of officer originated outside the concerns of the military or medicine—it is an official role, that is, one pertaining to performance of a duty or the responsibilities of a post held (an office) on behalf of others. Therefore, this chapter will briefly trace the history of the officer, then the emergence of military medicine as a professional medical activity, and finally the combination of the two in the modern military medical officer.

EMERGENCE OF THE ROLE OF OFFICER

The Oxford English Dictionary reports the word officer entered the English language from Old French in the 14th century. Two hundred years later, the word was applied to first the Royal Navy and then, in the 17th century, to Royal Army personnel holding the king’s commission, that is, those performing a duty in a post held on behalf of the sovereign.[1] It is not surprising that the association of officership with the navy antedates its association with the army because the navy operated outside the immediate control of the sovereign; therefore, the concept of duty or mission on behalf of the sovereign had to be reinforced for the captain (ie, leader) of a band of the king’s troops at sea in a way it did not for the captain of a band of troops ashore (under direct control of the king and his court officials). Formal guidance on duties was given in official documents, the Articles of War for all officers and the Sailing Instructions for officers of the Royal Navy.

However, these documents provided guidance only, as illustrated by the experience of the naval officer John Byng. After 40 years of highly successful service at sea, Admiral John Byng was dispatched, in 1756, to relieve the Mediterranean island of Minorca, which was under threat of French capture. Byng noted he had inadequate forces but was not reinforced. When he arrived he failed to relieve the island, already largely in French hands, and withdrew, in accordance with the Sailing Instructions, to the British base at Gibraltar. The following year he was tried by court martial and found guilty of “failing to do his utmost”; he was then shot in keeping with the 12th Article of War. Although nearly continual debate on the rightness of the execution has occurred since, it set a standard for officer behavior. An officer was one who could be trusted to do their utmost to meet the mission. The import of Byng’s experience was fully appreciated by Voltaire, who in his satire Candide has an English admiral executed, and the phrase pour encourager les autres—to encourage the others—became part of modern motivational rationales.[2] In the early American revolutionary military, it was the Byng court martial standard of officership that motivated John Paul Jones to reply with the inspirational “I have not yet begun to fight” and Nathan Hale to regret that he had “but one life to give for my country.”

TABLE 1-1

EARLY MILITARY SERVICE ACADEMIES*

Country

Date

Name

United Kingdom

1720

Royal Military Academy Woolwich

France

1748

Ecole du Corps Royal du Génie

Norway

1750

Krigsskolen

France

1751

Ecole Royale Militaire Austria 1751 Theresianische Militärakdemie

United Kingdom

1801

Royal Military College, Sandhurst

Prussia

1801

Akademie für junge Offiziere der Infanterie und Kavallerie

United States

1802

US Military Academy

*The early academies taught a special skill, the use of artillery, because aristocrats could not be presumed to know such a technical job. The advantages of specific military education led to general precommissioning academies and then to more advanced schools. But the responsibilities of officers changed dramatically over the course of their careers: leading a group of men so small an officer knew them all by name and could see them when deployed was different from developing plans for a large group on behalf of a senior officer, which was different still from being the senior officer in command of a group numbering thousands. As the services became increasingly larger and technical, the tasks an officer needed to perform changed, and the services began to develop education for the next set of jobs at staff and war colleges. Military professional education thus differs from other types of professional education, being learned in smaller doses throughout a career rather than all in the beginning.

The differences in naval and land force officership were further highlighted by the educational systems that underpinned their practice. A military ship was the most complex technology in existence in the early modern world. It was to be conserved if it all possible, the structure even more than the crew. To be trusted with this social investment meant having proved under a competent eye that an individual had mastered the job. The means to this end was called “the school of the ship,” a hands-on apprenticeship in ship handling under various real-world conditions. After certain skills were learned, the midshipman would stand an examination for lieutenant. Time in grade and demonstration of practical knowledge and skill allowed promotion to higher rank, and thus to the initial trust was added the characteristics of ability to perform the mission and faithfulness in meeting the mission.

In armies, which spent most of their time in garrison, it was more efficient to bring all cadets together in a school to provide initial training, so national service academies developed for army officer education (Table 1-1). Civilian professions were crystalizing in the same era, but none of them aspired to the same level of social responsibility. Although in the last century various commentators have considered the military a profession (see Chapter 3, Officership and the Profession of Arms in the 21st Century), it retains a unique unlimited obligation to accomplish its mission. Consequently, the military physician, by becoming an officer, adds to all other professional responsibilities a commitment to the larger society to fulfill the mission regardless of cost.[3]

MILITARY PHYSICIANS BEFORE BECOMING OFFICERS

The care of soldiers by a system of healthcare providers assigned to the military for that purpose dates to the Roman Empire and probably to the Egyptian armies of the Middle Kingdom (1700 BCE). There are elements of modern military medicine in various stories of healthcare associated with European armies of the late medieval and Renaissance periods. Arguably the best-known military surgeon of the 16th century was the great French surgeon Ambroise Paré. Paré is famous in medical circles for his care of gunshot wound patients without the use of boiling oil, the reintroduction of ligature for arterial bleeding, and setting a high standard for care of soldiers (Figure 1-1). Paré told the following story in his memoirs of the events he encountered as a young surgeon:

Figure 1-1. Ambroise Paré. Colored line engraving by C. Manigaud after E.J.C. Hamman.
Image courtesy of the Wellcome Library, London, England.

Now, at that time I was very inexperienced because I had not yet seen the treatment of wounds made by the arquebus; it is true that I had read in the first book of Jean de Vigo about wounds in general, chapter 8, that wounds made by firearms are poisoned because of the powder and for their cure he commands that they be cauterized with oil of elderberry to which a little treacle should be added. Not to fail in the use of this burning oil and knowing that such treatment could be extremely painful for the wounded, I wanted to know before I used it how the other surgeons carried out the first dressing; this they did by applying the said oil as nearly boiling as possible to the wounds using tents and setons so I plucked up courage to do likewise. At last I ran out of oil and was constrained to apply a digestive made of egg yolk, oil of roses and turpentine. That night I could not sleep easily thinking that by the default in cautery I would find the wounded to whom I had failed to apply the said oil dead of poisoning; and this made me get up at first light to visit them. Beyond my hopes I found those on whom I had put the digestive dressing feeling little pain from their wounds which were not swollen or inflamed, and having spent quite a restful night. But the others, to whom the said oil had been applied, I found fevered, with great pain and swelling around their wounds. From then I resolved never again so cruelly to burn poor men wounded with arquebus shot.4(p358)

Paré, and the community of military surgeons of which he was a member, were recognized as valuable by the state. As the minister who governed 16th century France, Cardinal Richelieu, noted: “two thousand men leaving a hospital cured and in some sense broken into the profession were far more valuable than even six thousand new recruits.”[5] As a result of Paré’s work, the French crown decided to establish military hospitals along the frontiers of the kingdom to provide care for wounded soldiers and to train military surgeons to provide such care.

Figure 1-2. Engraving of Sir John Pringle
Image courtesy of the National Library of Medicine, Images from the History of Medicine, Bethesda, Maryland. Reproduced from: http://resource.nlm.nih.gov/101426740.

The 17th century saw the spread and general recognition of the value of patient care provided by military medicine to the emerging standing armies of the era. Physicians outside the military commented on the diseases of soldiers and sailors in studying occupational relationships in disease etiology. The most famous is probably Bernardino Ramazzini, who published De Morbis Artificum Diatriba (Diseases of Workers) in 1700. In the mid-18th century several practitioners became committed to military preventive medicine in one form or another. Perhaps most significant, certainly recognized as exceptional in its ideas by contemporaries, was the 1752 work of Dr John Pringle (Figure 1-2), Observations on the Diseases of the Army in Camp and Garrison, which defined the nature of medical advice for the commander in the field and garrison for future generations.[6] Pringle summarized his purpose in the preface to his Observations as:

My chief intention here, was to collect materials for tracing the more evident causes of military distempers, in order that whatever depended upon those in command, and was consistent with the Service, might be fairly stated, so as to suggest proper measures either for preventing, or for lessening such causes in any future campaign.6(ppvi-vii)

At the same time, James Lind (Figure 1-3) illustrated the importance of preventive medicine issues for medical personnel in the Royal Navy through his classic work on scurvy, as well as his subsequent, less well known treatises on tropical medicine and infectious disease. In 1757 Lind published an underappreciated classic, An Essay on the Most Effectual Means of Preserving the Health of Seamen in the Royal Navy, in which he advocated command responsibility for the health of sailors.[7] Lind discussed the value of military medicine in the Navy as follows:

To a crew replete in health, what enterprise too dangerous? What achievement too great? Whereas, a sickly ship’s company, impotent and dispirited, have frustrated many a well-concerted expedition, and that bravery, which the enemies of our country have not been able to vanquish, has fallen a sacrifice to the cruel ravage of devouring disease.7(ppxii-xiii)

Figure 1-3. Portrait of James Lind, 1716-1794, physician at Haslar Hospital. Engraving by G. Chalmers after I. Wright.
Image courtesy of the Wellcome Library, London, England.

These works departed from the medical discussion of diseases associated with military life and argued for command of health, a military action or series of actions taken by the commander on advice of the doctor.

The American Revolution

In the United States, the commitment of excellent practitioners to the military needs of the nation predates the nation itself. American military medicine began in the armies of the Revolutionary War with pre-war militia surgeons and other volunteers who supported medical efforts. In the last third of the 18th century, military medicine was not highly regarded by most line officers. This was due, in large measure, to the absence of precision in the advice and treatment offered. There was also a social uncertainty about the role of an essentially middle class profession in what was traditionally an aristocratically led organization. The British traditions, accepted as patterns for the early revolutionary armies, placed surgeons in military units for the care of the injured and ill.

At the regimental level there was a hospital, medically managed by the senior surgeon with the aid of other surgeons and enlisted personnel detailed by line units. The detailed enlisted staff had no particular skill or training for the duties and were most often troops the line commander could best do without—the misfits and malcontents. The regimental hospital seldom cared for large numbers of patients except right after battle. In garrison there were expected to be general hospitals, staffed by the superior command, to relieve the regimental hospital during epidemics and to take members of the regiment too ill to deploy when the regiment left garrison. The American militia regiments understood, at least in theory, their need for surgeons and regimental hospitals, but when the war began no larger organization existed to provide general hospitals and the medical supplies necessary to keep the regimental hospitals functional over the course of the campaign.

Congress acknowledged the need for a larger medical organization to support the forces and in 1775 created the “Hospital,” headed by Dr Benjamin Church of Boston. As director general, Church was responsible for the Hospital Department, which included general hospitals, wherever and whenever established, as well as the surgeons recruited to work in the general hospitals. The Hospital Department was responsible for the acquisition and stockpiling of medical stores to meet the army’s needs. The nature of Church’s responsibility for and control over regimental surgeons was not specified. They continued to work for the colonel of the regiment and to draw supplies from the Hospital Department. They left wounded soldiers at general hospitals when the regiment moved, but frequently they did not cooperate with the general hospitals in staffing and patient distribution issues. The lack of a system, even in law or regulation, was in keeping with the humanitarian focus of military medical practice in the Hospital Department.

When the Revolutionary War began, leaders of American medicine produced guides and other works for the benefit of both practitioners of medicine and line officers in the new army. Perhaps most impressive was the little book of Benjamin Rush, published in 1778, which provided, according to its title, Directions for Preserving the Health of Soldiers Recommended to … the Officers of the United States Army. Rush was emerging as a leader in the medical profession of Philadelphia at the time. He was a member of the medical faculty of the College of Philadelphia (later the University of Pennsylvania) and, perhaps more importantly, a patriot of distinction. A delegate to the Continental Congress, he was one of the five physician signers of the Declaration of Independence in 1776. Rush’s advice in Directions was based in large measure on the work of Pringle and dealt with environmental issues as well as factors of personal hygiene, food, and clothing. What is striking is the recognition both in the title and the contents of the work that responsibility for the health of the force rested in the actions of the line officer rather than the medical practitioner. Doctors could and should provide good advice; the officers would have to implement it for it to be effective.

Command attention to medicine was a growing enterprise in the 18th century generally, and in the first regulations of the Continental Line (the formal name for the congressionally supported military in the Revolution), Regulations for the Order and Discipline of the Troops of the United States, prepared by Major General Baron von Steuben (Figure 1-4), inspector general of the army, specific direction was given for efforts to maintain health. These included careful placement of the kitchen and sinks, daily inspection of the tents by a company officer, and the appointment of an “officer of police” to inspect the camp.[8] The Regulations also discussed responsibilities of the regimental commander:

The preservation of the soldier’s health should be his first and greatest care; and as that depends in great measure on their cleanliness and manner of living, he must have a watchful eye over the officers of companies, that they pay the necessary attention to their men in those respects.8(p128)

Figure 1-4. (a) Painting of Major General Friedrich Wilhelm Augustus Baron von Steuben by Ralph Earl, 18th-century.
Image courtesy of Yale University Art Collection. Reproduced from Wikimedia Commons. (b) Steuben FWA. Regulations for the Order and Discipline of the Troops of the United States. Philadelphia, PA: Styner and Cist; 1779. Reproduced from: https://www.loc.gov/resource/rbc0001.2006batch30726/?sp=8.

While the regulations appeared in 1779, they were written contemporaneously with and probably inspired Rush’s Directions for Preserving the Health of Soldiers in 1778 (adoption of the Regulations by Congress and printing by government contract slowed their appearance).

Among the physicians serving in the revolutionary army and aboard naval ships, most were simply doing the best they could in a difficult situation. At the operational level, they were most often excluded from discussions of military events; thus, placement of hospitals was rarely a carefully conceived plan and was almost always dictated by space available near the point of need. Patriots in the field, true “minute men” who happened to be physicians, they did not consider themselves and no one considered them military officers, but these early military physicians started and supported a tradition that military medical officers have maintained: “the preservation of the soldier’s health should be [the] … first and greatest care….”8(p67)

Military Medicine in the Early 19th Century

At the turn of the century, while the young United States was closing down its standing army and medical establishment, European states were transforming the art based on the necessity of a new kind of war—the wars of the French Revolution—with its larger, levee en mass armies and, under Napoleon, a new and vigorous use of combined arms warfare.

By the end of the 18th century, both the practicalities of recruiting and retention and the moral philosophy of the Enlightenment had advanced the idea that troops were entitled to care in the field, and almost all armies in Europe had an organized medical service. When, in 1792, European countries decided that the French Revolution had gone too far and invaded to restore the kingdom, the members of the previous French Royal Army felt conflicted: did they stand with France or with the crown? Many stood with France, including a military surgeon named Pierre-François Percy, who was assigned as chief surgeon for the Army of the North. Percy recognized that surgeons assigned to individual units would become ineffective as the larger armies of the Republic took more casualties than previous, smaller royal armies. He developed new medical vehicles to take surgeons forward and advocated for a new type of medical soldier, the brancardier, or dedicated litter bearer, who would work for the surgeon in the field. Napoleon named Percy surgeon-in-chief of the Grande Armee and authorized the expanded recruitment and training of litter bearers in the early 19th century. Percy was also an early advocate of rank-immaterial, medically dictated triage. But Percy, with his common sense administrative suggestions, is frequently forgotten because of the success of his younger colleague, Dominic Jean Larrey (Figure 1-5).

Internationally the most famous military surgeon who ever lived, Larrey is generally credited with systematically and intentionally moving the surgeon forward on the battlefield to care for the wounded as early as possible. He achieved this goal by creating a surgical unit, the “flying ambulance,” which included a group of operating teams, field evacuation personnel, and evacuation vehicles under his consolidated guidance as surgeon to the Guard, Napoleon’s elite field unit. Larrey conceived the idea of the flying ambulance in 1794, when he saw the flying artillery rushing across the battlefield at Mainz. He designed a small wagon on an artillery carriage and, with an assistant and some non-medically trained aides, he took himself forward to aid the wounded in Italy later that year. Larrey was made a baron of the French Empire and a commander in the Legion of Honor, but his military rank remained surgeon major (major in the French army is the highest warrant rank; an O-4 is a commandant). Percy and Larrey achieved innovations because their ideas enjoyed line support from commanders who believed they had an obligation to care for their troops, but they might have been more effective if considered officers and allowed to know the commander’s plan before the battle.

In the United States, Congress appointed physicians to the forces, whether regiment, hospital, or ship; they did not hold military rank, could not give orders, and were not entitled to the privileges and courtesies due officers. On the other hand, they were not soldiers or sailors, nor were they civilians, as the first court martial established. Physicians were professionals and thus the social equal of many officers in the egalitarian culture of the new nation; however, traditions inherited from Europe drew a sharp distinction between the aristocratic classes, who led the fight, and those who supported them in the effort (Exhibit 1-1). The medical system in the War of 1812 was essentially that which had been developed in the Revolution and disbanded in the intervening years. In 1817, Surgeon Joseph Lovell called the attention of the commanding general of the Northern Division, Jacob Brown, to the defects of the medical establishment in a comprehensive and innovative report of inspection.[9]

Figure 1-5. Dominic Jean Larrey, a copy of Porträt des Barons Larrey, Erster Chirurg des Feldzuges nach Ägypten by Anne-Louis Girodet-Trioson, 1804.
Reproduced from: https://en.wikipedia.org/wiki/File:Anne-Louis_Girodet-Trioson_005.jpg. Source: The Yorck Project, 2002.

Following the War of 1812, Congress reorganized both the Army and the Navy but in quite different ways. In 1816, John C. Calhoun began his tenure as secretary of war with the goal of providing the Army in peacetime the structure it would need in war. He selected Major General Jacob Brown as his senior military advisor, and Brown, in turn, brought Lovell’s ideas to the attention of the secretary. In 1818, Calhoun convinced Congress of the value of establishing a permanent Army Medical Department (AMEDD) and a permanent position, the surgeon general of the Army, at its head. Joseph Lovell was appointed as the first surgeon general.

The Navy was reorganized with three senior line captains serving as commissioners to advise the secretary of war, but the secretaries of the next decade were primarily interested in cost containment. Officer education, on the British model, was still the school of the ship, with midshipmen learning while serving indefinite tenures until they could pass the examination for lieutenancy. Navy medicine would not enjoy a centralized system for another generation. In 1828, the naval committees in Congress were finally asked to reorganize naval medicine. The position of surgeon’s mate was abolished, as was direct commission of surgeons. Under the new law, physicians were recruited and took an examination to be appointed as an assistant surgeon. After 5 years and successful passage of another examination, they were, by seniority, promoted to surgeon when a billet became available.

EXHIBIT 1-1

SURGEON HEERMANN AND OPERATIONAL MEDICINE

The utility of medical officers and the problems of their ambiguous status were demonstrated in squadron deployments against the pirates of the Barbary Coast in the first decade of the 19th century. In 1801, an observation squadron was sent to the Mediterranean, and in 1803 one of its frigates, the Philadelphia, ran aground and was captured by the naval forces of Tripoli. Commodore Edward Preble authorized the ship’s destruction to deny it to the enemy. Stephen Decatur, at that time a lieutenant commanding the Enterprise, was given the task of leading a volunteer raid into the harbor to burn the vessel. He was given the captured ketch Intrepid to infiltrate the harbor. Decatur asked his surgeon, Lewis Heermann, to assist in screening the volunteers, for he wanted no one subject to sudden indisposition among the personnel on this dangerous mission. He further informed Heermann that the surgeon would accompany the expedition until the ketch was about to enter the harbor, and then he would be put aboard the brig Siren for safety.

Heermann requested that Decatur reconsider his decision with a tripartite argument that captured the essential features of military medicine and rings through the operational traditions of navy medicine to this very day: “My life, Sir, is not more valuable than that of the other brave officers and men who accompany you;…. the presence of a professional man to assist the wounded might save many valuable lives, … and will not sailors more regardlessly expose themselves, when they know that professional aid is near at hand? Should you have many wounded, would not some confusion arise, to impair your effective force?”[1] The appeal to humanitarianism and the importance of morale were important to Decatur, as they are to any officer, but given the mission and what is known of Stephen Decatur, it must have been the operational thinking that carried the day—the doctor went along.

____________

1. Pleadwell F. Lewis Heermann. Ann Med Hist. 1923;5:113–145.

The Navy examination system of 1828 was the first recognition that all military physicians needed certifiable dual competency. The examination of all candidates for entry was medical, serving as an acknowledgment that standards in the young nation’s medical schools had declined in the previous generation. To assure the sailors, and their families and friends, that the nation would adequately care for those who served, a board of senior medical officers examined the medical competency of all who were appointed. The examination for the grade of surgeon included not only medical knowledge but specific naval material on diseases at sea, examination of recruits, and the hygiene of ships. Surgeon Thomas Harris began a course of instruction at the Philadelphia Navy Yard for assistant surgeons on shore duty, in the hope of preparing them for their promotion examination.

In the Army, Joseph Lovell’s reform efforts were directed along several lines simultaneously. Significantly, he had to fight to establish control over the department in the face of congressional attempts at detailed management. Congress initially specified a wide variety of duties for Army surgeons, each with a different title and rate of compensation. These included hospital surgeons, hospital surgeon’s mates, post surgeons, and regimental surgeons and surgeon’s mates, as well as the apothecary general and his assistants. In 1821, Congress gave up attempts to specify the composition of the department in detail and created a two-tier system, of surgeons and assistant surgeons, who the surgeon general (with the consent of the secretary of war) could assign as he wished. Like the contemporary naval model, this created a hierarchical system, parallel to the commissioned officer grades. Medical officers were not awarded commissions, but the AMEDD gained a large element of control to respond to changing needs.

Lovell was perpetually concerned about the caliber of practitioners in the service. He believed, and the testimony of physicians of the era supports his belief, that the low pay of military physicians militated strongly against retention of the best practitioners. In 1832 Lovell instituted, on the Navy model, a mandatory examination of all those desiring to join the AMEDD. The examination lasted 3 days and was conducted by a board of three experienced officers; it covered basic science as well as clinical skills and included both written and oral formats. After 5 years of service, an assistant surgeon was obliged to take an examination for promotion to surgeon. In 1834 the pay of surgeons was tied to that of majors in the line; that of assistant surgeons of 5 years’ service to captains; and that of new assistant surgeons to the pay of lieutenants. This pay structure gave military medical officers relative rank; they ranked as lieutenants, captains, and majors, but they were not called lieutenant, captain, or major, and they could not perform the ancillary professional duties of a commissioned officer, such as sitting on a board of inquiry, nor could they issue a legally binding order to a soldier.

In 1842 a system of six bureaus was adopted to improve the functioning of the Navy in support of ships at sea. One of the bureaus was the Bureau of Medicine and Surgery, and like the others it had a chief who reported to the secretary of the Navy. The title of surgeon general was consciously not used in 1842 (it was introduced after the Civil War) because it implied more control and authority over the surgeons than the bureau system envisioned (Navy medicine still did not have a system). In August 1846, the secretary of the Navy, George Bancroft, ordered assimilated or relative rank. The surgeons were specifically denied the authority to exercise command, even in hospitals, because Bancroft felt that authority required approval of law.

The reason for Bancroft’s action is straightforward: he was trying to improve the effectiveness of ship’s surgeons in war. American ships blockading Mexico were frequently pulled from the line because a large portion of their crews had scurvy. British and French naval observers chastised the American Navy for this preventive medicine failure; in their view scurvy was a completely preventable disease. However, even when surgeons offered what to them were straightforward solutions, line implementation did not always follow. Fortunately, the blockade was short. In the years that followed the Mexican War, the secretary of the Navy gave the chief of the medical bureau additional authorities. Especially important to the status of medical officers was the creation of a technical chain of command and reporting established in 1848. Now the surgeon’s reports would go to the bureau and the ship’s commanding officer could not interfere; this was not authority, but it provided real persuasive power.

Figure 1-6. Florence Nightingale checking on her patients and administrating medicine at Scutari Hospital. Colored lithograph by J.A. Benwell.
Image courtesy of the Wellcome Library, London, England.

In February 1847, Congress passed legislation giving medical officers in the Army true commissions and real as opposed to assimilated rank, in part trying to improve the effectiveness of medical operations in the field. However, the law was not clear on what the new commissions meant. In both services the war had demonstrated that disease was at least as great an enemy as the opposing forces, and there was an increased desire to do something about it.

EXHIBIT 1-2

THE RED CROSS AND THE GENEVA CONVENTIONS

The Christian tradition in Europe has included several attempts at limiting the application of the “just war” doctrine to those engaged in the fighting. Some consider the Knights Hospitaller, who operated infirmaries and escorted pilgrims in the 12th and 13th centuries as a means to protect noncombatants, as the origin of the ideal, but their history is unclear at critical points. In the 16th century various legal scholars argued for the immunity of noncombatants. In 1625 Hugo Grotius published his influential De jure belli ac pacis libri tres (On the Law of War and Peace: Three Books), which argued for strict laws on going to war and conducting wars. Certainly by the 17th century there were also attempts in both Protestant and Catholic nations’ laws of war to protect churches, schools, and hospitals. The first mutually agreed-upon protection of hospitals is probably that between British and French military commanders at Aschaffenburg in the War of Austrian Succession (1740–1748).

But as war became more industrial and armies composed of more eclectic personnel, humane efforts were harder to preserve. A particularly vicious battle in the Second Italian War for Independence, the Battle of Solferino, was witnessed by a Swiss businessman, Henri Dunant, who wrote up his recollections of the experience in an effort to gain international cooperation to improve the conditions of those caught up in war. Friends in Switzerland helped form an international relief committee in 1863, now named the International Committee of the Red Cross. The Red Cross recognized national committees that various nation states agreed to charter and support.

Many of the signatories to the Red Cross idea met again the next year and adopted the Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field. The limited first Geneva convention provided four protections: (1) immunity from capture and destruction of all establishments for the treatment of wounded and sick soldiers; (2) impartial reception and treatment of all combatants; (3) protection of civilians providing aid to the wounded; and (4) recognition of Red Cross symbol as a means of identifying persons and equipment covered by the agreement.

At the time, the United States was in the midst of the Civil War and President Lincoln, fearing European involvement in the suppression of the rebellion, did not send a voting representative. Lincoln did send a team of two observers, and subsequently he issued General Order 100, which provided many of the same protections. In 1882, the United States ratified the Geneva Convention and the following year established a Red Cross society, largely due to a campaign led by Clara Barton.

Further treaties followed as war changed. The Hague Convention of 1899 applied the protections of 1864 to war at sea, and in 1906 a second Geneva Convention combined the 1864 and 1899 efforts. There were conventions about weapons in 1907 and 1925, motivated primarily by gas warfare, and in 1929 the treaties were expanded to include protections for prisoners of war. After the Second World War the treaties were again modified to reflect the changing conditions of war and expanded in an effort to protect civilian noncombatants while recognizing partisans as troops. Permanent Red Cross staff and the signatory nations to the Geneva Conventions continued to struggle with the concept of humane war as wars of national liberation, both nationalistic anti-colonial efforts and communist-inspired insurgencies, proliferated in the last half of the 20th century.

In the war trials following the surrender of Japan in World War II, the United States made the argument that nations and their military officers were bound by commonly agreed-upon international law, even if they did not sign the new treaties. Some signatory states of the 1949 Geneva convention have adopted further protocols in the 1970s and early 21st century, but the United States has not agreed to all of these provisions (see Chapter 6, The Law of Armed Conflict and Military Medicine).

____________

Data source: Gillespie G. A History of the Laws of War: Volume 1, The Customs and Laws of War with Regards to Combatants and Captives. Oxford, United Kingdom: Hart Publishing; 2011.

The British army was severely condemned for lack of preparation and preventive medicine efforts in the mid-1850s when it went to war in Crimea (1853–1856). Conditions were so bad that private philanthropy organized by The Times newspaper sent a civilian with official blessing, Florence Nightingale (Figure 1-6), to help in the troop hospitals. Supported by William Russell’s dispatches from the theater via the telegraph (the first nearly real-time reporting), Nightingale’s work came to international attention. Eventually her efforts helped shape an educated nursing community, inspired hospital reform, and most importantly, reinforced the well-understood but often ignored command obligation for the health of the soldier and sailor.

In 1859 Henri Dunant, a traveling Swiss businessman, came across the aftermath of the Battle of Solferino; his description of the experience is one of the classics of humanitarian action on fields of battle, Un Souvenir de Solferino, published at his own expense in 1862. It led to a series of meetings in Geneva, which resulted in the International Committee of the Red Cross and a proposed international treaty, called the Geneva Convention, to provide for the care of soldiers and make military medical facilities immune (theoretically off limits to enemy attack) (Exhibit 1-2). Clearly, in the mid-19th century the public showed an increasing concern with the health and care of those who served.

THE AMERICAN CIVIL WAR: MILITARY MEDICAL OFFICERS IN COMMAND

The lack of a traditional aristocracy and the creation of an education-based officer corps from the US Military Academy underpinned the American innovation of true commissions for Army Medical Corps officers. At various times in the 1850s, the adjutant general, the president, and the Congress made clear the command authority of doctors was restricted to the medical arena, but these directives were enough to fulfill the aspirations of generations of physicians on the battlefield who wished for a medical system. In keeping with the humanitarianism of the age, American officers on both sides of the Civil War understood troop health and care was their responsibility.

The US Army sent a team of officers to serve as observers in Crimea. There Richard Delafield, the team’s chair, lent his name to a commission and its widely read report. The American public also heard much about Crimea and Florence Nightingale through the civilian press. Consequently, the Army made many important innovations: various forward hospital and ambulance modifications; significant involvement of nongovernment organizations, especially the US Sanitary Commission; research and education work on the part of the Office of the Surgeon General; and an exceptionally vigorous program of hospital building, all capitalizing on previous ideas and efforts. However, in the history of the military medical officer, these achievements paled in comparison to the impact of the work of Jonathan Letterman, medical director of the Army of the Potomac from 1862 to 1864 (Figure 1-7).

After the first battle of Manassas Junction, President Lincoln named Major General George McClellan, one of the Delafield commissioners, as commander of the Army of the Potomac. McClellan decided to attack the Confederate capital by way of the James River peninsula, but the campaign was not well thought out, and logistics, including medical supply and evacuation, were a disaster. Spring and early summer were a time of sickness, and disease rates exceeded battle casualties, further complicating the medical support. Major Charles Tripler, the medical director at the time and one of the most experienced operational medicine experts in the Army, was unable to systematically bring medical supplies in or patients out of the area of operations. Not surprisingly, he lost the support of his seniors, both medical and line, and was replaced by Major Letterman, who was given license to change the current system.

Figure 1-7. Major Jonathan Letterman as medical director of the Army of the Potomac.
Image courtesy of the National Library of Medicine, Images from the History of Medicine, Bethesda, Maryland. Reproduced from: http://resource.nlm.nih.gov/101421695.

One of Letterman’s first observations was that the problem of patient evacuation was seriously compounded by the failure of teamsters, contracted by the quartermaster to evacuate the field of battle, to perform the job. A new approach was needed. In July 1862, McClellan approved a dedicated (used only for medical purposes) ambulance corps for the Army of the Potomac. Enlisted personnel would be trained to handle litters and move patients under the military chain of command, a noncommissioned officer in the regiments and a company grade officer at brigade, division, and corps levels, and Letterman would command the entire organization. Thus began actual command of regular troops in the field by the medical officer, albeit to perform a medical task; this was the job civilian doctors, or those under warrant, could not do.

In the original Army of the Potomac units with ambulance corps, the new system worked very well, but the battle of Antietam revealed other problems related to patient evacuation and medical supply. After the battle, as noted by both the press and Major Letterman, patients were stacked up in some hospitals while others were underused; there were flexible standards of care leading to amputations; and critical medical materials were in short supply. These problems pointed to the following changes proposed by Letterman: The medical director should have command of all field hospitals in the deployed force, and hospitals should be located at the division level rather than the traditional regimental location. Regimental aid posts should be established in conjunction with the ambulance system to facilitate sorting the patients for their move to the hospital. Operating teams needed to be preselected based on skill and experience rather than desire and rank, and there should be mandatory consultation on all amputation decisions. A medical officer should be designated to coordinate further evacuation from the field hospitals and medically appropriate transport arranged to move the wounded back to the general hospitals being built in Washington, Baltimore, and Philadelphia. Finally, medical supplies needed to be controlled centrally and pushed forward as needed rather than stored forward and subject to unnecessary wastage. Major General Ambrose Burnside, selected by President Lincoln to command the army after McClellan was relieved, approved all of Letterman’s suggestions, and a medically commanded field medical system came into existence for the first time.

The new system worked brilliantly at Fredericksburg in December 1863, even though Burnside and the Army lost the battle. Encamped before Fredericksburg that winter, the troops had begun to sicken. In discussions with the regimental medical officers, Letterman discovered that their diet was inadequate and living conditions were unsanitary. He took the problem to the new commander, Major General Joseph Hooker, who undertook corrective action and authorized Letterman to establish a formal medical inspectorate to assure the health of the army. The resulting Letterman system was complete: from prevention to echeloned care, the military medical officer had a set of new roles and responsibilities in the deployed force, roles that could be met only by those with military authority. Equally important, the system had been sanctioned by three commanding generals. In 1864, Letterman’s system became required by law in all US field armies for the duration of the war.

However, when the war ended in 1865, these measures disappeared from American practice. But the system did not vanish. European powers had sent observers to US battlefields, and the US Army published its medical experiences in the multi-volume Medical and Surgical History of the War of the Rebellion,[10] which was widely read and studied in Europe. The Prussian army used Letterman’s system effectively in the wars of German unification, and the French and British adopted parts of it in conjunction with other military medical reforms in the last quarter of the century. All the European armies were using it in World War I, and the AMEDD relearned it from the allies as the United States entered the war in 1917.

THE MODERN MILITARY MEDICAL OFFICER

When Florence Nightingale returned to London after the Crimean War, she realized some of the diseases seen in the Near East were not seen (or taught) in England, and military physicians needed enhanced education to serve wherever their duties took them. She called for a military medical school to provide the extra education civilian doctors recruited into the service would need, and in 1860 the British Army Medical School was established. At the same time a similar course of instruction was offered at the Val de Grace Hospital in Paris for deploying French military physicians. Such a school was first proposed by Surgeon General Hammond for the American army during the Civil War, but it was not established until 1893, by Surgeon General Sternberg.

By the 1890s all these schools were teaching microbiology of camp and tropical diseases, and military medical officers became among the best educated physicians. The new epidemiology (and other sciences) would eventually make medical advice predictable and consistent, but it took time for the officer corps to recognize this change. The schools also taught the growing body of military professional material that medical officers needed to understand, especially their unique place in the emerging international laws of war and their functions as staff advisors.

Military staff work had evolved slowly since the early modern period, but the nature of industrial war accelerated its growth and definition. Largely as a result of the extraordinary Prussian success in the wars of German unification (1866–1871), senior line officers in Europe and the United States were exploring advanced professional military education and its role in the creation of staff officers. At Annapolis a debate arose over the role of engineering officers in the new steam navy, and the reformation of the concept of a naval line officer to include at least junior engineers. A sharp distinction was set between officers of the line and officers of the staff in 1871 legislation; the Navy doctor, as an officer of the staff with relative rank, gained authority to command in medical facilities in the 1880s; and actual as opposed to relative rank was finally awarded to naval surgeons in 1899.[11] In the Army, the School of Application for Infantry and Cavalry was created in 1881 at Ft Leavenworth, patterned after the artillery school at Ft Monroe, to teach young officers to more effectively use their units.

Figure 1-8. (a) Edward L. Munson as a brigadier general at the end of World War I. (b) Title page of Munson’s classic text on the line officer use of medical assets, The Principles of Sanitary Tactics, 1911.
Image (a) courtesy of the National Library of Medicine, Images from the History of Medicine, Bethesda, Maryland. Reproduced from: http://resource.nlm.nih.gov/101424082. Image (b) reproduced from Internet Archive: https://archive.org/details/principlessanit00munsgoog.

The War With Spain

Unfortunately, these medical and military education efforts did not pay the dividends expected in the next US war. In part this was the result of the 18th-century approach to militia mobilization still in use in 1898. The medical departments and the combat arms units needed to recruit volunteers, and the volunteers, physicians and line officers, were not well informed about modern military applications, medical science, or prevention in the field. In the Spanish-American War, Surgeon General Sternberg sent out a circular on prevention of fecal-oral transmission of typhoid, concluding there should be no typhoid in the Army camps. Therefore, the surgeons did not diagnosis patients as having typhoid, instead describing the patients as having typhomalaria or some other disease. Sternberg was therefore surprised when the newspapers reported an epidemic of typhoid in the training camps. The second problem was similar: line officers had heard about germs but did not really believe something they could not see would make the men sick, and therefore they paid very little attention to advice from the doctors on the relative positioning of latrines and water sources. More Americans died of typhoid fever in US training camps than were killed by the Spanish.

Figure 1-9. (a) Paul F. Straub as a major on the War College staff. (b) Title page of Straub’s classic text for medical officers, Medical Service in Campaign, 1910.
Image (a) courtesy of the National Library of Medicine, Images from the History of Medicine, Bethesda, Maryland. Reproduced from: http://resource.nlm.nih.gov/101421695. Image (b) reproduced from Internet Archive: https://archive.org/details/medicalservicei01stragoog.

After the war, a presidential commission to study the work of the Army in the war, led by retired Brigadier General Granville Dodge and so called the Dodge Commission, concluded that the AMEDD needed a reserve of doctors to call during deployments because civilian physicians, while patriotic and willing, were not prepared to meet the mission. The Dodge Commission also concluded that line officers needed AMEDD education in care of troops during peacetime professional military education to make sure they understood the importance of the medical advice given during deployments.

Departments of hygiene were established at the US Military Academy and US Naval Academy, and surgeons assigned to the relatively new Naval War College began to offer lectures on the subject, but the most impressive program was at the Army’s School of Application in Leavenworth, Kansas. Soon renamed the Staff College, the school’s Department of the Care of Troops became the home of Major Edward L. Munson (Figure 1-8), who worked with the line instructional staff to teach line officers about medical readiness and to teach medical officers how to work on a division staff. Recognizing the need to speak to military leaders in terms they understood, Munson called his instruction “sanitary tactics.” He also developed summer encampments for reserve and National Guard medical units to help them prepare for deployed medicine.

Additionally, the Army Medical School in Washington, DC, reopened in 1901 and started a program of summer encampments for future regular medical officers. The 1909 encampment gave rise to an important professional manual, Medical Service in Campaign: A Handbook for Medical Officers in the Field,[12] by Major Paul Straub, a Medal of Honor awardee in the Philippine Campaign who was assigned part time to the War College planning staff (Figure 1-9). Between them, Munson and Straub defined the US Army special staff role for military medical officers and for line officers as part of the new military staff function. As officers trained to understand the military units, roles, and missions, the new members of the medical corps were better prepared to give advice that, in Pringle’s classic phrase, “was consistent with the Service.”

The same scientific progress that improved preventive medicine advice also changed therapeutic medicine and led to the involvement of more personnel in the healthcare enterprise. In the second half of the 19th century, the hospital became an increasingly common site of care as a result of industrial trauma, urbanization, and the changes in care dictated by the new medical sciences of physiology and microbiology. Military medicine had long used hospitals for custodial care of soldiers and sailors without family to care for them, and even this use of hospitals increased.

However, the issue of staffing was by no means clear. The new trained nurse served the civilian community, but the military had a long tradition of enlisted hospital stewards and baymen. These enlisted medical soldiers and sailors were temporary, but militaries around the world made them increasingly dedicated in the last quarter of the century. In the United States, the Army established the Hospital Corps in 1887, and the Navy did so in 1898. The Navy Hospital Corps’ was delayed by the problem of recruiting landsmen for service at sea without adequate sea service to care for themselves in the risky environment. Most medical services had used “nurses” at various times in their hospitals, especially in fixed hospital facilities, but these personnel had various levels of training and commitment.

By the 20th century the new scientific nurse training (inspired by Florence Nightingale) was in virtually every Western nation, and military hospitals began to use educated and registered nurses exclusively. The US Army added the Nurse Corps in 1901; the Navy followed in 1908. As other professional groups became important to military medicine, they were added; sometimes, like dentists, as a separate corps, at other times, like pharmacists, as part of a preexisting corps. Physicians continued to hold the command positions because many of these new groups were either civilians on warrants or enlisted. However, like physicians before them, many of these professionals campaigned for commissioned status on the argument they would be more effective as officers.

In addition to new types of personnel, the nature of the medical profession was being changed by the new sciences, which underpinned a rise in specialized practice. Few practitioners limited their practices to a specialty, but many were gaining a consultation and referral reputation in their locality. Military medical services were generally ambivalent about the civilian specialization efforts because all military medical officers needed to be able to practice in isolation and be fully competent in all aspects of practice. While Army doctrine since Letterman had recognized different levels of skill, the US Army made no effort to codify surgical skill and experience. The US Navy developed a post, supervising surgeon, in its larger hospitals, with the duty to encourage and supervise the education and training of junior officers in the surgical arts.

The Great War

In European services the long tradition of separate communities of physicians and surgeons easily allowed recruitment of surgical consultants to hospitals from civil life in times of need, especially during large-scale mobilizations. In the United States, however, as the Army prepared for war in 1916, there was no obvious solution to assure recruitment of medical staff with the required skills. The surgeon general, William Gorgas, was familiar with the academic preventive medicine community, and although he had less personal knowledge of expertise in American surgery, he knew those who did.

Leaders in American medicine had created the Physicians’ Committee on Preparedness in 1916 to mobilize the medical profession for the possibility of war. William J. Mayo was its chair. The committee encouraged physicians to enroll in the reserve corps and polled county medical societies to build lists of physicians with specialized skills. General Gorgas asked Dr Mayo to come onto active duty and report to the Office of the Surgeon General as his advisor on surgical personnel; unfortunately, the laws on the assignment of officers prevented such an advisory or consulting appointment. The 1916 legislation that created a new reserve component also limited reservists to commissions as a major. For credibility with allied medical departments and as a sign of professional stature, leading physicians in the reserve corps thought they should be colonels. Dr William Mayo and his brother, Dr Charles Mayo, worked in their civilian capacity to get these laws changed, and consequently Major William Mayo was able to report to the Office of the Surgeon General for assignment as a newly promoted colonel.

Colonel Mayo, in conjunction with other leaders in American surgery, worked out a system of assigning surgeons from the reserve to deployed hospitals while preserving surgical skill to support the civilian population and wartime industries in the United States. The practical need to be a colonel to get things done in Washington and the importance of parity with allied officers was readily conceded by combatant arms officers. However, the creation of instant reserve corps medical colonels, when a colonelcy took almost 20 years to earn in the regular service, line or medical, in addition to the direct commission of medical specialists as field grade officers, led to some resentment among regular officers. In the 15 years following World War I, both the Army and the Navy resisted the use of specialization in regular medical corps officers. Both services expected the specialized medical expertise to be found in the reserve corps and actively encouraged academic medicine’s participation in the reserves, where the abbreviated route to promotion and direct commissions at field grade would be less offensive.

In Europe during World War I, medical officers worked with both enlisted personnel and nurses in an intense operational environment. Nurses were deployed forward in mobile hospitals and staging facilities despite their ambivalent status as civilians recruited by the Red Cross and attached to the Army. Following a French example, to reduce the time before point-of-wounding care was initiated, first the Marines and later the Army deployed enlisted personnel from ambulance units forward on temporary duty with the combatant units. As a result, World War I was the last war in which a medical officer, Lieutenant Joel Boone, US Navy Medical Corps, was awarded the Medal of Honor, and the first war for a Navy corpsman to receive the medal.

Because there were many more enlisted medical personnel than medical officers, and they could be trained in first aid to do almost as much as a physician in the field, the future use of forward medics became a policy norm. Assuring their training and role in a coordinated field care environment became a critical new function of medical officers. The war also witnessed the temporary creation of a new class of medical department officers, the administrative and sanitary corps, consisting of non-physicians with needed skills to contribute in critical areas that did not absolutely require physician participation, such as administration, epidemiology, and logistics. These corps were disbanded after the war, re-created in World War II, and consolidated in the post-World War II period as the Medical Service Corps.

Regular medical officers were largely responsible for command and control of the medical system in the theater of operations during the World War I European deployment. Examples of excellence and innovation included Colonel Gilchrest’s deployment of gas decontamination units[13] and Colonel Lyster’s development of aviation medical support units.[14] However, Major General Merritt Ireland, medical officer of the American Expeditionary Forces (and after 1918 the surgeon general), thought the overall level of coordination and communication was subpar and needed to be improved. Because field medicine was the traditional essential competence of the medical officer, Ireland established the Medical Field Service School in 1921 to teach basic field skills to new Medical Corps officers. The school also provided a training center for medical units that allowed more experienced officers the opportunity to practice skills of command, control, coordination, and communication in a predeployment situation.

The Second World War and the Emergence of Medical Specialization

During World War II the military medical officer role was similar to that of World War I: the regulars provided command and control while the reserves provided specialists, especially consultants. The vast majority of medical personnel served as providers and had minimum military training, mostly common field skills so they could take care of themselves when deployed. These physicians were officers by courtesy and, although they held military authority, their de facto authority was medical in the medical setting. A change, mostly for generalists, was an increasing number of officers assigned to support the aviation arms of both services.

The other significant change in World War II was more difficult for the services and their medical departments to accommodate. The war had proven the absolutely essential nature of specialists as part of the regular AMEDD. After the war all three services established graduate medical education programs that initially depended on the civilian academic community for educators and accreditation; however, these programs slowly developed expertise of their own as officers went through the process and matured as specialists.

But career patterns developed for general practitioners were not always adaptable to medical specialist practitioners. In a medical department of general practitioners, all officers were available for all duties commensurate with their rank and years of service, but the new medical departments of the late 1940s had to adapt to medical officers with narrower interests. If an officer with 1 year of postgraduate education spent 6 to 8 years with the active forces and was assigned as a division surgeon, he would know something of preventive medicine and field hospital utilization for surgical medical and psychiatric patients. But the new specialist major, who had spent 5 of those years in a teaching hospital as a surgical resident, could not be expected to do the same job effectively. The difficulties of providing professional military education and experience during graduate medical education would be made fatally obvious during combat on the Korean peninsula, when young officers without field experience were ineffective in command of battalion medical units.

Postwar tensions evolved into the so-called Cold War that turned into combat action in Korea in 1950. Because insufficient physician volunteers were available, a doctor draft was instituted, which continued until 1973 (when an all-volunteer force policy was initiated). During the doctor draft all healthy male physicians completing internship were subject to a 2-year service obligation. The obligation could be deferred for residency, but the cost was an increase in obligation. Only about 4% of obligated physicians stayed in the service, and a peculiar force structure developed (a surplus of O-3s and a dearth of senior O-4s and O-5s). In an effort to retain more physicians, a separate promotion board was established in 1960 to promote Medical Corps officers separately from other officers. Higher promotion rates and faster promotion resulted, and retention was slightly improved. However, a perceived lack of rigorous military standards for medical officer promotions damaged the credibility of medical officers among other members of the officer corps.

Drafted doctors, who received only abbreviated professional military education before being sent to Korea, and then in the 1960s to Vietnam, reinforced the general perception of their inadequate leadership and professional military skills. In Korea several battalion aid stations were lost to the enemy because of failures in common field skills and leadership on the part of inadequately prepared battalion surgeons. Vietnam witnessed the Levy case, in which a drafted doctor refused to train medics for the Special Forces because (1) he thought they would misuse their medical knowledge (a violation of his medical ethics) and (2) the war was immoral and probably illegal, so the order to train them was not legal, and he should be excused by the Nuremburg precedent that one did not need to obey illegal orders.[15] (Levy was convicted under the Uniform Code of Military Justice, and his conviction was upheld by the Supreme Court on appeal; see Chapter 5, Military Law and Ethics.)

The negative perception of medical officers was furthered by the conduct of many field grade specialty providers in hospitals in the United States who failed to get appropriate haircuts and wore the uniform improperly, compromising good order and discipline. These problems declined with the discontinuation of the doctor draft, but some force structure problems persisted because of the rapid promotion of medical officers who did not have commensurate military experience. Frequently the physician was the second most senior officer in the battalion or on the cruiser, and not all specialty training was particularly adaptable to deployed settings. Additionally, professional military education for Medical Corps officers remained an administrative struggle because the medical service benefit for uniformed and then retired service members grew steadily after its introduction in 1956, and physicians were needed to provide care in peacetime.

The need for providers, especially specialty providers, made gaining professional military education and subsequent staff and command experiences at a junior level increasingly difficult for military medical officers. At the end of the Persian Gulf War, the Army surgeon general introduced a requirement thought radical by most of the AMEDD: that to be considered for the rank of colonel, a physician would need to successfully complete the Officer Advanced Course, a requirement for promotion to captain in the 1950s. The course, since renamed the Captains Career Course, is now mostly online with little required on-site instruction.

CONCLUSION

The military needs physicians to succeed as officers, and there is some evidence that the public and soldiers want physicians to be in charge of medical areas. There is a strong belief that physicians naturally take patient care questions into consideration in making command decisions. However, being a good, or even great, physician will not make someone a good commander; only good officers can command successfully. By the end of the 20th century, the need for officers to command had given rise to corps-immaterial command opportunities in medical units. While medical service and nurse officers have done exceptional jobs in command roles, the 21st century has seen a resurgence of Medical Corps command opportunities as military medical officers make the conscious decision to prepare themselves for command by pursuit of professional military education (often online) and seek appropriate positions earlier in their careers. To help combat service support as well as National Guard and reserve officers, the Staff College, renamed Intermediate Level Education, is available at various sites as well as online. Learning to be effective on a staff still requires knowing what is “consistent with the Service.”

Medical officers should attend Intermediate Level Education in their second medical utilization tour. They will find they know the medicine, and while all providers are constantly struggling to stay current, the provider with 4 or 5 years of practical experience is no longer concerned that their medical skills are inadequate. Also, at that point it is easiest to take a couple years out of the 60-hour-a-week clinic and serve on a staff or in a command preparation position. Consultants and specialty leaders are available to help with career planning. Good officership, like good medicine, is a deliberate choice and requires more than meeting a minimum requirement; in the words of the Byng court martial, it requires the commitment to “do your utmost.”

REFERENCES

1.   Oxford English Dictionary. Oxford and New York: Oxford University Press; 1971: sv “officer.”

2.   Royal Naval Museum. Information sheet: John Byng. http://www.royalnavalmuseum.org/info_sheets_john_byng.htm. Accessed August 15, 2017.

3.   Hackett JW. The Profession of Arms. London, England: Times Publishing Company; 1962: 63.

4.   Paré A. Les oeuvres de M. Ambroise Paré conseiller, et premier chirurgien du Roy avec les figures & portraicts tant de l’Anatomie que des instruments de Chirurgie, & de plusieurs Monstres. Paris, France: Gabriel Buon; 1575.

5.   Internet Archive. Full text of Chirurgiens et blessés à travers l’histoire des origines à la Croix-Rouge. https://archive.org/stream/chirurgiensetble00caba/chirurgiensetble00caba_djvu.txt. Accessed June 6, 2017.

6.   Pringle J. Observations on the Diseases of the Army. London, England: A Millar and D Wilson; 1752.

7.   Lind J. An Essay on the Most Effectual Means of Preserving the Health of Seamen, in the Royal Navy. London, England: D. Wilson; 1762. https://archive.org/details/essayonmosteffec00lin. Accessed June 6, 2017.

8.   Steuben FWA. Regulations for the Order and Discipline of the Troops of the United States. Philadelphia, PA: Styner and Cist; 1779.

9.   Craig SC. “Some System of the Nature Here Proposed”: Joseph Lovell’s Remarks on the Sick Report, Northern Department, U.S. Army, 1817, and the Rise of the Modern US Army Medical Department. San Antonio, TX: Borden Institute; 2015.

10.   The Medical and Surgical History of the War of the Rebellion. Washington, DC: Government Printing Office; 1870–1888.

11.   Laws Relating to the Navy, Annotated. Washington, DC: Government Printing Office; 1922.

12.   Straub PF. Medical Service in Campaign: A Handbook for Medical Officers in the Field. Philadelphia, P. Blakiston’s Sons; 1910.

13.   Gilchrist HL. A Comparative Study of World War Casualties From Gas and Other Weapons. Edgewood Arsenal, MD: Chemical Warfare School; 1928.

13.   Ireland MW. Medical Aspects of Gas Warfare. Vol XIV in: The Medical Department of the United States Army in the World War. Washington, DC: Government Printing Office; 1926.

14.   US War Department, Air Service, Division of Military Aeronautics. Air Service Medical. Washington, DC: Government Printing Office; 1919.

15.   Parker v Levy, 417 US 733 (1974). https://supreme.justia.com/cases/federal/us/417/733/case.html. Accessed June 6, 2017.

Chapter 2

ROLES AND RESPONSIBILITIES OF THE MILITARY MEDICAL OFFICER

JUSTIN WOODSON, MD, MPH*

INTRODUCTION

THE UNIQUE MILITARY ENVIRONMENT

In Garrison

In the Field

Deployment

Human Performance Optimization and Medical Research

BEING A MILITARY MEDICAL OFFICER

The “Vector” Model of the Military Medical Officer

The Legal Context of Accountability as a Military Medical Officer

Training and Professional Military Education

Leadership as a Medical Officer

MILITARY HEALTHCARE

FORCE HEALTH PROTECTION AND MEDICAL READINESS

THE SPECTRUM OF ASSIGNMENTS

SUMMARY

*Colonel, Medical Corps, US Army; Associate Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

The new military medical officer (MMO) has joined a proud tradition of military medicine. That much becomes evident while reviewing the first chapter of this textbook, on the history of military medicine, which reaches back to long before the US military was even created. A new MMO follows in the footsteps of the likes of Ambroise Paré, Dominique Jean Larrey, John Pringle, Benjamin Rush, Robert Brocklesby, Jonathan Letterman, William Hammond, George Sternberg, and the countless modern military medical officers who have shaped this profession, saved thousands of lives, and improved the lives of thousands more. But unlike these historic figures who forged the way, current MMOs enter into a well-established system of military medicine in which many of the hard-fought challenges have already been won. But what makes the military medical system different? What is unique about practicing medicine in the military as compared to the more common pathway of civilian medicine? The purpose of this chapter is to explore those questions, many of which will be amplified in later chapters in this textbook. This chapter will provide a framework for MMOs beginning to think about their new role as a uniformed medical officer in the US Army, Air Force, Navy, Coast Guard, or Public Health Service.

THE UNIQUE MILITARY ENVIRONMENT

The discussion begins with a conversation about the unique aspects of the military environment. Typically, the public associates the military with combat. But the mission of the Department of Defense is much broader than just combat. A new MMO is likely to be placed in supporting units in a variety of environments, including in garrison, in the field, and deployed, each of which presents a unique set of challenges.

In Garrison

The garrison is where it begins and where the MMO will spend most of his or her time. This is the permanent positioning of military assets throughout the world. A quick Internet search will reveal the breadth of geographic assignments available. The US military is deployed on a standing basis throughout the world and has military bases not only in the continental United States (CONUS) but also in a large number of countries outside the continental United States (OCONUS).

In garrison, permanent structures and buildings, well-established computer networks, and a generally resource-rich context form a familiar setting. Garrison hospitals, established in locations where service members are concentrated, generally function much as civilian hospitals do and are subject to many of the same constraints, including outside accreditation, interaction with the community, insurance billing, medical training programs, and the requisite administrative load. Yet even in garrison there are palpable differences from the civilian environment. While the patient population may look much like it does in a civilian hospital (including children, adult family members, aging retirees, and ill or injured active duty service members), the practice of medicine will often feel less restricted because access to care, financial considerations, and medical insurance are generally not issues. The healthcare team will be mixed, including active duty providers, government employees, and contractors, and each group presents unique leadership challenges.

For the MMO within this setting (as in all others), leadership is an inherent part of his core responsibilities. Although the medical team will not generally be dealing with the immediate threat of combat, the complexity of the garrison environment makes leadership demanding. As a leader, an MMO is likely to struggle with balancing multiple superimposed missions and external influences while maneuvering through large organizational staffs that often lack cohesion[1] and may focus on varying aspects of the mission. Also, medical teams are often recovering from frequent and recent deployments with the inherent accompanying emotional burdens. As their leader, an MMO must be in tune with these challenges while attempting to balance the mission against team members’ personal lives outside the workplace.

It is well established that in this context, boredom often leads to poor decision-making, which may result in unwanted injuries or fatalities, from causes including privately owned vehicle accidents, suicide, and recreational mishaps.2–5 Addressing these hazards must be an ongoing focus for leaders. Additionally, the attention of effective leaders will center on the support and development of their team members as professionals through informal mentorship and formal programs, while also attending to their own personal growth and development. New MMOs must establish themselves as a physician and officer while becoming familiar with general life in the military.

The new officer will find a robust support infrastructure in garrison, including physical fitness facilities, recreational facilities, financial counseling, emotional and spiritual counseling, professional mentorship, and a thriving community of military peers and neighbors to lean on. An assignment in garrison will ultimately prove rewarding as an opportunity to develop a sense of belonging and pride in being part of a longstanding military tradition.

In the Field

Often, an MMO assigned to a fixed medical facility will also be attached to an operational unit as a secondary duty. The details of this responsibility vary throughout the different uniformed services and evolve over time. One constant, however, is that training remains a focus for operational units. Any time a military unit trains in the field, it is accompanied by a medical officer. The medical officer is usually integrated into the commander’s staff as a command surgeon, similar to arrangements in the deployed setting. (The details of this role will be discussed in more detail in Chapter 8, The Medical Officer on the Commander’s Staff.)

Providing medical support in the field environment serves as a rehearsal for deployments. Undergoing training without the stress of the combat environment will better prepare MMOs for future operational assignments. The MMO must learn to work without the infrastructure typical of the garrison hospital, adjusting to providing care in a resource-constrained setting, a universal feature of military operations. Exploring these pitfalls in the field environment where there is an “escape valve” (typically available in the nearby garrison) will prepare MMOs for missions in which no safety net will be present.

New MMOs are encouraged to seek opportunities to join the operational unit in training, which can provide some of the most rewarding experiences of a new military career. Such opportunities may include training outside the Army or Marine Corps garrison, flying on a cross-country mission with the Air Force, or going underway with a seaborne unit in the Navy or Coast Guard. Experiencing life at sea, in the field, or in the air is what truly makes a military medicine career unique. Short field exercises, cruises, or cross-country flights will require very little preparation; however, longer exercises demand early involvement with the unit and planning. Gaining new skills and new relationships with other service members will also go a long way toward building credibility within those units, particularly when MMOs deploy with the same unit. There is also no better opportunity than participating in the field exercise or training mission to develop leadership skills as an officer and staff member, skills which the junior medical officer will do well to develop early; these skills will pay large dividends throughout a military medicine career.

Deployment

A “deployment” refers to any activity in which military personnel and materials are moved from their home station (garrison) to a specified destination, typically overseas (OCONUS), although domestic deployments are not uncommon, particularly in response to natural disaster relief efforts. Deployments come with a wide variety of missions, ranging from security operations in which the primary focus is diplomacy and conflict prevention, to large-scale combat operations, with many types of mission in between (Figure 2-1).[6]

Because the unit may have a mission that falls anywhere on this spectrum of conflict, and because the location of that deployment may be anywhere in the world (including CONUS), the nature of each experience will be unique. What is nearly universal, however, are long work hours often punctuated by long periods of boredom. Deployments are what military officers train for. It is the challenge of accomplishing the mission with usually limited resources in suboptimal conditions while testing leadership skills, medical skills, military skills, creative thinking, and problem-solving that make deployments rewarding beyond compare. Deployments are essential to developing a full spectrum of leadership and military medicine skills when and where they count the most.

Deployments consist of four phases, during which the medical officer will play very different roles. During the predeployment phase, the MMO plays a critical role in ensuring all members of the unit are prepared for extended deployment from a medical perspective. During this phase, in addition to evaluating and supporting unit members’ readiness for deployment, the MMO must ensure the medical team is trained and ready for the mission, as well as completing personal preparation.

During the deployment phase, while actually on the mission, the MMO’s duties will span a spectrum of responsibilities no civilian medical provider would encounter. The scope of these responsibilities (discussed in more detail in later chapters) ranges from medical treatment to disease prevention to complex medical planning. During deployments, the medical officer is faced with challenges in the patient population (the unit) related to freedom of movement, fatigue, long working hours, threats from hostile action, endemic disease, stress-induced physiologic changes, and general physical and emotional demands related to the specific mission. The MMO’s importance to the commander cannot be understated, and the better prepared they are, the better they will perform as the principal medical advisor to the unit.

Figure 2-1. The conflict continuum.
Reproduced from: US Department of Defense. Joint Operations. Washington, DC: DoD; 2017. Joint Publication 3-0: VI-2.

During the postdeployment phase, the MMO will play a key role in assessing the impact of the deployment on unit members. And finally, during the reintegration phase, the MMO will be a key set of eyes and ears for commanders as they endeavor to ensure unit members successfully overcome postdeployment challenges and rejoin their families and communities.[7]

Human Performance Optimization and Medical Research

Whether in garrison, in the field, on a training mission, or deployed in a theater of operations, the demands on the military “patient” are generally amplified over that seen in the civilian occupational setting (although some civilian occupations or sports do present extreme exposures). Accordingly, one of the unique aspects of military medicine is gaining a thorough understanding of environmental and operational challenges and their countermeasures as summarized by the scientific discipline of human performance optimization (HPO). HPO refers to the process of enabling persons to perform with a high level of well-being and resilience and with minimal risk and stress, despite the challenges of the operational environment. This field includes physical fitness, dietary supplements and nutrition, mind and body management, family and relationships, and environmental conditions (eg, heat, cold, altitude, aerospace, water, and extended operations).[8] The MMO is expected to be well-versed in the science of HPO in order to provide counseling to individual service members and commanders and facilitate the successful mission completion, regardless of environment. Accordingly, an entire section of this textbook (chapters 19 through 31) is dedicated to this science.

Because the military operates in the worldwide environment, it is also incumbent on the MMO community to continue engaging in medical research and development programs that focus on unique aspects of military medicine. This may include combat trauma management, HPO, human factors systems (eg, aviation, weapons systems, or combat vehicles), and a wide variety of other topics of unique interest to the military. Additionally, military medicine requires global biosurveillance programs that enable worldwide deployment with manageable risk for biological and disease threats, while also helping protect world populations against pandemic and epidemic disease.[9]

BEING A MILITARY MEDICAL OFFICER

“If you are looking for perfect safety, you will do well to sit on a fence and watch the birds; but if you really wish to learn, you must mount a machine and become acquainted with its tricks by actual trial.”

—Wilbur Wright, from an address to the Western Society of Engineers
Chicago, IL, September 18, 1901[10]

While it is possible for any medical provider to practice “medicine in the military,” it is the unique characteristic of the professional MMO to truly integrate all aspects of military medicine and officership into a dedicated practice of “military medicine.” Practicing military medicine requires that the individual develops skills in multiple dimensions. The MMO is a dual professional—both a physician and an officer—and must excel in each role to be successful. The nature of this duality will be further explored in Chapter 8.

The “Vector” Model of the Military Medical Officer

Through the years, attempts have been made to summarize the qualities of a good MMO, but most frequently these discussions devolve into a general statement of advice that “you just have to experience it to understand it.” While it is true that experience will elucidate the complexity of the unique role of the MMO, it is helpful to provide a simple visual model that embodies the full spectrum of characteristics of the ideal balanced MMO.

The “vector” model of the MMO was first proposed at the Uniformed Services University in the early 1990s by then commandant of students, Colonel Barry Wolcott. An emergency medicine physician by training, Dr Wolcott understood the challenges of developing young medical officers and the value for those officers in providing visualization to help direct their growth. Modified slightly over time, the vector model simply places three primary domains of required skills for the ideal MMO onto the axes of a 3-dimensional graph (Figure 2-2). This graph illustrates the need for the individual to develop military skills, medical skills, and leadership. Effectively developing skills in these three arenas ultimately merges them into collective competencies in operational medicine, physicianship, and officership, which define the dual professional MMO. These terms, as applied in the model, are defined as follows:

- Officership is a set of skills that allows one to function effectively as an officer in the military. Underlying officership are principles, practices, and values that guide an officer’s judgment, decisions, behavior, philosophy, and vision. Inherent in officership is effective leadership.

- Physicianship is a set of skills that allows one to function effectively as a physician with skill in the art of healing. A physician is educated, clinically experienced, and licensed to practice medicine.

- Operational medicine adds to standard clinical medicine all of the unique challenges of the practicing military provider in the operational environment, many of which may be non-medical in nature. This includes a combination of both military and medical skills and implies direct and indirect leadership within the context of the military mission.[11]

- Leadership is influencing people by providing purpose, direction, and motivation. It is the sum of the qualities of intellect, human understanding, and moral character to enhance the motivations, cognitions, and behaviors of individuals and groups for successful accomplishment of the assigned mission.[12]

- Professionalism is the fundamental core of a medical officer’s values and behavior, including the critical attributes of personal courage, respect, openness, fairness, empathy, self-improvement, social responsibility, integrity, honor, officership, non-judgment, altruism, and leadership.[12]

Figure 2-2. The dual professional “vector” model.
Figure courtesy of: Colonel (Retired) Barry Wolcott, Commandant of Students, Uniformed Services University of the Health Sciences, 1982–1993.

The Legal Context of Accountability as a Military Medical Officer

Beyond the challenges of duality and environmental and operational variables already discussed, there is also a collection of constraints and requirements that are unique to practicing medicine in the military. The most important of these is the legal context of general military service, which will be discussed in further detail in Chapter 5, Military Law and Ethics. However, it should be made clear that wearing the uniform inherently introduces accountability of the individual to the American public. The military officer is first and foremost a member of the military, meaning that he or she is subject to military law, which is founded in the Uniform Code of Military Justice, the Manual for Courts-Martial, and the military code of conduct.[13] The disciplinary measures applicable to other service members apply equally to the military physician, and because consequences of misconduct can be severe, disciplinary action for such conduct is also potentially severe.

EXHIBIT 2-1

CODE OF CONDUCT FOR MEMBERS OF THE UNITED STATES ARMED FORCES

I

I am an American, fighting in the forces which guard my country and our way of life. I am prepared to give my life in their defense.

II

I will never surrender of my own free will. If in command, I will never surrender the members of my command while they still have the means to resist.

III

If I am captured I will continue to resist by all means available. I will make every effort to escape and aid others to escape. I will accept neither parole nor special favors from the enemy.

IV

If I become a prisoner of war, I will keep faith with my fellow prisoners. I will give no information or take part in any action which might be harmful to my comrades. If I am senior, I will take command. If not, I will obey the lawful orders of those appointed over me and will back them up in every way.

V

When questioned, should I become a prisoner of war, I am required to give name, rank, service number and date of birth. I will evade answering further questions to the utmost of my ability. I will make no oral or written statements disloyal to my country and its allies or harmful to their cause.

VI

I will never forget that I am an American, fighting for freedom, responsible for my actions, and dedicated to the principles which made my country free. I will trust in my God and in the United States of America.

____________

Reproduced from: 3 CFR, 1954-1958. Code of Conduct for members of the Armed Forces of the United States, 1955. Executive Order 10631.

Military officers are additionally obligated by law to demonstrate exemplary personal and public conduct (Exhibit 2-1).[14] Unfortunately, more than one new medical officer has become entangled in the legal landscape with the threat of imprisonment or other adverse legal and administrative action based on a failure to understand their obligations under military law. Additionally, the system of military law has sometimes presented an ethical conflict in which the medical officer’s obligation to follow lawful orders from the commander and superiors may come into conflict with the Hippocratic principles of medical care. Learning to balance concerns such as patient confidentiality and sometimes competing obligations to the commander can be challenging, but understanding expectations of personal conduct in times of peace and war may prevent troubles down the road.

Training and Professional Military Education

Upon entering military service, the new MMO is normally offered an opportunity to attend initial officer training (eg, the Army’s Basic Officer Leadership Course, the Navy’s Officer Indoctrination School, or the Air Force’s Commissioned Officer Training or equivalent). This training provides an orientation to military customs and courtesies, administrative and legal education, and basic military knowledge and skills. This minimal training is intended to start a career with minimal delay, but by no means is it adequate preparation for a full career in military medicine. To develop officership, the military services provide a series of professional military education (PME) courses strategically placed at different points in the career timeline.

While the structure of this PME is different in each service, the intention is the same—to develop general knowledge and capabilities as an officer in the parent service as an individual matures in the ranks. The reality, however, is that medical education and the demands on an individual officer often interfere with or delay this training. In keeping with the earlier discussion about professional development along three axes, it is incumbent upon MMOs to advocate for themselves and seek out opportunities to attend this training at key points in their careers. Doing so will better prepare an MMO to integrate seamlessly into a multidisciplinary team when assigned to a military unit.

Additionally, the military offers a wide variety of short courses that focus on specific military skills, which may be relevant depending upon specific career choices and assignments. While it may seem low priority to attend such training while being heavily engaged in early professional medical development (eg, residency, fellowship), failure to receive appropriate PME may delay promotion, and more importantly, result in suboptimal preparation for deployment and integration with operational units.

MMOs must recognize that they are members of both the profession of arms and of the profession of medicine. Programs such as those offered at the Uniformed Services University of the Health Sciences or in general PME can help jump-start careers in military medicine with an understanding of basic principles, but they are only a starting point. Experience will serve an MMO well; however, true professionals will continue to develop themselves as both officers and physicians through continuing medical education and continuing military education. This further education may take the form of personal reading programs, military short courses, and of course formal medical education such as residency and fellowship. Just as someone cannot expect to be a whole doctor after completing medical school, he or she cannot expect to be a whole officer and leader after attending an introductory military course. Success demands a commitment to professional development as an officer.

Leadership as a Medical Officer

Leadership, one of the three pillars of military medical practice, is critical to an MMO’s success. At the Uniformed Services University, leadership is taught through the “PITO” (personal, interpersonal, team, organization) model of leadership, adapted from the US Air Force Academy and using the “four Cs” of leadership (Character, Competency, Context, and Communication).[15] Leadership is a multidimensional process, which is discussed in detail in Chapters 4 and 8. It should be noted that while direct leadership is often required, the MMO must (perhaps uniquely) often provide tangible leadership when not in a position of direct authority. This aspect of medical leadership presents a unique challenge to the medical officer, one that must be mastered in order to most effectively influence the mission and the command. The ability to gather support from below as well as from above, or “leading up,”[16] is a critical component of the successful MMO. Leadership in the military is challenged by the diversity of personnel, the spectrum of missions, dynamic operations, and unique environments. A continual thread of personal leadership skills development accompanies the successful MMO’s career. In addition to formal programs of education in leadership, which will only scratch the surface, officers are encouraged to engage in a personal reading program to broaden their perspectives and abilities to influence others to accomplish the mission, regardless of the types of assignments they encounter.

The military is no better than its people, and the American public has charged the MMO with caring for them. Taking care of his or her soldiers, sailors, airmen, and or marines is paramount. As a leader in the military, the new MMO will also be responsible for a number of junior officers and noncommissioned officers. Accordingly, he or she will serve as both mentor and sometimes commander of these individuals. This requires effective mentorship. It requires extra time in a hectic military setting to submit awards recommendations when deserved, and to spend the extra effort learning how to write effective periodic evaluations, which enhance the promotion prospects of team members. These skills in and of themselves are not taught, but rather obtained through personal education and development, once more highlighting the need for self-directed education as a military officer. New MMOs should seek out those who understand the nuances of evaluation writing, such as the senior enlisted advisor for the command or fellow staff officers with more experience. One of the best ways to gain credibility with subordinates is by reaching out in mentorship to assist them in developing their own careers both in and after the military.

Successful military leadership, particularly with increasing rank and position, relies heavily on effective communication. This comes in the form of one-on-one communications that serve to provide specific guidance to individuals, meeting management, written communications, and often large-scale public speaking. Speeches may range from a short set of well-chosen words at a promotion ceremony to a command-wide briefing given to address a problem or provide motivation. In the military, all staff officers are expected to frequently provide briefings to senior officers, commanders, and large assemblies—opportunities to build (or lose) credibility. Briefings often have a formal structure MMOs need to be familiar with. The ability to eloquently deliver a public address is a universal requirement for effective military officers. Young and experienced officers alike are encouraged to build these skills by actively seeking opportunities for public speaking and large group teaching. Speaking skills will enhance their ability to lead and will improve vital skills as an educator (inherent in medical leadership). Military communication skills are further discussed in Chapter 11, Military Communication.

MILITARY HEALTHCARE

At first glance military medical care is very similar to civilian medical care. Residencies and military training hospitals are similar to those in large academic medical centers throughout the country. As discussed earlier, the patient populations can be quite similar to the civilian population, which includes the full spectrum of humanity from fetal care to caring for the aged and dying. Military training hospitals require the same spectrum of full-service clinical capabilities and research programs as are found outside the military. While it may be possible for some MMOs to serve their entire military careers in an academic military medical center, these centers are not where all, or even most, medical care happens in the military. For MMOs who choose (or are selected) to serve outside the academic medical center environment, medical care delivery may take on a very different feel. In the unit, in the field, or on deployment, delivering medical care is integrated with the diverse administrative and leadership tasks that have been discussed thus far in this chapter.

MMOs will often be taking care of friends or colleagues who they have relationships with outside of the clinical setting. The unit’s medical officer is implicitly trusted, often to the exclusion of other medical providers, unless he or she loses credibility. Establishing and maintaining a trusting relationship with the patient population in this setting is paramount to success in delivering medical care. MMOs without credibility in the unit will find themselves bored and alone when their patients choose to go elsewhere or simply do not seek treatment. This dynamic highlights the importance of effective communications and leadership, as discussed earlier. To a large degree, while doctrine will provide a specific level of medical capability for the unit, the ability to provide care will be highly dependent upon the medical officer’s diligence in establishing programs and relationships within the unit, and with neighboring and higher level medical units.

When a member of the unit reaches out for help with a medical or mental health concern, there may not be the benefit of privacy or a robust medical capability as is customary in a medical facility. Learning to do more with less is the rule rather than the exception. However, the goal should be to provide the same standard of medical care in the resource-constrained, remote, or austere environment as would be expected in the academic medical center. Knowing who the more experienced senior physicians and consultants are and how to consult them at all times is paramount, even when a consultation may require a helicopter or telemedicine. MMOs will also need to interact with higher level medical authorities or the medical treatment facility in order to facilitate the unit’s medical mission. This may mean interacting with medical consultants on behalf of a specific patient for clinical concerns or working with other units for the sake of medical logistics or disease and nonbattle injury (DNBI) reporting. Once again, understanding the MMO’s place in the system will be critical for success.

Integrating medical practice with the unit’s operational flow is not only critical, but can be very difficult, requiring extensive communication with commanders or key leadership personnel in the unit or across the military installation. Traditionally, “sick call” is held at times convenient to the command. Upon arrival at the unit, the MMO should learn about the systems of scheduling sick call that are currently in place or have worked (or failed) at that location. While it may be convenient to have all of the clinical workflow for the day show up at the same time, this methodology may not work well for the commanders or patients. On the other hand, in some settings distributed scheduling of medical appointments throughout the day may not be conducive to mission accomplishment. These considerations are not often encountered in civilian medicine and require the constant attention of the MMO.

Once evaluated, military patients are expected to return to duty as soon as possible. A critical role of the MMO is to evaluate the ability of service members to return safely to their regular duties. Given the nature of military operations discussed thus far, it should go without saying that this assessment must be made in the context of the occupational requirements for that individual’s duty. This highlights the importance of participating in the local training to the extent possible in order to gain a personal understanding of the operational context. Throughout history, successful military medicine practitioners have advocated for medical officers to train with their units for this purpose, whether flying with an aviation unit, diving with a diving unit, or practicing on the weapons range with a combat unit. Getting into this habit earlier rather than later will help not only to build a personal military skill set, but more importantly will enhance the ability to communicate and interact effectively with the commanders. Accordingly, when the time comes to advocate for a patient’s healthcare or duty restrictions, the MMO will be in a much better position to make appropriate decisions about patients while minimizing adverse effects on mission accomplishment.

In the military more than perhaps any other environment, medical care relies on established programs and systems to provide a full range of medical capability. In a theater of operations, systems of medical evacuation and a hierarchical system of medical capabilities are established based on doctrinal principles.6,17 Individuals are assigned throughout those systems to provide direct management and expertise for specific capabilities, which require specific training. The MMO may be expected to attend such training as well as to train others. Understanding who and what they are responsible for will help guide priorities, but MMOs should expect to be placed in positions with direct training responsibilities for hospital corpsmen, combat medics, physician assistants, nurse practitioners, nurses, or other medical personnel. The MMO may conduct formal training programs or simply provide continuing education for medical personnel. Commanders may have interest in developing common medical skills among their nonmedical personnel, in which case the MMO will be asked to supervise broader medical training programs such as the combat lifesaver program, which focuses on immediate combat casualty response for laypersons, or basic life support cardiopulmonary resuscitation programs. Whatever the case, conducting and supervising training will be a key component of any military medical practice.

The demands of military operations have resulted in remarkable achievements in military medicine throughout history. Recent conflicts have seen the introduction of new approaches and training programs that have resulted in improved survivability on the modern battlefield.[17] Specifically, the Tactical Combat Casualty Care system of emergency medical response, which emphasizes altered priorities of emergency medical delivery in the combat threat environment, now governs the approach to the combat casualty. This program is taught in a variety of venues targeting the full spectrum of military medical providers. Beyond the immediate life-saving response, casualties must be moved through an evacuation system that requires specific expertise in en route care and health service support planning. Later sections in this textbook will address the delivery of healthcare in the tactical environment and operational health service support, both pillars of military medical practice.

FORCE HEALTH PROTECTION AND MEDICAL READINESS

Arguably more important than responding to combat trauma or other health-related events is preventing them. Casualty prevention is a key component of what is referred to in the US military healthcare system as force health protection. Force health protection includes a broad spectrum of prevention and protection capabilities, including preventive medicine, health surveillance, combat and operational stress control, preventive dentistry, vision readiness, laboratory services, and veterinary services.[17] The key element of this system, which is somewhat unique to military medicine, is a focus on the population. In contrast, traditional medical education and practice places focus on the individual patient. For the MMO, the entire unit is the “patient.” As described in Figure 2-3, MMOs must attend to the individual patient while simultaneously caring for the population. This requires a focus on leadership, public health, preventive medicine principles, and systems-based practice. It typically means integrating with established force health protection systems at the macroscopic level while simultaneously creating effective force health protection systems at the local level.

An important aspect of force health protection is managing physical standards for military service. Through experience, the military learned it had to evaluate the medical fitness of its members to ensure they were free of medical conditions that could limit their performance in the military operational environment. Current physical standards for induction or continued service in the armed services are published by the Department of Defense18,19 and implemented according to service-specific regulations (eg, Army Regulation 40–501,[20] Air Force Instruction 48-123,[21] and NAVMED P-117[22]). While new recruits are typically processed in military entrance processing stations across the country, applicants for entrance into officer commissioning programs or special duties often present directly to the MMO for evaluation. Furthermore, service members are subject to separate (and often higher level) physical standards when they apply for special duties (eg, aviation, Airborne, undersea, or special operations). The MMO must be familiar with published physical standards for general and special duty as applicable in their respective service. Specific administrative processing of such applications often permeates the military medical practice of the physician assigned to an operational unit.

Figure 2-3. The spectrum of focus for military medicine.

The same physical standards apply when an individual service member becomes ill or injured. In these instances, temporary restrictions to duty may be necessary. Specific systems of communicating such restrictions to the service member’s leadership are in place to prevent misunderstanding. Such “limited duty (LIMDU) chits” or “profiles” reflect the published physical standards for each service and must be mastered by the MMO. In developing appropriate duty restrictions, the MMO effectively protects the service member from further injury while at the same time protecting the unit by eliminating unsafe or ineffective duty performance.

Under certain circumstances, such as when a new diagnosis is made or a temporary condition lingers for an extended period of time, the service member may no longer be physically qualified for continued military service under the published physical standards. In these cases, a formal review process is invoked, during which the service member must undergo a medical and physical evaluation board process, and possibly service-specific formal boards, that evaluate the service member’s limitations against their ability to perform their assigned military occupational specialty. Understanding and working with this process is a necessary part of military medicine. Placing individual medical disposition decisions in the context of a thorough understanding of the military environment and the task that the individual service member has to perform further enhances the MMO’s value to the command team.

In addition to managing individual service members’ conditions and duty disposition, the MMO performs a preventive medicine function to identify and employ countermeasures (carefully coordinated with the command team, as discussed in Chapter 1, History of the Military Medical Officer) for the prevention and control of communicable diseases and endemic, occupational, or environmental threats.[17] History has shown that DNBIs have had a more significant impact on military outcome than combat injuries. Accordingly, a tremendous emphasis has been placed on preventing DNBI. Immunization programs, preventive dentistry, area assessment, and disease monitoring and reporting are important aspects of force health protection. At all levels of medicine in the military, someone is tracking and reporting disease incidence with the intent of identifying trends and epidemics and implementing preventive countermeasures.

Additionally, preventive immunization programs are mandated throughout the military, and compliance with these requirements is routinely reported at the command level. At the local unit level, and occasionally when assigned in a specific staff role at a higher level, the MMO can expect to prepare periodic reports and briefings on DNBI rates and individual medical readiness for the unit. As Benjamin Rush recognized, command authority is necessary to effectively employ countermeasures to prevent disease.[23] But it is the MMO who must identify both the problem and the appropriate corrective action. These and many additional force health protection factors that make military medical practice unique will be further discussed in the second section of this textbook.

THE SPECTRUM OF ASSIGNMENTS

While it would be attractive to place a career map on the table to guide the way, it is simply unrealistic to articulate a specific pathway that each new MMO should take. Although attempts to define a career lifecycle for MMOs have been made, the reality is that such structure has never stood the test of time. There are simply too many variables and too many opportunities (in terms of types of assignments) to explore. New officers should talk to as many people as possible to explore what types of missions and assignments may be pursued. With some planning and effort, MMOs can craft their own military medical career.

In the Army, the first decision is whether to pursue an assignment in a tactical or a nontactical unit. Each has its own rewards and challenges. In a tactical unit, the MMO works closely with combatants, likely as a member of the command and staff team (discussed in detail in Chapter 8). In these units an MMO has the opportunity to function in a truly operational capacity as a member of a multidisciplinary team pursuing a military mission in the unique operational environment. On the other hand, an MMO may choose to focus on nontactical assignments such as academic medicine, or to engage in unique research or challenges in clinical medicine. The choice is personal, but the best advice has been described as sharing time between “white coat” assignments and “muddy boots” assignments. Doing so provides the broadest perspective on Army medicine and best preparation for promotion to the ranks of general officer. Whether or not this aspiration prevails, a diversity of assignments and experiences are waiting, and the full spectrum of opportunities should be explored.

In the Navy, a critical decision is whether to pursue assignment in the seagoing Navy or in the Marine Corps. They are very different communities, and each has its own proud traditions. While it is possible to share time between them, most naval medical officers choose to focus on a progression of assignments in one or the other. If the interest is in tactical assignments, the Marine Corps has a wide variety of missions requiring support from highly motivated MMOs. On the other hand, shipboard medicine presents unique opportunities for international travel and expeditionary medicine. Aviation medicine, undersea medicine, and naval special operations are other unique opportunities.

In the Air Force, the primary choice is whether to join a flying or a nonflying unit. In either case, the MMO should become a flight surgeon. The Air Force is all about aviation, and understanding aviation medicine is a key component of Air Force medicine. The Air Force is an expeditionary force and also presents its own opportunity for ground-based expeditionary medicine. If the MMO’s passion is to establish medicine in far-reaching places across the globe, this may be the right choice. On the other hand, there is possibly no more rewarding opportunity than to work with the high-performance combat equipment in the world’s largest and most advanced Air Force—equipment that challenges the limits of human performance. Mastering human performance optimization may be the MMO’s passion, and what better place to do it than the US Air Force?

In the Public Health Service, opportunities are available in a wide variety of assignments. The Indian Health Service will take the MMO to remote locations with resource constraints similar to those of the military deployed setting. There are also roles available supporting the US Coast Guard with opportunities in operational or aviation medicine. Or the choice may be to work in various agency jobs shaping national healthcare policy with an opportunity to impact the health of the entire nation.

SUMMARY

Regardless of the type of assignments encountered, a career in military medicine will be exciting and rewarding. Nowhere else will there be the opportunity to engage in such a diverse range of experiences. While frustrations abound in any type of work, the rewards of service in military medicine far outweigh any inconveniences an MMO may encounter. Opportunities to gain new skills through education programs in both military and medical disciplines, unique life experiences, and being a part of the distinguished heritage of the armed services all contribute to the allure of military medicine. Having said that, it should be emphasized that this career is only as good as the individual makes it. MMOs must be their own advocate; they should seek out opportunities to challenge themselves and to experience the full spectrum of military service. MMOs should actively endeavor to fulfill their goals, stay proactive, manage their personal administrative requirements, and seek out the best training opportunities and assignments. Speaking regularly with a senior military mentor and a career manager can help to shape the MMO’s military medicine as desired.

The remainder of this textbook is designed to provide exposure to the unique aspects of military medicine introduced in this chapter. Reading and assimilating this knowledge will build a firm foundation for beginning a career as an MMO. However, it is incumbent upon the new MMO to commit to a career-long personal development program in leadership, military skills, and medical skills in order to truly become a dual professional MMO.

REFERENCES

1.   Roginkski J. Operational assessments in the garrison environment. Infantry Magazine. 2015;104(2):26–29.

2.   US Army Combat Readiness Center. Army statistics and reports, weekly update. https://safety.army.mil/STATISTICS.aspx. Accessed June 26, 2017.

3.   Naval Safety Center. How goes it FY 2016. http://www.public.navy.mil/NAVSAFECEN/Documents/statistics/How-GoesIt.pdf. Published October 27, 2016. Accessed June 26, 2017.

4.   US Department of the Navy. Occupational safety mishap summary FY 2007 to 2017. http://www.public.navy.mil/NAVSAFECEN/Pages/statistics/index.aspx. Updated June 23, 2017. Accessed June 26, 2017.

5.   Goldberg MS. Updated Death and Injury Rates of U.S. Military Personnel During the Conflicts in Iraq and Afghanistan. Washington, DC: Congressional Budget Office; 2014. Working Paper 2014-08.

6.   US Department of Defense. Joint Operations. Washington, DC: DoD; 2017. Joint Publication 3-0.

7.   Marek LI, Hollingsworth WG, D’Aniello C, et al. Returning Home: What We Know About the Reintegration of Deployed Service Members Into Their Families and Communities. St Paul, MN: National Council on Family Relations; 2012.

8.   Uniformed Services University Consortium for Health Military Performance. About HPRC. http://hprc-online.org/about-us/about-hprc#about-us. Accessed June 26, 2017.

9.   US Department of Defense. Special report: biosurveillance. https://www.defense.gov/News/Special-Reports/1012_bio-surveillance/. Accessed June 26, 2017.

10.   Smithsonian Institution, Board of Regents. Annual Report of the Board of Regents of the Smithsonian Institution. Washington, DC: Smithsonian Institution, 1902:134. https://library.si.edu/digital-library/book/annualreportofbo1902smit. Accessed June 15, 2018.

11.   Woodson J. USUHS leadership development program. Lecture presented at: Military Contingency Medicine and Operation Bushmaster; June 27, 2011; Uniformed Services University, Bethesda, MD.

12.   Woodson J. Becoming a battalion surgeon. Lecture presented at: Tzameret Program; April 29, 2015; Hebrew University, Jerusalem.

13.   3 CFR, 1954-1958. Code of Conduct for members of the Armed Forces of the United States, 1955. Executive Order 10631.

14.   Requirement of exemplary conduct. 10 USC § 3583 (1997).

15.   O’Connor F. Military medical practice and leadership program of instruction. Lecture presented at: Uniformed Services University faculty assembly; November 13, 2014; Bethesda, MD.

16.   Useem M. Leading Up: How to Lead Your Boss So You Both Win. 1st ed. New York, NY: Three Rivers Press; 2001.

17.   US Department of Defense. Health Service Support. Washington, DC: DoD; 2012. Joint Publication 4-02.

18.   US Department of Defense. Physical Standards for Appointment, Enlistment, or Induction. Washington, DC: DoD; 2000. DoD Directive 6130.3.

19.   US Department of Defense. Physical Standards for Appointment, Enlistment, or Induction. Washington, DC: DoD; 2004. DoD Instruction 6130.4.

20.   US Department of the Army. Medical Services. Standards of Medical Fitness. Washington, DC: HQDA; June 14, 2017. Army Regulation 40-501. https://armypubs.army.mil/epubs/DR_pubs/DR_a/pdf/web/ARN3801_AR40-501_Web_FINAL.pdf. Accessed June 15, 2018.

21.   US Department of the Air Force. Medical Examinations and Standards. Washington, DC: USAF; November 5, 2013. Air Force Instruction 48-123. http://static.e-publishing.af.mil/production/1/af_sg/publication/afi48-123/afi48-123.pdf. Accessed June 15, 2018.

22.   US Department of the Navy. Manual of the Medical Department (MANMED). Washington, DC: USN; June 1, 2018. NAVMED P–117. http://www.med.navy.mil/directives/Pages/NAVMEDP-MANMED.aspx. Accessed June 15, 2018.

23.   Rush B. Directions for Preserving the Health of Soldiers. Lancaster, PA: John Dunlap; 1778.

Chapter 3

OFFICERSHIP AND THE PROFESSION OF ARMS IN THE 21ST CENTURY

ISAIAH WILSON III, PHD,* AND MICHAEL J. MEESE, PHD†

INTRODUCTION

THE OFFICER’S OATH AND COMMISSION

THE ROLES OF AN OFFICER

Warrior-Leader in the Profession of Arms

Member of a Profession

Servant of the Nation

Leader of Character

CIVIL-MILITARY RELATIONS AND SOCIETY TODAY

The “Unequal Dialogue” and the All-Volunteer Force

The Military Profession and the Defense Bureaucracy

Role of Professional Officers—Even After Retirement

TYPES OF SPECIALIZED EXPERTISE

The Army: Obedient Servant Emphasizing People

The Air Force: Victory Through Technology

The Navy: Independent Exercise of Sovereignty

The Marine Corps: The Nation’s Force of Choice

Special Operations: The “Quiet Professionals”

CONCLUSION

*Colonel (Retired), Aviation, US Army; Senior Lecturer of Global Affairs, Jackson Institute for Global Affairs, Yale University, New Haven, Connecticut

†Brigadier General (Retired), Professor, US Military Academy, US Army; Executive Vice President of American Armed Forces Mutual Aid Association, Fort Myer, Virginia

INTRODUCTION

The military medical officer (MMO) is distinct from other medical professionals because of his or her unique role as an officer in the profession of arms. While most of an MMO’s training, and indeed most of this book, concentrates on the development of MMOs as medical professionals, this chapter describes their unique position as military officers and the added roles and responsibilities they accept as commissioned officers in the US armed forces.

This chapter builds on the history of the origins of the officer, which was introduced in Chapter 1, The History of the Military Medical Officer, by explaining the importance of officership, which is derived from the military commission. It then explains the four roles of an officer and how those roles distinguish military officers from others in society. Given this understanding of officers, the chapter briefly describes some of the particular challenges in civil-military relations that affect an officer’s role in the profession of arms in the 21st century. Finally, the chapter discusses the distinctive nature of the specialized expertise of each of the “subprofessions” within the profession of arms—the Army, Air Force, Navy, Marine Corps, and Special Operations Forces.

THE OFFICER’S OATH AND COMMISSION

Examining the profession of arms begins with the commissioning oath of the armed forces officer and the meanings of that commission. The commission is the encapsulation and embodiment of the long history, theories, and core value-based guiding and governing principles of the armed services professional ethos and the professional practices of the commissioned officer. The oath that all officers take upon commissioning is:

I will support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the duties of the office upon which I am about to enter; So help me God.[1]

Several aspects of the oath are distinctive, including both what is included and what is omitted. This is probably best illustrated by comparing the oath with that which is taken by enlisted members of the armed forces, which is:

I will support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same; and that I will obey the orders of the President of the United States and the orders of the officers appointed over me, according to regulations and the Uniform Code of Military Justice. So help me God.[1]

The focus of both oaths is the support and defense of the Constitution—not service to the president, any political party, and certainly not a monarch, as it might be in other nations. The oaths require “true faith and allegiance,” to the Constitution, which may seem obvious today, but was less so during the Revolutionary War and the American Civil War.

The officer oath is distinctive in three important ways. First, unlike the enlisted oath, it does not mention “that I will obey the orders of the President of the United States and the orders of the officers appointed over me, according to regulations …” Officers are selected and commissioned because they have specialized expertise to make decisions in the profession of arms, which is the application of violence on behalf of the nation. The commission explains that the president of the United States has reposed “special trust and confidence in the patriotism, valor, fidelity, and abilities” of each officer to use those abilities to act with discretion on behalf of the nation.

Second, officers state they “take this obligation freely, without any mental reservation or purpose of evasion.” Enlisted soldiers have no such requirement. When America had a military draft, many draftees performed their service, but may not have done so freely or without mental reservation. Officers who could not accept their obligation “freely without any mental reservation” could resign their commission and serve in the enlisted ranks to fulfill their military obligation.

Finally, officers affirmatively state that they “will well and faithfully discharge the duties of the office upon which I am about to enter.” This requires a specialized knowledge of and training for the “duties of the office” so that they can be “well and faithfully” discharged. Officers must act in unclear and uncertain situations where there may not be specific orders about what to do from the president or the chain of command; at these times they must be able to serve in the best manner possible to support and defend the nation.

Military historian S.L.A. Marshall wrote the first and classic edition of Armed Forces Officer in 1950, reflecting his thoughts and philosophical guidance on the attitudes, conduct, standards, and duty for officers of the United States. He explained (at the time, women comprised only 1.5% of the military, and it was common to use only the masculine pronoun):

Upon being commissioned in the Armed Services of the United States, a man incurs a lasting obligation to cherish and protect his country and to develop within himself that capacity and reserve strength which will enable him to serve its arms and the welfare of his fellow Americans with increasing wisdom, diligence, and patriotic conviction.

This is the meaning of the commission. It is not modified by any reason of assignment while in service, nor is the obligation lessened on the day an officer puts the uniform aside and returns to civilian life. Having been specially chosen by the United States to sustain the dignity and integrity of its sovereign power, an officer is expected so to maintain himself, and so to exert his influence as a worthy symbol of all that is best in the national character.[2]

This obligation is what distinguishes an officer in the armed forces from other members of society. Once an officer has received the trust of the nation through the commission, executing this special responsibility in practice is what is meant by officership. This practice, unique and even peculiar in its expertise and functions, is inspired by a unique professional identity that is further shaped by what an officer must BE, KNOW, and DO. In this sense, officership is a matter of both personal identity (character) and specialized expertise (knowledge and experience).

THE ROLES OF AN OFFICER

In 2007, the Department of Defense published an updated version of The Armed Forces Officer.[3] This effort was the culmination of nearly a decade of research, study, and discussion about officership and the profession of arms that took place at the service academies, at war colleges, and within the joint staff.3–5 This book captured and described four key roles for the military officer: (1) warrior-leader in the profession of arms, (2) member of a profession, (3) servant of the nation, and (4) leader of character. Understanding each of these roles is important because together they comprise the key aspects of officership.

Warrior-Leader in the Profession of Arms

The primary reason to commission officers is because the nation needs individuals with specialized expertise to selectively and discriminately administer violence on behalf of the state. “The defining mission of the armed forces is the preparation for and the conduct of war, which includes securing military victory until peace is restored politically.”3(p12) Regardless of the specific branch of service or role within that branch, the preeminent role of an officer is that of a warrior-leader in the profession of arms. It is this unique role that distinguishes officers from members of all other professions and places particular responsibilities on them.

The profession of arms is unique because of the lethality of the organizations officers lead and the ultimate responsibility they have over life and death, which can affect success or failure for American national security. As James Toner wrote, “The preeminent military task, and what separates [the military profession] from all other occupations, is that soldiers are routinely prepared to kill…. In addition to killing and preparing to kill, the soldier has two other principal duties…. Some soldiers die and, when they are not dying, they must be preparing to die.”[6] By serving in the military, all soldiers, sailors, airmen, and marines have committed to unlimited liability in service on behalf of the nation, even to the point of dying for their country. General Sean MacFarland explained, “The words ‘to kill and die’ are as central to the profession of arms as ‘to serve and protect’ are to the law enforcement profession, or ‘equal justice under the law’ are to the legal profession.”[7] Military officers are leaders of the profession that prosecutes violence on behalf of the nation and whose members may die as a tragic, but normal, consequence of their professional calling.

The fact that officers’ decisions may ultimately affect life and death reinforces the paramount importance of developing and maintaining specialized professional expertise. For an officer, this is not merely being proficient on a specific skill such as firing a weapon, flying an aircraft, or operating a naval vessel; rather, it means actively pursuing greater understanding of the broader, abstract knowledge of the profession. The essence of warfighting is engagement with a dynamic, uncertain enemy, and the study, discussion, and practice of warfare is the responsibility of the professional officer, so that he or she is prepared to make critical decisions upon which life or death and victory or defeat may depend. This is equally important for officers in all specialties. The logistics officer who determines supply rates, transportation options, and maintenance practices, and the medical officer who coordinates illness prevention, casualty care, evacuation procedures, and hospital locations—each must do so from a depth of expert knowledge of warfighting and their own specialty, honed from a career of study and professional practice.

Officership includes not just being a member of the profession of arms, but also being a leader in the profession. Chapter 4, Military Medical Leadership, discusses leadership in more detail, but in the context of the warrior ethos, military officers must be capable of providing not only effective decisions, but also the inspirational winning spirit for their unit in combat. To do so requires significant preparation in all aspects of the human experience—physically, intellectually, and morally.[8] The essence of warrior-leadership is to inspire others to action, frequently doing things that are challenging, dangerous, and perhaps against their own personal interest and safety. “Organizing, mobilizing, motivating, justifying, indeed inspiring others are essential talents for the officer in the profession of arms.”3(p17)

With the high-quality service members who comprise the all-volunteer force, it is not enough to give a rousing speech like a coach before a big game. Soldiers, sailors, airmen, and marines must be convinced that their officers have:

- the intellectual skills to properly understand war’s complexity and assiduously evaluate courses of action;

- the physical courage and stamina to lead them at the most challenging times; and

- the moral courage to always make the best possible decisions that maximize the chance of mission success.

Member of a Profession

An officer is not only a warrior-leader, but also has responsibilities as a member of a profession. Samuel Huntington explained that, “The modern officer corps is a professional body and the modern military officer [is] a professional …. The distinguishing characteristic[s] of a profession as a special type of vocation are its expertise, responsibility, and corporateness.”[9] MMOs are simultaneously members of both the military profession and the medical profession, and the attributes of expertise, responsibility, and corporateness apply to both professions. All three elements must be present for practitioners to be members of a profession. Expertise without the other two components is a specialized occupation without ethical standards or self-enforced accountability. Each of these characteristics will be discussed in turn. It is useful to think about the implications and challenges of being members of two professions simultaneously.

Expertise is important to professions because society collectively determines that it must trust a body of individuals—a profession—to develop, promote, learn, and practice a specific body of knowledge on behalf of all citizens. The Armed Forces Officer explains:

Working as a professional involves responding to diverse and highly contextual problems requiring continued delivery of a quality service of a discretionary character. This contrasts sharply with the bureaucrat’s routine response by rule to generally similar tasks. Application of an educated discretionary judgment is the real skill of the professional.3(p22)

The specialized expertise for the military officer is warfighting or one of its subspecialties, such as ground combat, air combat, naval combat, or amphibious warfare (discussed later in this chapter). For the medical doctor, the specialized expertise is medicine, including preventive medicine, primary care, cardiology, or orthopedics. In each case, the profession and professionals commit significant resources to developing new expert knowledge in their respective areas, maintaining or updating that knowledge in a dynamic scholarly environment, and promulgating that knowledge through professional journals, professional education, and professional associations. Society defers to medical doctors and military officers the life-and-death decisions. Their environment ranges from an operating room to the battlefield, and the expectation is that, as members of a profession, they have been certified in their abilities to practice medicine and are continually striving to improve their expert knowledge to apply to new, complex, and uncertain situations.

Just as professions are granted discretionary authority to act on behalf of society in their professional practice, they have a responsibility to do so in a way that continues to sustain the public trust. These responsibilities are generally codified by the profession in a written canon of ethics or code of conduct. For a doctor or officer to violate their professional responsibility is normally considered much more serious than if they make a reasonable error in judgment in applying specialized expertise, or when a known complication ensues from accepted therapeutics. The widespread public outcry when a scandal occurs at a service academy, or when an officer violates their professional responsibilities, reflects the seriousness with which the public regards an officer’s dereliction of duty. It is a violation of the trust society has placed in the profession. Ultimately, if the profession continues to fail in its professional responsibility, society, often through its elected leaders in Congress, will investigate and curtail some of the discretion previously granted to the profession. For example, Congress recently reviewed military law and justice after a series of sexual assaults in the military. Senator Kirsten Gillibrand proposed a law to limit the professional jurisdiction of military commanders and prevent them from deciding whether to prosecute in cases of sexual assault. Her proposed law would have changed this jurisdiction to military lawyers—another distinct profession—to address the perceived problems in judgment among military commanders.[10]

Finally, members of a profession share a sense of corporate self-identity and think of themselves as a group set apart from other groups and society at large. “Professions are exclusive, self-conscious, functional collectivities or subcultures entrusted by society to perform or regulate performance of important functions.”6(p26) This is because of their specialized expertise and specific responsibilities, as well as the long period of education and stringent requirements for admission into the profession. Each profession establishes and maintains the standards of the profession among its members, promotes education about the guiding ethos of the profession, and takes responsibility to discipline or expel any member who has violated professional standards. Indeed, officers are generally trained, educated, mentored, socialized, evaluated, and eventually promoted by other officers within the profession. This distinctiveness of being a member of a profession, characterized by expertise, responsibility, and corporateness, is a fundamental part of officership.

As a member of two professions, the MMO has an interesting challenge. Assuming they meet the standards of each profession and can maintain their requisite specialized expertise, MMOs are often wrongly presumed to face a choice between whether the medical or military profession will dominate their self-identity. In reality, the two professions are rarely in conflict, and astute members of both professions strive to shape professional jurisdictions so that they do not come in conflict. However, there are occasions when an MMO must choose the self-identity that is appropriate to an unusual situation: the medical profession when caring for the individual patient, or the military profession when planning battles or putting the health and welfare of the whole unit over the welfare of the individual service member. Sometimes the choice is not obvious, and MMOs must ask themselves, “Who am I?”

Servant of the Nation

An officer in the US armed forces has particular responsibilities as a servant of the nation. These are based on the US Constitution and the unique national history that has evolved and developed since the American Revolution. Although it can conjure up images of slavery or subordination, the self-abnegating concept of “servant” is essential to officership: officers voluntarily choose to subordinate their own personal desires to that of the nation. This fiduciary obligation is the foundation of the professional ethos of the military officer—and of the physician. It is not about the officer, it is about their unit, and ultimately about the nation. This concept has several formulations. The Air Force describes it as “Service before self.” The Navy describes it as “Ship, shipmate, self.” The US Military Academy’s motto is “Duty, honor, country.” The role as a servant of society is reinforced when members of a grateful nation say, “Thank you for your service.” Officers must recognize that they are servants in a cause greater than themselves.

This cause is based on the oath of office and the Constitution, as discussed previously. Although officers work for the president as commander-in-chief, the Constitution specifies that officers must be confirmed by Congress, which is also given the duty “To raise and support Armies; To provide and maintain a Navy; To make rules for the government and regulation of the land and naval forces.”[11] When officers testify before Congress during confirmation hearings, they are nearly always asked and respond affirmatively to the question, “Will you always provide your personal and honest opinion directly to Congress, even if it is in conflict with that of the president and the administration?” As a servant of the nation, officers are responsible to all branches of government and indeed to the nation as a whole.

This role is particularly American because its history dates to George Washington. As commander-in-chief of the Revolutionary Army that defeated the British, and with the widespread respect throughout the colonies that eventually made him America’s first president, George Washington had immense popularity and power. In the waning days of the American Revolution, Congress had failed to provide sufficient funds for the Army. A group of officers encamped in Newburgh, New York, threatened to deliver an ultimatum to Congress with a thinly veiled threat of a military takeover. Washington certainly had his challenges with Congress, and he could easily have ridden the Army’s passions and power to an unparalleled position of domination in the fledgling nation. Instead, he quelled the potential mutiny with a famous speech that properly placed the military subordinate to civilian authority in Congress:

Let me entreat you, Gentlemen, on your part, not to take any measures, which viewed in the calm light of reason, will lessen the dignity, and sully the glory you have hitherto maintained; let me request you to rely on the plighted faith of your Country, and place a full confidence in the purity of the intentions of Congress; … [I implore you] to express your utmost horror and detestation of the Man who wishes, under any specious pretenses, to overturn the liberties of our Country, and who wickedly attempts to open the flood Gates of Civil discord, and deluge our rising Empire in Blood.[12]

Washington set the preeminent example of why and how the American military must be subordinate to civil authority.

The officer’s role as a servant of the nation is enshrined in both law and practice. For example, federal law requires that an officer must be retired for 7 years before becoming secretary of defense or 5 years before becoming a service secretary.[13] This minimizes the likelihood that a general or admiral would assume a civilian leadership position in the Department of Defense, or at least requires congressional exception for them to do so. (This law has only been waived in the cases of General George Marshall in 1950 and General Jim Mattis in 2017.) These provisions help guard against the temptation for popular and powerful military leaders to subvert civilian control amid a public crisis or otherwise.

Subordination to civilian control is fulfilled in practice when military leaders are removed from office. In 1951, General Douglas MacArthur challenged President Truman’s policies in the Korean War, sending his objections in a letter to Congress. MacArthur’s letter directly violated the president’s directives and led to President Truman’s relieving MacArthur from command on April 11, 1951. “The issue at stake was no less than the continuation of civilian supremacy and of the President’s authority as commander-in-chief.”[14] More recently, in 2010, when a magazine article about General Stanley McChrystal, commander of US and international forces in Afghanistan, included disparaging statements about Obama administration officials, President Obama asked General McChrystal to resign. It is interesting to note that:

McChrystal and his staff were not criticized for their lack of military competence, for their dissent over policy, or for failure to implement strategy. Their professionalism—especially those professional competencies related to understanding the roles and responsibilities of military leaders vis-à-vis the civilian political leadership in the context of democratic civil-military relations—was found wanting.[15]

Both cases led to debate about whether the actions justified the president’s relieving a senior commander in wartime, but nearly all civilian and military analysts agree that professional officers have a special responsibility as a servant of the nation to conform to the standards and traditions of civilian control of the military.

Leader of Character

Officers must be leaders of character because their most important actions are frequently performed with limited oversight. They must have ingrained the internal ethical standards to make the right decisions every time. Character is inextricably linked to decision-making because the choices officers make often reveal their underlying character. Every pre-commissioning source is replete with examples for cadets and midshipmen to understand and internalize to help them develop a moral core as officers. The Armed Forces Officer examined the themes emphasized in each branch of service and found that several common themes emerged: honor, respect, duty, service, excellence, courage, commitment, loyalty, and integrity. While the specific terminology may vary, these attributes must become part of an officer’s self-identity so that they have the moral compass to lead themselves and their subordinates.

Individually, officers must have the character to understand, confront, and overcome challenging moral/ethical decisions because of the position of trust they are in. Decisions can be as inconsequential as “fudging” the numbers on a bothersome report to higher headquarters or as important as deciding which of several bad options will minimize the risk of death to subordinates in combat. Being a leader of character means not only making the right decision, but also being able to do so without becoming paralyzed by the situation. Officers are in a special position of trust and responsibility because they have the specialized skills to gather and evaluate critical information needed for decision-making, coupled with the character to make difficult decisions on behalf of their client—the nation that has commissioned them.

Collectively, subordinates are not likely to follow officers who eschew their moral compass when things get tough. Being a leader of character sets the example and establishes a culture for an officer’s unit. Having the physical courage to lead a platoon on a route strewn with roadside bombs is important, but so is standing up for what is right in the Pentagon, even if it contradicts conventional wisdom or bureaucratic politics. Character includes recognizing and respecting the value of all members of the team and striving to maximize the contribution of each individual, while enforcing the standards of military training and behavior. Character is also involved in refraining from engaging in partisan political activities or publicly expressing political opinions that undermine the authority of elected civilian leaders. Officers are always “on parade,” with subordinates assiduously watching to identify a lapse in character. This is why officers must be vigilant against threats to their integrity. Integrity may be difficult to maintain, but it is immensely more difficult to regain if it is lost.

Character must be internalized as officers are preparing to be commissioned. It was therefore appropriate that, in 1924, the US Military Academy codified many aspects of an officer’s character in the words of the Cadet Prayer. These words were spoken weekly by nearly all cadets (at least until mandatory chapel ended in 1972) and reflect a nondenominational recitation of moral precepts that are important to officership:

Strengthen and increase our admiration for honest dealing and clean thinking, and suffer not our hatred of hypocrisy and pretense ever to diminish.

Encourage us in our endeavor to live above the common level of life.

Make us to choose the harder right instead of the easier wrong, and never to be content with a half-truth when the whole can be won.

Endow us with courage that is born of loyalty to all that is noble and worthy, that scorns to compromise with vice and injustice and knows no fear when truth and right are in jeopardy.

Guard us against flippancy and irreverence in the sacred things of life.

Grant us new ties of friendship and new opportunities of service.

Kindle our hearts in fellowship with those of a cheerful countenance, and soften our hearts with sympathy for those who sorrow and suffer.[16]

Having officers recite many of the attributes they need to become leaders of character is an important developmental activity, irrespective of religious affiliation or nonaffiliation.

CIVIL-MILITARY RELATIONS AND SOCIETY TODAY

As part of the military profession, officers must be aware of many of the perennial discussions concerning the appropriate role of the military in society. This section surveys some of the most important issues officers will confront throughout their careers. The American polity was conceived by statesmen who deeply mistrusted standing armies, were suspicious of any insufficiently bridled aggregation of power, and believed in the power of citizens as the ultimate authority.[17] Effective arrangements of shared power through the design of separate and separable institutional structural ways, means, and mechanisms are essential to American citizens’ relationship with power and governance.[18] American civil-military relations are no different.

The history of American civil-military relations, like many things American, is rife with paradox. While maintaining a baseline anti-military undertone throughout its history, the country has often turned to the military as a touchstone for core national ideals in times of ambiguity, has periodically considered military heroes as presidential candidates, and has occasionally used the military as a laboratory for social change. Society has celebrated the military model of fair treatment of ethnic and racial minorities, for the advancement of women, and most recently for the fuller inclusion of homosexual and transsexual individuals.

For the United States, the central problem of American civil-military relations is not about preventing a military takeover of the state. Rather, it is about finding the proper relationship between civilian and military leaders as they determine the preparation and use of force on the one hand, and the ends of policy on the other. Several scholars have posited alternative formulations for how this dialogue between civilians and military leaders should take place. In 1957, Samuel Huntington argued that the healthiest and most effective form of civilian control of the military is that which isolates the military from politics and require officers’ judgment only on military matters. Civilian leaders should set clear but general strategic objectives and then leave the military as much latitude as possible to achieve these goals. This is what he described as a system of “objective control.”[9] This view is in contrast to that of Morris Janowitz, who contemporaneously argued for “subjective control” through greater citizen involvement with the military, especially the use of citizen-soldiers, who might provide an ability to control the military through multiple points of influence throughout society.[19]

More recently, the American political scientist and scholar Eliot Cohen updated these perspectives in his book Supreme Command: Soldiers, Statesmen, and Leadership in Wartime. Contrary to conventional wisdom, which tends to coincide more with Huntington’s “objective control,” Cohen concluded that the highest political authority should be very much engaged with the details of war and war planning. He argued that civilian leaders were most effective when they had an “unequal dialogue” with military leaders, in which “both sides expressed their views bluntly, indeed sometimes offensively, and not once but repeatedly—and unequal, in that the final authority of the civilian leaders was unambiguous and unquestioned.”[20] This more engaging relationship between civilian “master” authority and military subordinated “servant” has been reinforced with the advent of nearly constant communications and meetings that take place between commanders and civilian leaders. This “unequal dialogue” with ongoing engagement between presidents and their military leaders has generally characterized supreme command under the administrations of George W. Bush, Barack Obama, and Donald Trump.20,21

The “Unequal Dialogue” and the All-Volunteer Force

Since the advent of the all-volunteer force in 1973, an increasingly fewer number of Americans have served in the military. While over 70% of Congress had served in the military when the draft ended in the 1970s, now less than 20% have served.[22] In the 2016 presidential election, no competitive candidates of either party had any military experience. In spite of the decreasing military experience among elected officials, there is an increasing tendency to appoint military leaders to senior government positions that do not require, nor have been routinely filled by, senior military officers. For example, upon his inauguration, President Obama appointed three retired four-star generals to cabinet-rank positions: General Eric Shinseki as secretary of veterans affairs, General Jim Jones as national security advisor, and Admiral Dennis Blair as director of national intelligence. Appointment of retired senior officers has continued in the Trump administration, with General Jim Mattis as secretary of defense, General John Kelly as secretary of homeland security (and later White House chief of staff), and Lieutenant General Mike Flynn as national security advisor (later succeeded by an active duty officer, Lieutenant General H.R. McMaster).

The increasingly routine appointment of former senior military officers to traditionally “civilian” positions has been the subject of significant commentary.23,24 In policy deliberations, these officers provide advice in their personal capacity, which may or may not agree with the best professional military advice from the uniformed military leaders charged with providing that advice. In addition to potential conflicts among leaders at the pinnacle of the profession, the presence of current or former military officers in civilian positions can raise suspicion about the aggregation of power in the military as an institution. If a smaller elite military force of “volunteers” becomes increasingly separate from the society it serves, yet increasingly powerful in determining government decisions, it may put at risk the critically important relationship between society and the military profession.[25]

The Military Profession and the Defense Bureaucracy

Budget stringency affects strategy and force modernization, including decisions on: “why we fight,” “how we fight,” and “what we fight with.” As Bernard Brodie elegantly explained, “strategy always wears a dollar sign.”[26] However, the ultimate imperative and obligation facing national security policy makers is not how much of the federal budget is spent on defense or a particular service, but how federal spending should be used to best provide national security. While the military is a profession, and officers lead the profession, the Department of Defense is also a large bureaucracy, and the bureaucratic tendencies of the organization can sometimes dominate the characteristics of a profession. Military officers must both provide their best professional military advice and fulfill their role as leader of and advocate for their particular part of the defense bureaucracy. Understanding the distinction between the characteristics of a profession and those of a bureaucracy are important, as reflected in Exhibit 3-1.

EXHIBIT 3-1

“PROFESSION” VERSUS “BUREAUCRACY”

Profession

Bureaucracy

Expert knowledge

vs

Non-expert knowledge

Accepts life-long learning

vs

“You develop me”

New situations

vs

Routine situations

“Practice” by humans

vs

Work done by all

Unlimited personal liability

vs

Little personal liability

Invests in humans first

vs

Invests in SOPs; hardware

Measure = effectiveness

vs

Measure = efficiency

Trust relationship with client

vs

Public transactional relations

Granted some autonomy

vs

Closely supervised

Develops worldview

vs

No imposed viewpoint

Maintains ethos, self-policed

vs

Externally imposed rules

Intrinsic motivations

vs

Extrinsic motivations

A life-long “calling”

vs

A “job”

____________

SOP: standard operating procedure

There are times when the military should act as a bureaucracy—when it performs routine things routinely, such as the annual budget process. Just as the medical profession should guard against arguing for doctors’ parochial interests (instead of the interests of patients and overall healthcare) in the national healthcare debate, military officers must guard against wrongly using their specialized expertise merely to advance a bureaucratic agenda. To do so could sacrifice the value of professional advice and relegate the military to being considered as just another interest group.

As the United States grapples with the post-9/11 conditions of new enemies, new battlespaces, and new kinds of wars, military officers should avoid at least three traditional pitfalls typically associated with times of geostrategic ambiguity, budget stringency, and force reductions: (1) becoming overcommitted to the latest technological trends at the expense of historical military challenges; (2) being tempted to rename, oversell, and fetishize new war concepts, especially in support of single-service parochial interests; and (3) overplaying the “hollow force” card, asserting that any reduction will irreparably degrade national security. Instead, military effectiveness needs to be seen, understood, appreciated, and approached from a comprehensive, multiservice perspective. Military professionals need to focus on maximizing national security while recognizing the fiscal impact that military spending has on overall national power.[27]

Role of Professional Officers—Even After Retirement

In his farewell speech to Congress, General of the Army Douglas MacArthur said, “Old Soldiers never die, they just fade away.”[28] If MacArthur were correct, there would be far less confusion about the proper role of military officers in political debates and presidential campaigns. As an example of the former, there were significant conflicts among military professionals concerning the strategy for the war in Iraq. An April 13, 2006, front-page Washington Post article described a small but significant number of retired US military general officers who publicly objected to current US strategy toward Iraq and called for the resignation of Secretary of Defense Donald Rumsfeld.[29] Dubbed the “generals’ revolt,” these objections challenged US intelligence, planning for postwar Iraq, counterinsurgency strategy, and the effectiveness of Secretary Rumsfeld. The generals’ protests did not cause Secretary Rumsfeld to resign, but did exacerbate civil-military tensions and raised questions about the relationship between the American military and the American state, and the proper role and limits of military officers in affairs of politics and war.

In political campaigns, especially since 1992, it has become common for each major candidate to “round up the military vote” by securing endorsements of senior officers. Prior to 1992, most presidential candidates had military experience, so military endorsements were not as important. Admiral William Crowe’s endorsement of candidate Bill Clinton is generally regarded as the beginning of the era of military endorsements of presidential candidates.[30] While this tactic may be useful for winning a campaign, it has negative implications for officership. Although officers may be retired, they have not broken their lifelong commitment to their profession. This is especially the case with flag officers, whose rank is broadly recognized and respected. In the 2016 presidential campaign, teams of retired flag officers were led by retired Marine General John Allen for Hillary Clinton and by retired Army Lieutenant General Michael Flynn for Donald Trump. The former chairman of the Joint Chiefs of Staff, General (retired) Martin Dempsey, rebuked these public political performances in an open letter to the Washington Post:

The military is not a political prize. Politicians should take the advice of senior military leaders but keep them off the stage. The American people should not wonder where their military leaders draw the line between military advice and political preference. And our nation’s soldiers, sailors, airmen and marines should not wonder about the political leanings and motivations of their leaders.[31]

While military officers have the right to speak, just like any other citizen, it may not be right for them to do so, especially in a way that sullies the profession and could cheapen the value of military advice in the future.

The difference between a military in the service of the United States and a praetorian guard in the service of an empire and emperor teeters on a thin line of legal, ethical, and professional principles that define the proper limits of the military’s jurisdictions in affairs of war, peace, and politics. The American public’s skepticism of a standing military is a historic and healthy one; it is rooted in experiences under military occupation in the years prior to 1776. A mix of legal statutes and professional conventions within US military services restrict the military from engaging in issues deemed “political.”[32] Whether what American society witnesses in terms of the “unequal dialogue” between civilian authorities and their subordinated military professionals reflects more of the Huntington “objective control,” or more of a relative and perhaps cloudy “subjective control” civil-military relationship as described by Janowitz, is a function of the circumstances at hand, the civilian leaders, and the military leaders of the profession.

TYPES OF SPECIALIZED EXPERTISE

This chapter has discussed officership in the context of the “profession of arms,” which might cause an incorrect conclusion that there is only one military profession. Just as the medical profession has subspecialties (eg, cardiology, family medicine, orthopedics, aviation medicine, dermatology), each of the military’s specialized professions operates somewhat independently, with their own standards, norms, and cultures. If America’s profession of arms is like a tapestry or quilt, the semi-independent service arms are the separate panels and patches that, knitted together, form and sustain the overall profession. While any generalization is made with great trepidation because there are certainly many exceptions, the following is a broad attempt to depict the general culture of each military service.[33]

The Army: Obedient Servant Emphasizing People

RAND Corporation senior analyst and service culture scholar Carl Builder described the US Army as “first and foremost, the Nation’s obedient and loyal military servant.”[34] The Army focuses on the readiness and preparation of its personnel and emphasizes that the Army’s “boots on the ground” in an area is the ultimate expression of American national will and power. At the US Military Academy at West Point, cadets spend 4 years walking past statues of Washington, MacArthur, Eisenhower, Patton, and other leaders, reinforcing the criticality of the human dimension of the profession. The Army hallways of the Pentagon are adorned with division and regimental flags, pictures of battles that focus on images of soldiers, and tributes to individuals from the Army’s history. The Army emphasizes cooperation and coordination both within and between services because success in battle requires the effective coordination of all arms and services. While officers from some maneuver branches—particularly the infantry and armor—still tend to dominate leadership positions, no battle can be won without transportation support; fire from artillery; close air support from aviation; data from intelligence sources; communications from signal units; mobility from engineers; security from military police; sustainment from logisticians; field sanitation, preventive medicine, and casualty care from medical personnel; and myriad other functions based on the requirements of individual dynamic engagements. The need for the complex coordination and independent synchronization of all units leads to a great emphasis on fairness, inclusiveness, and, to the extent possible, decentralization among all branches and units in the Army.

As difficult as it is to characterize service culture, it is even more difficult to generalize about the intellectual progenitors of a profession’s doctrine or thinking, or to summarize a comprehensive body of thought about military power in a few sentences. However, making such generalizations is important because they provide a window through which the specialized expertise of a profession can be understood. For the US Army, if officers were asked to identify an intellectual godfather, many would name Carl von Clausewitz, who wrote On War[35] in the 19th century. Clausewitz’s dictum that “war is an extension of politics by other means,” resonates well with the Army as the obedient and loyal military servant of political masters. His emphasis on the “fog and friction in war” reinforces the need for military judgment, what Clausewitz calls “military genius.” Army leaders are comfortable with his emphasis on the human dimension of warfare and the need for consistent yet constrained linkages between political leadership and military decision-making. They strive to develop the specialized expertise in land warfare that supports effectiveness in battle.

The Air Force: Victory Through Technology

As the youngest service, spun off from the Army in 1947, the US Air Force sees itself as the service that best embodies the modern American way of war—use of decisive technological superiority to overwhelm and defeat any potential foe while avoiding risk of American casualties. From General Billy Mitchell’s use of airpower to sink battleships in 1921, to the World War II air raids over Europe and the nuclear bombs dropped in Japan, to the shock and awe at the opening of the Iraq War, the Air Force continues to emphasize the use of high technology to deliver decisive military victory. At the Air Force Academy, cadets hold formation in a quadrangle surrounded by airplanes on pedestals and gaze at the cold-metal roof of the academy chapel that sweeps up toward the heavens. The Air Force halls in the Pentagon, like most Air Force headquarters and the Air Force monument near the Pentagon, emphasize sleek, functional, modern designs, much as might be seen in the corporate offices of a high-technology firm. In contrast to the Army’s pictures where the soldier is the centerpiece, the pictures and murals in the Air Force section feature aircraft from different eras, with fewer depictions of the airman. Also in contrast to the Army’s general equanimity with regard to all branches, the Air Force prioritizes the pilot as the focus of its human capital strategy because it is the pilot who commands the sophisticated and expensive technology and renders the decisive power in combat.

Air Force proponents will often point to several strategists who have recognized the decisive nature of air power in warfare, including Giulio Douhet, Billy Mitchell, Hap Arnold, and Curtis LeMay. Recently, John Warden, who helped design and implement the use of air power in Desert Storm, has been an influential strategist. Expanded information technology has enhanced centralization and prioritization of precision technology so that the Air Force can provide more effective, efficient, and decisive effects on targets anywhere in the world. This centralized control is embodied in two mainstays of Air Force operations—the single integrated operational plan (SIOP) for nuclear weapons and the air tasking order (ATO) for conventional engagements. Both plans are developed by dynamically assimilating all possible intelligence and environmental information and then precisely allocating virtually every weapon of each plane or each warhead of each missile against an optimal target. With its penchant for precision application of technology, the Air Force has also pushed for leadership in the development of cyber warfare capabilities as well. With increasingly sophisticated intelligence and network connectivity, air power can become an even more decisive element of modern warfare.

The Navy: Independent Exercise of National Sovereignty

The US Navy is “the supranational institution that has inherited the British Navy’s throne to naval supremacy … sea power [is] the most important and flexible kind of military power for America as a maritime Nation.”34(p32) The Navy is quick to point out that “70 percent of the earth is covered by water, 80 percent of the world’s population lives in close proximity to the coast, and 90 percent of the world’s international commerce is transported via the sea.”[36] The Navy can exert American sovereignty throughout the globe and literally show the flag without the inconvenience of placing US soldiers in harm’s way on another nation’s soil. Moreover, the Navy is its own complete joint force with air power through naval aviation, land power through the Marines, and Navy SEAL teams providing special operations.

At the Naval Academy, the midshipmen’s lives are dominated by Bancroft Hall—a single imposing dormitory that houses all midshipmen. Like a large ship, it subordinates the accomplishments of any single individual to the overall success of the institution as a whole. In the Pentagon, the Navy hallways exude tradition and imposing dignity with dark wooden walls, brass door hardware, and impressive model ships that reflect the extension of naval influence across the globe. In spite of modern communications that can impede the previously cherished independence of sea operations, great autonomy is still provided to a ship’s captain or a fleet admiral. Being accustomed to giving orders that cause a ship full of sailors and marines to change course, Navy leaders are more deferential toward senior-ranking officers, who, in turn, are more likely to act autonomously and be somewhat less concerned with inclusiveness of all components in their decision-making.

Most Navy leaders would point to Alfred Thayer Mahan as the grand theoretician who established the Navy’s view toward global warfare. Mahan’s belief that a state’s power and sovereignty is inextricably linked to its sea power reinforces the Navy’s self-image and importance.[37] This view is consistent with the Constitution, which, as noted above, requires Congress “to provide and maintain a navy” but only to “raise and support armies,” reflecting the nation’s intended permanence of the naval service for the United States as a maritime power.[11] The US Navy, like the other services, has leveraged information technology to exploit network-centric warfare and increased the effectiveness of its ships while reducing the overall size of the Navy.

The Marine Corps: The Nation’s Force of Choice

The US Marine Corps’ organizational culture is summed up in their recruiting motto: “The few. The proud. The Marines.” Completely dependent on the Navy for budgetary, administrative, and logistics support and competing with the Army for many land power missions, the Marine Corps best represents the challenge that all services face in the continuous reexamination of service roles and missions, despite their successes in past conflicts. The Air Force had to demonstrate its contribution to the ground war following its introduction in the early 20th century as an arm of the Army Signal Corps. The Doolittle raid on Tokyo served this purpose, as did strategic bombing in Europe. The Navy’s addition of aircraft and submarines extended its utility beyond the iron ships of the early 20th century. The Army’s experimentation with missile- and artillery-delivered tactical nuclear weapons at the outset of the Cold War and its more recent transition into dispersed forces across an expansive and often austere battlespace represent similar efforts at reengineering.

Although the dismantling of the US Marine Corps is unlikely, Marine Corps leaders at all levels act as if it could happen any day if they fail to forcefully and publicly demonstrate its continuous relevance to US national security. This is why Marine Corps documents advertise the service as “the nation’s 911 force,” or “the expeditionary force of choice,” and its leaders endeavor to be recognized as the lead force in nearly any global engagement. The Marine Corps makes every individual marine believe that the fate of the Corps (and the nation) is in their hands, and they must make the Corps proud. Every marine is first a rifleman and will endure any burden and suffer any sacrifice “to do what must be done ‘in any clime and place’ and under any conditions … to respond quickly and win.”[38]

The Marine Corps does not have its own academy, but derives many of its traditions from the Navy. In the Pentagon, the marines maintain a relatively small presence, with much of their headquarters in nearby Henderson Hall. However, any time marines are near any headquarters, just like the Marine guards at every US embassy, they are highly visible and exemplify spit-and-polish service standards that are second to none.

Marine Corps officers read widely and benefit from both Army and Navy strategic thought to develop their own professional identity and specialized expertise. If pressed to name an individual who drives their thought, marines might identify heroic individuals such as Lieutenant General Lewis “Chesty” Puller, whose five Navy Crosses for heroism epitomize the marine’s can-do attitude.[39] It is more likely, however, that they would identify the current or a recent commandant of the Marine Corps as the source of their intellectual thought. In contrast to the other services, which frequently have from eight to eleven four-star generals or admirals each, the Marine Corps is much smaller and typically has only three or four four-star generals. Consequently, the commandant is truly supreme within the Corps, facing little pushback to directives because, other than the assistant commandant, there is no other four-star general within the service proper. (Other Marine four-star generals may command combatant commands or serve as chairman or vice chairman of the Joint Chiefs.) When General Dunford issued his initial planning guidance as commandant of the Marine Corps, for example, he cited no outside authorities other than five quotes from four previous commandants.[38] The ability to carefully construct and then focus the Marine Corps on a single, compelling, and consistent message is important to the Corps’ organizational culture and professional identity.

Special Operations: The “Quiet Professionals”

Although technically not a service, the United States has created essentially a fifth branch of the military—those involved in US Special Operations, who increasingly operate with each other and separately from their original services. All uniformed personnel in special operations are originally recruited and trained by their specific service (Army, Air Force, Navy, or Marine Corps) and then must volunteer and be selected by special operations organizations. Special operations personnel address unique, specialized, and difficult military problems that require exceptionally trained, exquisitely equipped, and tremendously supported warfighters. While other services can overwhelm enemies with massive combat power, special operations provides discreet, sometimes covert, precision military capabilities that have become increasingly relevant in modern warfare. Special operations missions include direct action, counterterrorism, special reconnaissance, civil affairs, psychological operations, unconventional warfare, supporting indigenous forces on their internal defense, and countering proliferation of weapons of mass destruction.

Although the lineage of special operations dates to work with the Office of Strategic Services in World War II, President Kennedy described the environment that gave rise to special operations forces in his 1962 West Point graduation speech:

This is another type of war, new in its intensity, ancient in its origin—war by guerrillas, subversives, insurgents, assassins, war by ambush instead of by combat; by infiltration, instead of aggression, seeking victory by eroding and exhausting the enemy instead of engaging him … [It requires] a whole new kind of strategy, a wholly different kind of force, and therefore a new and wholly different kind of military training.[40]

With President Kennedy’s emphasis and the needs of Vietnam, services expanded their own special organizations forces: Army Rangers, Army Special Forces, Navy SEAL teams, Navy Special Boat squadrons, and Air Force Special Operations squadrons. These units operated under service control and cooperated with each other, but were certainly not integrated. The failed mission to rescue American hostages in Iran in 1980 and the lack of coordination among services in Grenada in 1983 reflected significant shortcomings. In response, the 1986 Goldwater-Nichols Act created the US Special Operations Command (SOCOM) with special status and authorities. SOCOM operates as both a military service that provides forces, in that it organizes, trains, and equips special operations forces, as well as a combatant command that employs forces throughout the world. This unique status, with its own funding authorities and ability to report directly to the Office of the Secretary of Defense, has distinguished special operations personnel from their parent service and contributed to their development as a separate and distinct profession.

Members of special operations forces undergo rigorous selection and training, which sets them apart from their parent service and creates a greater bond among special operators, who often identify first as being part of special operations and second as having originally joined their specific service. In this regard, if they sought a single personification of special operations, many might identify John Wayne in his classic depiction of a Special Forces officer in the Vietnam-era movie, The Green Berets. This movie emphasized the exceptional small unit teamwork, precision action, cultural understanding, innovation, and problem-solving ability of elite special operations forces. In the current environment, SOCOM has integrated those elite small units with exceptional intelligence capabilities to empower and enhance their effectiveness. This integrated intelligence-operations linkage, known as the “find, fix, finish, exploit, and analyze” or the F3EA concept, has allowed SOCOM to expand and execute more systematic actions against high value targets in Iraq and Afghanistan. The most noteworthy example was the May 2011 raid that killed Osama bin Laden. These expanded, high-profile operations have raised the visibility of special operations, even leading some members to write books or grant interviews about previously highly secret operations. Navy Seal Mark Bissonette wrote a book about the “the Mission that Killed Osama Bin Laden,” and was eventually forced to pay $6.6 million to the US government and forfeit any profits, royalties, and movie opportunities for violating nondisclosure agreements.[41] While proud of the work that all special operations teams do, most special operations professionals would prefer that their stories remain largely untold, reinforcing their ethos as the “quiet professionals.”

CONCLUSION

It is appropriate to conclude by reiterating the importance of the professional armed forces officer’s commissioning oath. Returning to S.L.A. Marshall’s classic work, The Armed Forces Officer, both Marshalls—S. L. A. Marshall and George C. Marshall, secretary of defense at that the time—emphasized the linkage of the officer corps with service to nation:

Thereafter, [the officer] is given a paper which says that because the President as representative of the people of this country reposes “special trust and confidence” in his [or her] “patriotism, valor, fidelity, and abilities,” he [or she] is forthwith commissioned.2(p4)

S.L.A. Marshall went on to highlight one quality in particular: fidelity. Fidelity is commonly considered “faithfulness to something to which one is bound by pledge or duty.”[42] In spite of all the formal rules and legal statutes obligating the commissioned officer to the Constitution, and through it, to the American people, officers’ fidelity has proven to be the most enduring tie that binds officership and the profession of arms to the nation. This bond has helped the nation weather many storms, both foreign and domestic. Similar to the medical profession’s code of medical ethics, which traces its origins to the historic Hippocratic oath, the fidelity of the military professional has always found its strongest roots in the rich soils of American history. Examples set by leaders from General George Washington to General Martin Dempsey reinforce the principle of subordination of the military practitioner to the “patient needs,” in this case, to civilian authority, and through that authority, to the defense of the nation. It is this ultimate duty and obligation that unites the medical profession and the profession of arms.

REFERENCES

1.   US Army. Oaths of enlistment and oaths of office. US Army Center of Military History website. http://www.history.army.mil/html/faq/oaths.html. Accessed January 22, 2018.

2.   Marshall SLA. The Armed Forces Officer. Washington, DC: Department of Defense; 1950. DA Pamphlet 600-2.

3.   US Department of Defense. The Armed Forces Officer. Washington DC: National Defense University Press; 2007.

4.   Snider DM, Watkins GL, eds. The Future of the Army Profession. New York, NY: McGraw Hill; 2002.

5.   Snider DM, Matthews LJ, eds. The Future of the Army Profession. 2nd ed. New York, NY: McGraw Hill; 2005.

6.   Toner JH. True Faith and Allegiance: The Burden of Military Ethics. Lexington, KY: University Press of Kentucky, 1995: 22–23.

7.   MacFarland S. Fight, kill, die, buddy: words professional soldiers live by. Milit Rev Special Edition. 2011;91(suppl):51–55.

8.   Yingling P, Nagl J. The Army officer as warfighter. Milit Rev. 2003;83:9–14.

9.   Huntington SP. The Soldier and the State. Cambridge MA: Harvard University Press; 1957: 7-8.

10.   Bassett L. Senators shoot down Gillibrand’s military sexual assault reform bill. Huffington Post. December 11, 2014. http://www.huffingtonpost.com/2014/12/11/gillibrands-military-sexual-assault_n_6309108.html. Accessed February 9, 2018.

11.   US Constitution, article 1, section 8.

12.   Washington G. Newburgh address, March 15, 1783. Presidential Rhetoric.com. http://www.presidentialrhetoric.com/historicspeeches/washington/newburgh.html. Accessed January 22, 2018.

13.   10 USC § 113, 3013, 5013, 8013.

14.   Spanier J. The Truman-MacArthur Controversy and the Korean War. Cambridge, MA: Harvard University Press; 1959: vii.

15.   Ulrich MP. The General Stanley McChrystal affair: a case study in civil-military relations. Parameters. 2011;41:86–100.

16.   Snider DM. Forging the Warrior’s Character: Moral Precepts From the Cadet Prayer. Sisters, OR: Jerico LLC; 2007.

17.   Cohen EA. Foreword. In: Snider DM, Carlton-Carew MA, eds. U.S. Civil-Military Relations: In Crisis or Transition? Washington, DC: The Center for Strategic and International Studies; 1995: vii.

18.   Neustadt RE. Presidential Power and the Modern Presidents: The Politics of Leadership from Roosevelt to Reagan. New York, NY: The Free Press; 1990.

19.   Janowitz M. The Professional Soldier: A Social and Political Portrait. New York, NY: The Free Press; 1960.

20.   Cohen EA. Supreme Command: Soldiers, Statesmen, and Leadership in Wartime. New York, NY: The Free Press; 2002: 209.

21.   Moten M. Presidents and Their Generals: An American History of Command in War. Cambridge, MA: Belknap Press; 2014.

22.   Manning JE. Membership of the 115th Congress: A Profile. Washington, DC: Congressional Research Service; 2017. CRS Report for Congress R44762. https://www.hsdl.org/?abstract&did=799693. Accessed January 22, 2018.

23.   Rucker P, DeBonis M. Trump hires a third general, raising concerns about heavy military influence. Washington Post. December 7, 2016.

24.   Graham DA. All the president-elect’s generals. Atlantic. December 8, 2016.

25.   Kaplan F. The secretary’s rebuke: James Mattis tells the troops that their president is failing them. Slate. http://www.slate.com/articles/news_and_politics/war_stories/2017/08/why_james_mattis_viral_rebuke_of_trump_was_so_disturbing.html. Accessed January 22, 2018.

26.   Brodie B. Strategy in the Missile Age. Princeton, NJ: Princeton University Press; 1959: 358–389.

27.   Wilson I III, Smitson S. Solving America’s Gray Zone Puzzle. Carlisle, PA: Strategic Studies Institute Press; 2017: 65.

28.   US Congress. House. General Douglas MacArthur’s Speech to Joint Session of Congress. 82nd Congress, 1st Session, Congressional Record, April 19, 1951, 4123-4125.

29.   Ricks TE. Rumsfeld rebuked by retired general. Washington Post. April 13, 2006, A1.

30.   Evans D. Crowe endorsement of Clinton raises more than eyebrows. Chicago Tribune. September 25, 1992.

31.   Dempsey ME. Military leaders do not belong at political conventions. Letter to the Editors, Washington Post. July 31, 2016.

32.   Wilson I III. Being “the good soldier.” Democracy Arsenal. April 15, 2006, http://www.democracyarsenal.org/2006/04/being_the_good_.html Accessed January 22, 2018.

33.   Meese MJ, Wilson I III. The military: forging a joint warrior culture. In: George RZ, Rishikof H, eds. The National Security Enterprise. Washington, DC: Georgetown University Press; 2011: Chap 6.

34.   Builder CH. The Masks of War: American Military Styles in Strategy and Analysis. Baltimore, MD: Johns Hopkins; 1989: 33.

35.   von Clausewitz C. On War. Howard ME, Paret P, trans-eds. Princeton, NJ: Princeton University Press; 1976.

36.   Winter DC. Posture Statement of the U.S. Navy. Washington, DC: Department of the Navy, 2008: 3.

37.   Crowl PA. Alfred Thayer Mahan: The Naval Historian. In: Paret P, ed. Makers of Modern Strategy: From Machiavelli to the Nuclear Age. Princeton, NJ: Princeton University Press; 1986: 444–477.

38.   Dunford JF Jr. 36th Commandant’s Planning Guidance. Washington, DC: U.S. Marine Corps, 2015. pp 4.

39.   Hoffman JT. Chesty: The Story of Lieutenant General Lewis B. Puller, USMC. New York, NY: Random House; 2002.

40.   Kennedy JF. Remarks at West Point to the Graduating Class of the U.S. Military Academy. June 6, 1962, http://www.presidency.ucsb.edu/ws/?pid=8695 Accessed 22 Jan 2018.

41.   Owen M, Maurer K. No Easy Day: The Firsthand Account of the Mission that Killed Osama Bin Laden. New York, NY: Dutton Penguin; 2012.

42.   Fidelity. Merriam-Webster online dictionary. https://www.merriam-webster.com/dictionary/fidelity. Accessed January 22, 2018.

Chapter 4

MILITARY MEDICAL LEADERSHIP

CHARLES W. CALLAHAN, DO,* AND NEIL E. GRUNBERG, PHD†

INTRODUCTION

FOUR CE-PITO FRAMEWORK OVERVIEW

WHY DEVELOP MILITARY MEDICAL LEADERS?

WHY IS MILITARY MEDICAL LEADERSHIP IMPORTANT NOW?

HISTORY OF LEADERSHIP

ELEMENTS OF FOUR CE-PITO

Character

Competence

Context

Communication

PITO

HOW TO USE THE FOUR CE-PITO FRAMEWORK

SUMMARY

*Colonel (Retired), Medical Corps, US Army; Professor of Pediatrics, Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Vice President, Population Health, University of Maryland Medical Center, Baltimore, Maryland

†Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

Leadership is the enhancement of behaviors, cognitions, and motivations to achieve goals that benefit individuals and groups. Military medical leadership must consider situations and interactions among healthcare team members, line commanders, and the public to achieve these goals. The FourCe-PITO leadership framework presented in this chapter includes four domains of leadership—character, competence, context, communication—across four levels of interaction—personal, interpersonal, team, organizational. This framework draws upon many leadership models and is intended to help develop adaptive and effective leaders.

“Omnia uno tempore agenda” (“Everything had to be done at once”) is how Julius Caesar described his response to an attack by the Nervii, the fiercest of the Belgic tribes of northern Gaul (modern-day northern France), in 57 BCE. The attack came at three different points on his flanks while part of his army was crossing a river and another part was setting up camp. At one point in the battle, his Twelfth Legion was hard-pressed, fighting too closely bunched together. Caesar described his own perception and actions in third person:

He perceived that his men were hard pressed … he likewise perceived that the rest were slackening their efforts … having therefore snatched a shield from one of the soldiers in the rear (for he himself had come without a shield), he advanced to the front of the line, and addressing the centurions by name, and encouraging the rest of the soldiers, he ordered them to carry forward the standards and extend the companies, that they might the more easily use their swords. On his arrival, as hope was brought to the soldiers and their courage restored, while everyone for his own part, in the sight of his general, desired to exert his utmost energy, the impetuosity of the enemy was a little checked.1(ch25)

Effective leadership was key to the success of Caesar’s army. His leadership involved character (he “advanced to the front of the line”); competence (“encouraging … the soldiers … to carry forward the standards”); comprehension of the context (“he perceived that his men were hard pressed … that the rest were slackening their efforts”); and clear communication (“addressing the centurions by name”).[1]

Leadership is expected of military medical professionals, and is essential for the success of the Military Health System (MHS). Leadership is defined as the enhancement of behaviors (actions), cognitions (thoughts and beliefs), and motivations (reasons for actions and thoughts) to achieve goals that benefit individuals and groups. Military medical leadership must consider situations and interactions among healthcare team members, line commanders, and the public to achieve these goals. Leadership depends upon who the leader is; what the leaders knows and does; and where, when, and how the leader acts. The FourCe-PITO framework includes elements of various leadership models and is intended to increase the understanding, development, and evaluation of leaders and leadership.[2] The four Cs (character, competence, context, communication) address who, what, when and where, and how, respectively. PITO (personal, interpersonal, team, organizational) addresses levels of psychosocial interaction and awareness. While this chapter discusses the training construct utilized at the Uniformed Services University of Health Sciences, leadership training is a lifelong journey.

FOUR CE-PITO FRAMEWORK OVERVIEW

The FourCe elements are consistent with Army,[3] Navy,[4] and Air Force[5] leadership concepts. Other models identify various “Cs of leadership.”6–12 The FourCe (or four C) domains are:

- Character (“who” the leader is) refers to all aspects of the individual, including demographics, attributes, personality, attitudes, values, and physical characteristics. Self-awareness of character is critical for a leader to achieve optimal success.

- Competence (“what” the leader knows and does) includes role-specific and transcendent leadership knowledge and skills (eg, critical thinking, decision-making, problem-solving, motivating others, emotional intelligence). Both types of knowledge and skills are learned, refined, and honed with experience and effort.

- Context (“when” and “where” leadership occurs) involves physical, psychological, social, and cultural environments. It also includes effects of stress and the importance of situational awareness.

- Communication (“how” leaders interact with followers) is sending and receiving information, verbally (oral and written words) and nonverbally (nonverbal elements of oral communication, body language, and facial expressions). Most models of leadership include communication as a competence. Communication is identified as its own domain to emphasize and highlight its importance.

These four Cs of leadership occur across several psychological and social levels. The four psychosocial levels (PITO) were developed by the leadership training program at the US Air Force Academy.13–15

- Personal focuses on aspects of the individual leader and self-awareness.

- Interpersonal focuses on interactions between the leader and others (eg, patient, colleague, subordinate, superior officer).

- Team focuses on operations of small groups (eg, healthcare professionals) aligned around a shared task, goal, or purpose.

- Organizational focuses on large groups, institutions, and systems.

The FourCe domains and PITO levels overlap, interact, and operate together. The FourCe-PITO framework is relevant to education, development, and assessment of leaders (ie, the persons who lead) and of leadership (ie, the relationships and culture of aspiration and inspiration). The FourCe-PITO framework is intended to be inclusive and comprehensive.

WHY DEVELOP MILITARY MEDICAL LEADERS?

For the past 40 years, the Harris poll has asked Americans whether they had confidence in the leadership of American institutions. For as many years, medicine has ranked among the top groups that inspired confidence among those polled.[16] In 2014, the medical doctor was considered to be the most prestigious occupation in the United States by another Harris poll.[17] Physicians and medical professionals are expected to lead.

The military officer was the second most prestigious profession in America, according to the 2014 Harris poll, rated as “prestigious” by 78% of Americans, just behind physicians (88%). Nurses also were listed in the top five professions. America has “a great deal” of confidence in military leadership according to both Harris and Gallup polls.16,18 In fact, military leadership has been highly ranked in Harris polls as confidence inspiring for decades. In the United States, the military epitomizes leadership. American military officers are expected to and must lead.

Despite these high expectations of leadership from physicians and military officers, a 2011 report of the RAND Corporation in collaboration with the MHS Office of Transformation, titled Developing Custodians of Care, indicated a need to improve healthcare leadership development within the MHS.[19] This call was consistent with the 2008 Affordable Care Act’s focus on the development of “accountable care organizations” in which “doctors, hospitals, and health care providers come together voluntarily to give coordinated high quality care to the Medicare patients they serve.”[20] Physician medical leadership is necessary for the healthcare system to be effective, efficient, and accountable. For the MHS, which serves the nation’s warriors and their families, physician leadership to optimize performance, safety, and effectiveness, while containing costs, is essential.

WHY IS MILITARY MEDICAL LEADERSHIP IMPORTANT NOW?

The MHS is the only American healthcare system that goes to war. Uniformed providers and staff have deployed increasingly since the Vietnam War for military, humanitarian, and stability operations.[21] Since 2001 the MHS has provided continuous forward care for wounded, ill, and injured in the wars in the Middle East—the longest war fought by volunteers in this nation’s history. Moving back and forth between the theater of war and home-based hospitals, professionals have frequently cared for the same patients they saw in combat when they returned to their duty stations in the United States.

The MHS serves 9.7 million beneficiaries directly through a system of Department of Defense (DoD) military medical treatment facilities (MTFs), including 56 hospitals and 365 clinics, as well as through civilian care purchased from private providers where uniformed care is unavailable. The MHS is the world’s largest global integrated healthcare system, operating on every continent and employing roughly 58,000 civilians and 86,000 military personnel.[22] According to the Congressional Budget Office, in fiscal year 2013 the MHS budget exceeded $50 billion for the first time, accounting for more than 10% of the DoD budget. When combined with the Department of Veterans Affairs, the largest integrated healthcare system in the United States, the two federal organizations provide care to 14 million people at a cost of $104 billion, representing 11% of all federal healthcare costs.[23]

Healthcare costs in the MHS have increased fivefold since 2001.[23] As one government official said, “Today, we’re on the path in the Department of Defense to turn it into a benefits company that may occasionally kill a terrorist.”[24] The rising healthcare cost of the MHS cannot be sustained. In the United States, the imperative to deliver quality care while cutting costs and eliminating system variation requires thoughtful and effective leadership.

Residents training in primary care programs today (family medicine, pediatrics, internal medicine) still provide the bulk of inpatient care coverage for children and adults, but they do so with one-fifth less training time since the 80-hour work week became the standard a decade ago (compared to the previously “standard” 100-hour work week). As the inpatient census drops in hospitals across the nation, trainees may have decreased overall patient experience because of diminished patient exposure. At the same time, the care of critically ill hospitalized patients has become more complex.[25] Designing safe systems to care for these complex patients with less experienced personnel requires leadership.

The days of all-knowing, “one-stop-shop” physicians, or physicians always available for house calls, are long past. Increasingly, patients in the hospital and in the clinic require multidisciplinary and interdisciplinary care teams of professionals to assure the highest outcomes.[25] Healthcare in the 21st century involves a team of primary care physicians, specialists, nurses, psychologists, social workers, dentists, physical therapists, occupational therapists, and others. Leading these teams requires professionals who can seamlessly move back and forth from hierarchical to shared leadership roles as different therapists and providers take the lead during various aspects of patient care. Juggling to attain a balance between complex and dynamic care team scenarios requires well-developed leadership skills.

Finally, the challenges and scrutiny that face today’s military healthcare leaders are only increasing. A recent lay publication noted that nearly one in five military healthcare leaders of major Army healthcare facilities in 2014 were either relieved or suspended.[26] Future military healthcare leaders must be acutely aware of the concepts of moral, ethical, and legal leadership and understand the terminology and impact of “toxic” leadership. They must be able to distinguish the differences among strategic, operational, and tactical leadership, and understand that tactical-level decisions can have strategic-level implications.

HISTORY OF LEADERSHIP

Interest in and discussion of leaders and leadership date back millennia, appearing in Homer’s Iliad, the Old Testament, the New Testament, the Bhagavad Gita, and the Koran. These historical texts emphasized personal and physical characteristics and abilities of individual leaders. The empirical study of leadership began in the mid-20th century and was pioneered by Kurt Lewin, the “father” of experimental social psychology.[27] Lewin identified three different leadership styles—autocratic, laissez-faire, and democratic—and studied group dynamics among leaders and followers. During the latter half of the 20th century, there was an explosion of definitions, conceptualizations, and studies of leadership. With this increased attention to “what is leadership” came different views emphasizing individual characteristics and traits of the leader and the led; social interactions and group dynamics; processes and goals; situational influences; relevant knowledge and skills; and many other individual, interpersonal, and group distinctions.

In the last decades of the 20th century, group processes became the focus, highlighting how the leader and members of the group interact, including transactional (focusing on behaviors), transformational (focusing on motivations), servant (focusing on mission and followers), and authentic (focusing on leaders’ communication) leadership. More recently, Heifetz[28] emphasized leadership through adaptive work versus technical work and the challenges of leading with and without authority. Kolditz[29] emphasized leadership in extreme situations. Pearce[30] emphasized the importance of self-awareness and expressions of one’s emotions in concert with cognitions for leaders to communicate effectively. Day and Antonakis combined aspects of the individual leader, group processes, and leadership context in describing leadership as “an influencing process and its resultant outcomes that occurs between a leader and followers, and how this influencing process is explained by the leader’s dispositional characteristics and behaviors, follower perceptions, leader attributes, and the context in which the influencing process takes place”[31] (see Day and Antonakis[32] and Northouse[33] for detailed discussions of leadership theories and styles).

ELEMENTS OF FOURCE-PITO

The definition of leadership offered in this chapter was developed to capture concepts and findings from extant leadership literature. As mentioned above, leadership is defined here as the enhancement of behaviors (actions), cognitions (thoughts and beliefs), and motivations (reasons for actions and thoughts) to achieve goals that benefit individuals and groups. This wording includes the overlapping elements of psychology (behavior, cognition, motivations); the influence of leadership as an “enhancer” of these elements; and the end result of achieving or attaining goals (physical, psychological, and/or social) for the welfare of individuals or groups. The elements of the FourCe-PITO framework and their relevance to development and evaluation of leaders are described in more detail below.

Character

Krishna, Moses, Buddha, Jesus, Muhammad; Washington, Lincoln, FDR, Victoria, Thatcher; Gandhi, King, Mandela; Carnegie, Rockefeller, Gates; Newton, Darwin, Pasteur, Freud; Lovell, Letterman, Sternberg, Gihon, Rixey, Stokes, Carlton: individual leaders have emerged in belief systems, politics, business, science, and military medicine. These impressive individuals had powerful and admirable elements of character that helped them attain status and effectiveness as leaders.

Character includes all aspects of who we are physically, psychologically, and demographically. It includes personality, attributes, values, attitudes, appearance, aspirations, temperament, and so on. Everyone can become a leader, but we must know who we are and others’ perceptions of who we are to become effective leaders. It is important to understand what aspects of self contribute to success as leaders and what aspects of self detract from effective leadership. Among the many aspects of character, self-confidence, humility, integrity, trustworthiness, responsibility, optimism, and empathy are particularly important to successful leadership.

Individual qualities of leaders have been an interest for as long as people have formed groups. The “savannah” hypothesis of leadership emphasized leader physical strength, stamina, and extraversion for small groups of human ancestors on the African plains.[34] Ancient literature is replete with examples of leader behavior with an emphasis on individual characteristics: those who are leaders because of position (eg, ex officio as king); physical size, strength, or looks; or individual personality traits or charisma. Homer’s epic poems the Iliad and the Odyssey, written more than two millennia ago, present various models of leadership in the characters of Agamemnon (leader because he was the Greek king who led his countrymen against the Trojans), Achilles (leader because of his demigod warrior status), Ajax (leader because of his size and strength), Odysseus (leader because of his cunning), and Hector (leader because of his courage and dedication to his people).[35]

In the Old Testament, Joshua was challenged with the universal warrior’s standard of personal leadership: “Be strong and courageous, do not tremble nor be afraid.”[36] In Beowulf (an Anglo-Saxon poem, ca 1,000 CE), a young prince’s behavior is recognized as affecting those who follow: “By praise-worthy actions must honor be got,” or alternatively, “Behavior that’s admired is the path to power among people everywhere.”[37]

Early writings on leadership and social behavior focused on the leader and the leader’s character. Carlyle wrote, “the history of what man has accomplished in this world, is at the bottom the History of the Great Men who have worked here.”[38] Carlyle’s emphasis on the character of the individual leader gave rise to the “great man” theory of leadership.

Genetic factors can impact “leader emergence.” Twin studies of both genders suggest that up to 30% of the differences that lead to leadership roles could be the result of genetic factors,39,40 leaving 70% to environment, education, training, and experience. There is not a significant correlation between intelligence and leader role occupancy, leader advancement, or motivation in children or adults. However, the extraversion temperament style is a predictor of leader emergence, along with the personality traits of conscientiousness, emotional stability, and openness to experience.[41] Children ages 2 to 16 years who are more accepting of new situations, are more extroverted as adolescents, and develop greater social skills are more frequently found to have work-related leadership responsibilities.[42] “Nature” plays a part in who becomes a leader, but “nurture” carries the day. Leadership can and should be taught and developed.

Leader traits as a reflection of temperament and personality also may affect the leader’s dominant style. Lewin and Lippitt studied school children and identified three different leadership styles: authoritarian (autocratic), participative (democratic), and delegative (laissez-faire). Autocratic style tended to yield high productivity with low creativity. The democratic style participants were less productive but more creative, and the delegative style was the least productive of the three.[43] Although the three classic styles identified by Lewin,[43] as well as other styles (eg, authentic, servant, transactional, and transformational leadership), may come more “naturally” to some, all styles can be learned. Also, the context (including culture, stress, and time pressures) alters the effectiveness of various leadership styles, reflecting the overlap among the FourCe dimensions.

Weber introduced the term “charisma” (from the Greek “favored”) to describe a leader who was imbued with special gifts that empowered him or her to bring about social change.[44] A substantial amount of leader research has focused on charismatic, transformational leaders. According to Bass, these gifted men and women “by the power of their person have profound and extraordinary effects on their followers.”[45] This transformational style has been presented as a contrast to the more “transactional style” characterized by “a process of exchange” that is similar to an economic contract and depends on “the good faith of the participants.”[46] Charisma, recast as “idealized influence” by leadership researchers, is different than transactional leadership in that “transformational leaders shift goals of followers away from personal safety and security toward achievement, self-actualization, and the greater good.”[47]

Business consultant and contemporary leadership scholar Jim Collins surveyed successful companies that he wrote about in his 2001 best-seller, Good to Great. His research team concluded that the companies that exceeded their peers’ economic performance were led consistently by what he termed “Level 5” leaders. These leaders demonstrated traits and behaviors that he characterized as “a paradoxical mix of personal humility and professional will.”[48]

It is clear that a leader’s character, including personality (with emphasis on confidence, trustworthiness, and resilience/hardiness) and emotional intelligence affect leadership effectiveness. Emotional intelligence, discussed below in more detail under “Competence,” can be learned and developed, even though there are clear differences among individuals. It includes essential aspects of “relationship management,” and is a strong predictor of successful leadership. Because leadership effectiveness relies on interactions with followers, leader competence and the followers’ response to the leader are critical.

Competence

Competence refers to abilities, skills, and knowledge relevant to leadership that transcend various roles, professions, and responsibilities. Competence also refers to the abilities, skills, and knowledge specific to particular roles, professions, and responsibilities of relevance to a leadership position. Lack of individual professional and technical competence creates additional leadership challenges, and leaders should have a working understanding of the professional and technical competence specific to the role, but transcendent leadership competence is particularly important.

Effective leadership competence that transcends particular leadership roles includes management skills, problem-solving skills, emotional intelligence, and ability to influence and inspire followers. It is crucial for leaders to develop excellent problem analysis, critical thinking, and decision-making competencies. To develop these skills requires awareness of cognitive biases and various heuristics that affect perception of information. It is useful to be knowledgeable about principles of social psychology and group dynamics that influence interpersonal relationships and willingness to express ideas.49,50 Thoughtful and critical decision-making that encourages and considers broad input from the members of the group requires practice, feedback, and more practice.

The extent to which a leader needs management skills depends on the context, including the organization and culture. According to management expert Peter Drucker, both the military and healthcare industries require people who know how to “get the right things done.” So mastering management is necessary, but not sufficient, to be an excellent military healthcare leader. For example, military medical leadership requires competent management of personnel. Drucker writes, “Management is about human beings. Its task is to make people capable of joint performance, to make their strengths effective and their weaknesses irrelevant.”[51] Other important management skills address time management, organization, and optimal use of resources (including people, materials, and finances). Zaleznik[52] argued that managers and leaders are different types of people. Kotter[53] made the case that managers and leaders serve different but complementary roles. More recently, Watkins argued that excellent managers can become great leaders by changing from “specialist to generalist,” “analyst to integrator,” “tactician to strategist,” “bricklayer to architect,” and “warrior to diplomat.”[54] It seems that managers can learn to be leaders, but leadership competence goes beyond management.

Table 4-1 presents a comparison of management and leadership. Note that management focuses on affecting behaviors of followers, whereas leadership affects behaviors, cognitions, and motivations. Also note that management emphasizes accountability and productivity, whereas leadership is aspirational and inspirational.

Leadership is largely a matter of influence. Influence is tied to perception, and perception is generally affected by emotion.[55] One of the key competencies that must be further developed in leaders is emotional intelligence. This psychological construct was identified in the mid to late 20th century as psychologists recognized that the traditional intelligence quotient (IQ), which focuses on verbal and quantitative abilities, was an incomplete assessment of cognitive and other abilities.56–58 The concept of emotional intelligence (or EQ) gained attention and popularity following Goleman’s book on the subject.[59] Essentially, EQ refers to the ability to accurately perceive emotions in oneself (self-awareness), to manage one’s own emotions (self-regulation), to accurately perceive and understand emotions of others (empathy), and to use that understanding to optimize relationships (social skills). EQ has been described by models that emphasize traits (making it an aspect of character), abilities (making it an aspect of competence), and both traits and abilities. Certainly individuals have different levels of EQ from an early age, but there are various styles of EQ that can be learned,[60] and EQ can be taught and developed. Therefore, EQ is categorized here as a competence, but overlapping with character.

TABLE 4-1

COMPARISON OF MANAGEMENT AND LEADERSHIP

Management

Leadership

Behaviors

X

X

Cognitions

X

Motivations

X

Vision

Follow

Set

Emphases

Administration and oversight

Motivation and inspiration

Efficiency

Innovation

Productivity

Creativity

Effective, inspirational, and transformative leaders are thought to be particularly good at creating positive emotional reactions in followers.[55] Research by the Hay-McBer group examined the impact of emotional intelligence on individual leadership behaviors and organizational performance. In their research, leaders with greater emotional intelligence competence (self-awareness, self-management, empathy, relationship management) were more influential than peers who lacked these strengths. Business units led by men and women with high marks in emotional intelligence financially outperformed units led by leaders without this competence by 20%, and nearly 90% of the leaders with greater emotional intelligence placed in the top third for annual salary bonuses based on unit performance.[61] Leadership styles reflecting emotional competence had a reproducible effect on organizational climate, and leaders who were able to manifest different styles depending on the individual needs of the followers were considered most effective as measured by business unit performance.[61]

Emotional intelligence is an important feature of the relationship between the leader and follower. It has been extensively studied and has contributed to the understanding of the “leader-member exchange” school of leadership. This relational approach posits that “when managers and subordinates have good, trusting, open, and supportive relationships, they report more positive attitudinal and behavioral outcomes, and workplace and leadership dynamics are more effective.”[62] This “constructionist” approach to leadership suggests that relationships are “the generative source of leadership,” so it is little surprise that ability to establish strong relationships in accordance with high emotional intelligence should predict leader effectiveness in this model.[62] (See Goleman[59] and Goleman, Boyatzis, and McKee[63] for detailed discussions of EQ, how it relates to leadership, and how to develop EQ.)

A related competence of leadership is the ability to inclusively relate to others. Inclusive leadership rests on a foundation of listening, demonstrating respect for and willingness to involve others on the part of the leader. This point is consistent with the observation of the 24th century BCE Egyptian philosopher Ptah-hotep, who understood the importance of leader-listening: “Those who must listen to the pleas and cries of their people should do so patiently, because the people want attention to what they say even more than the accomplishing for which they came.”[62] It also highlights the overlap between leader competence and communication.

As the foundation of a relationship, attentive, “active” listening is the place to begin honing leader competence. Listening skills affect the leader’s competence across a range of leader tasks: the dynamics of running meetings, strategic planning, mentoring, coaching, and leader succession planning. The information gathered by leaders through strong relationships with the group and excellent communication is used to make informed, thoughtful, and appropriate decisions relevant to the group and the members of the group.

Leadership is characterized by strong partner relationships between leader and followers. “The role of the leaders in these processes is to provide environments that are inclusive, trusting and supportive to followers; the role of the followers is to be active partners in the leadership process.”[62] Emotional intelligence, interpersonal management, and decision-making occur in a social context that is affected by the unit’s task, its organization, and its culture. Therefore, the effective leader must also be facile at leading in a specific organizational or situational context.

Context

Context includes the physical, psychological, social, cultural, and economic environment; various situations; and stress that a leader may face. According to Bennis, “context always counts when it comes to leadership.”[64] Kellerman also emphasizes the importance of considering context in optimal leadership.[51] Context is particularly important in military medical leadership because of the extreme and varied situations where leadership is required (physically, psychologically, and socially). Military healthcare leaders must be able to perform in volatile, uncertain, complex, and ambiguous (“VUCA”) environments; in other words, leaders must adapt to context.[65]

With regard to leadership, context also includes characteristics that are unique to the group of the subordinates being led; the nature of the subordinates’ tasks; the situation in which the leader and subordinates operate; and characteristics of the organization where the leadership occurs.[66] Fiedler first proposed a model of leadership that took into account both the leader’s orientation (character and leader competence) and the situation (context, subordinates, task, organization). Orientation reflects “an internal state intrinsic to the leader” that is affected by subordinates and the task to be accomplished (situation).[67]

Watkins has studied and written about business units and their impact on leader context, categorizing different organizations as start-ups, turnarounds, or organizations undergoing accelerated growth, realignment, or sustained success. He contends that leaders who fail in new positions do so when they “rely on the skills and strategies that worked for them in the past” instead of taking the new workplace context into consideration when approaching the required leadership approach.[68] Research has supported Watkins’s assertions.[66]

The organization’s culture includes a set of repeated behaviors motivated by thoughts (cognitions) and feelings (motivations/emotions) that are based in collective belief developed over a long period. These beliefs are reinforced by symbols, artifacts, and rituals, and affect the individuals as they mature and grow within the culture.[69] The consideration of culture is relevant to uniformed leaders operating across different service cultures. It is critical to understand the different service cultures in order to avoid misunderstandings and misinterpretations, including chains of command, preferred uniforms, and appropriate ways to address colleagues, superiors, and subordinates.

Each of the uniformed services has a well-defined, discernible culture, as Builder discusses in The Masks of War. Builder summarizes the different services’ primary cultural foundations: Navy, independent command at sea; Air Force, devotion to technology; and Army, service to the country as a citizen-soldier.[70] These different cultures affect the way business is conducted in each service and the way the leaders learn to conduct business. This pattern of repeated behaviors can lead to leadership conflict when the leader attempts to operate in the context of one service culture using learned behaviors from another.[71]

Leadership context must take into consideration nuances of the era as well as the organization. Generational sociologists Strauss and Howe have articulated the differences between the “generations” represented in today’s military: baby boomers (born 1940–1960), generation X (born 1960–1980), and millennials (born 1980–2000).[72] For millennials as leaders and as followers, challenges and opportunities of digital and social media must be considered and addressed.[73]

Other individual differences, including gender, should be considered as an aspect of context that may affect leader-follower perceptions, relations, and effectiveness. In 1996, the number of women in the United States with bachelor’s degrees exceeded the number of men, and in 2010 for the first time more women than men earned master’s degrees.[74] Women have become major players in many professions, including health services.[75] Gender bias as well as any ethnic, racial, and other biases must be continually addressed for leaders to succeed. (For further discussion of gender in leadership see Ayman and Korabik[76]; Cheung and Halpern[77]; and Eklund, Barry, and Grunberg.[78])

In addition to organizational culture, other cultural differences must be considered for effective leadership. US military medicine is practiced in every part of the globe, and this practice is an essential part of “soft power” to support national security and provide humanitarian service throughout the world. Therefore, it is imperative to recognize that leadership must consider every aspect of cultural context, including gender, age, race, ethnicity, religion, traditions, verbal language, body language, eye contact, and interpersonal space.

Leadership in crisis situations (eg, life-threatening, resource-limited, time-urgent) presents a unique set of contextual challenges, requiring different considerations that may be uniquely important to military medical leaders. “In-extremis leadership,” according to Kolditz, requires focus on the external environment to make decisions about appropriate actions. Moreover, leaders must share the same risks as subordinates, and must be sufficiently competent to inspire trust, loyalty, hope, and confidence in subordinates. Kolditz cites examples of combat leadership to illustrate how to adjust to extreme conditions and context.[29]

Leaders respond to context in multiple ways. They learn to have situational awareness, change behaviors to suit the situation, or manage and alter the situation. This responsive adaptation has been proposed by Ayman and Adams as representing Sternberg’s model of “triarchic” intelligence: the individual’s “purposive adaptation to, selection of and shaping of the real-world environment relevant to one’s life and abilities.”[66]

Additionally, leaders must consider how perceptions, challenges, and behaviors are altered in the context of stress. A leader’s dominant responses become more marked or prominent under stress. If the dominant response is to do something correctly, then performance improves. But if the dominant response is to do something incorrectly, performance deteriorates.79,80 Decision-making often relies on automatic or dominant responses in the context of stress. In addition, people tend to yield more readily to authority when under stress.[28] Therefore, the leader—whether right or wrong—can become more influential in stressful situations.

Research has indicated that stress is related to performance and hedonics by an inverse U-shaped function, so that performance and mood are optimal at moderate stress, but poorer at minimal or extreme stress.[81] When leadership occurs under stress (as it often does in military medical practice, whether in the emergency department, operating theater, or field, because of harsh environmental conditions or combat), leader authority is particularly influential and dominant responses (good or bad) of leaders and followers emerge.

Military medicine occurs in broad and varied contexts. For teams and groups to function effectively in all contexts, clear and accurate transmission of information is critical. Communication, therefore, is the fourth critical domain of leadership (see Chapter 11, Military Communication, for a broader discussion of communication relevant to military medicine).

Communication

Effective communication, a critical element in most leadership models, takes into consideration the leader’s narrative, vision for the group or organization, and style of communication. Rhetoric is the communication of this narrative in person, electronically, in video, or in writing. It is important to recognize that communication involves sending and receiving, verbally (oral and written words) and nonverbally (including tone of voice, intonation, volume, body language, facial expressions, and gestures). “Reading” and “receiving” information from followers’ faces, body language, and moods are as important as listening to their verbal input. “Sending” information nonverbally through facial expression, gesture, and touch are as important as clearly expressed words. Tone of voice, pitch, rhythm, timbre, and volume also are important in oral communication. All forms of written messages (eg, memos, directives, policy statements, emails, tweets, instant messaging) must be carefully constructed for clarity. They should convey rational and well-reasoned decision-making, consideration of input, and respect for others. Verbal and nonverbal communication must be in synchrony to be effective and trustworthy.

Communication requires planning and practice. It also involves awareness of applicable principles and techniques. It is important for the communicator to be credible, trustworthy, and knowledgeable about the information conveyed. Communications that consider primacy (information that is presented first), recency (information that is presented last), repetition, clarity, and relevance of information to the audience are most effective. Point-counterpoint (ie, addressing opposing opinions), memorable imagery and anecdotes, and consistency of nonverbal expression and verbal content all add to persuasive communication.82–85

Influential leaders communicate in appropriate, emotionally modulated ways, packaging their messages so that they are easily understood, able to captivate audiences, and adjusted to the emotional needs of followers (eg, when to fire them up, when to calm them down; when to be empathetic and when to be authoritarian). Effective leaders are good storytellers. They know how to use voice and body gestures and are masters of rhetoric. In a discussion of charismatic leadership, Antonakis identified Aristotle’s work Rhetoric as a summary of the importance of communication to leadership.[47] It also is apparent that Aristotle appreciated the importance of character, competence, and context to communication. With regard to character:

The first kind (of persuasion) depends on the personal character of the speaker … Persuasion is achieved by the speaker’s personal character when the speech is so spoken as to make us think him credible. We believe good men more fully and more readily than others: this is true generally whatever the question is, and absolutely true where exact certainty is impossible and opinions are divided.

…

It is not true, as some writers assume in their treatises on rhetoric, that the personal goodness revealed by the speaker contributes nothing to his power of persuasion; on the contrary, his character may almost be called the most effective means of persuasion he possesses.[86]

Aristotle’s opinions suggest cognizance of emotional intelligence by considering the listeners’ feelings:

Persuasion may come through the hearers, when the speech stirs their emotions. Our judgments when we are pleased and friendly are not the same as when we are pained and hostile.[86]

Aristotle underscores the importance of context by addressing the communication within the “case in question”:

Persuasion is effected through the speech itself when we have proved a truth or an apparent truth by means of the persuasive arguments suitable to the case in question.[86]

Effective communication is a hallmark of successful leadership. The message is a crucial aspect of the leader’s rhetoric. In military medicine, messages are compelling and essential. Leaders advise about life and death and how to sustain health and avoid injury and illness; recover from injury and illness; and prepare for and deal with death. These communications must be clear, unambiguous, sensitive, compassionate, and respectful.

Retired Air Force General Johnnie Jumper tells the story of walking through a crowd of fresh recruits recently graduated from basic training. He asked a young graduate how she felt. “Sir,” she told him, “for the first time in my life, I feel as though I am a part of something bigger than myself.” Leaders must learn to tell the story in ways that will be understood and embraced, to tell what Sinek would call a story about “why.”[87] Pearce emphasizes that leaders must understand and express their emotions with their message to truly communicate authentically and to optimize influence.[30]

Frankl believed that “man’s search for meaning is the primary motivation of his life.” He proposed that “at any moment, man must decide, for better or worse, what will be the monument of his existence.”[88] Most military medical leaders share the same sense of purpose in caring for warriors and their families and training the next generations of providers. This sense of purpose can be conveyed in ways to inspire and strengthen others.

Military service provides meaning and significance for service members and the healthcare professionals who care for them. Veterans often miss the camaraderie after they leave the military. The basis of this camaraderie is unity around a single purpose. Service members are drawn to this message of unity of purpose, and they miss it when it is gone.

Sonnenfeld and Ward, writing about personal leadership in crises, observed that “the most common theme in the research on resilience is the necessity of a core sense of meaning in the person’s life.”[89] The story that sustains service members, their families, and the professionals who care for them through the challenges of severe illnesses and injuries, deployments and separation, and the pressures of practice and living in a “glass bowl” is the narrative of being part of something bigger than themselves. The military medical leader’s understanding of that narrative, genuine belief in it, and ability to communicate this sense of meaning verbally and nonverbally may be the single most important contribution to the group and to the organization.

TABLE 4-2

SAMPLE ELEMENTS OF FOURCE-PITO FRAMEWORK

Character (Ch)

Competence (Cp)

Context (Cx)

Communication (Cm)

Personal

Identify core values

Develop self-awareness

Understand service cultures

Communicate effectively

Interpersonal

Share core values

Enhance emotional intelligence

Work in dyads

Communicate difficult information

Team

Build team values

Understand group dynamics

Work in small groups

Communicate with team under stress

Organizational

Inspire core values in large groups

Learn strategic vision

Understand various cultures

Communicate to large groups

PITO

The four domains (or four Cs) of leadership should be considered, developed, and evaluated (by each leader and by others) across the four psychological, social psychological, and sociological levels—personal, interpersonal, team, and organizational—to develop outstanding leadership.13,90 Combination of the FourCe domains with the PITO levels creates a powerful framework to guide leadership education and development as well as self-evaluation and evaluation by others, including peers, subordinates, and supervisors.

Figure 4-1 presents the FourCe-PITO framework now used by the Uniformed Services University of the Health Sciences Leadership Education and Development Program to identify elements of leadership training, needs for research and scholarship, and ways to assess military leadership. Figure 4-2 presents a more detailed version of this framework, listing examples of key elements of each of the four Cs. Figure 4-3 and Table 4-2 present more granular versions of this framework with examples of leadership goals for each of the four Cs at each of the four PITO levels. Figure 4-4 presents an abbreviated version of the FourCe-PITO framework.

Figure 4-1. FourCe-PITO framework.

Figure 4-2. Expanded FourCe-PITO framework.

Figure 4-3. Expanded FourCe-PITO framework with examples of lessons.

Figure 4-4. Abbreviated FourCe-PITO framework.

HOW TO USE THE FOURCE-PITO FRAMEWORK

The FourCe-PITO leadership framework offered in this chapter can be used to develop and evaluate oneself and others as leaders. A leader can reflect upon and list strengths and gaps in each of the 16 cells of the FourCe-PITO matrix. In addition, a leader can ask others (including peers, subordinates, and supervisors) to do the same exercise for a full or “360°” assessment. Identified gaps, places to improve, and ways to refine elements of the model can be addressed with self-study and reflective writing, interpersonal discussions with peers and coaches, team-building exercises, and other leadership development experiences that are available via in-person workshops as well as online courses and exercises. Evaluation of leadership performance using the FourCe-PITO framework can also be done in hospital, clinic, field, and other settings.

SUMMARY

Effective military medical leadership is important for the successful, safe, and efficient delivery of healthcare, prevention, treatment, and rehabilitation services. Leadership is the enhancement of behaviors (actions), cognitions (thoughts and beliefs), and motivations (reasons for actions and thoughts) to achieve goals that benefit individuals and groups.

The four Cs of leadership are character, competence, context, and communication. Character includes confidence, humility, responsibility, integrity, trustworthiness, optimism, empathy, and service values (for military medical leadership). Competence includes transcendent leadership knowledge and skills and sufficient expertise determined by the role and specialty. Context includes physical, psychological, social, cultural, and economic environments; various situations; and stress. Communication refers to sending and receiving information, verbally and nonverbally. The psychological, social psychological, and sociological levels of interaction relevant to leadership are personal (the individual), interpersonal (dyads), team (small teams), and organizational (large groups). The FourCe-PITO framework provides a guide for military medical leadership education development and evaluation.

Acknowledgments

We especially thank Erin S. Barry for her valuable assistance preparing this chapter. We also thank Shelley McKechnie Cryan, Melissa Givens, Shawn Kane, Hannah Kleber, Matthew Moosey, Anita Novarro, Dale Smith, Eric Schoomaker, and Angela M. Yarnell for their critiques and suggestions.

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Chapter 5

MILITARY LAW AND ETHICS

SAMUEL J. SMITH JR, JD*

INTRODUCTION

THE MILITARY JUSTICE SYSTEM

OFFENSES UNDER THE UCMJ

HOW THE MILITARY JUSTICE SYSTEM WORKS

COURTS-MARTIAL

DISCIPLINARY RULES UNIQUE TO PUBLIC HEALTH SERVICE OFFICERS

THE FEDERAL TORT CLAIMS ACT AND THE FERES DOCTRINE

THE DEPARTMENT OF DEFENSE JOINT ETHICS REGULATION

SUMMARY

*Colonel (Retired), Judge Advocate General’s Corps, US Army; Deputy General Counsel, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

Military service is subject to unique laws, regulations, and policies that limit the rights of military personnel and “regulate aspects of the conduct of members of the military which in the civilian sphere are left unregulated.”1(p750) The US Supreme Court has “long recognized that the military is, by necessity, a specialized society separate from civilian society,”1(p743) which must be ready to fight and win the nation’s wars. In order to accomplish its missions, the military has an absolute need to “foster instinctive obedience, unity, commitment, and esprit de corps.”[2] This has led to the development of significant differences between military law and civilian law.[1] Exhibit 5-1 defines key terms used in this chapter.

EXHIBIT 5-1

MILITARY LAW DEFINITIONS

Convening authority. Commanders at various levels who are vested with vast authority in the military justice system. Among other responsibilities, convening authorities appoint court-martial panel members (military jurors), decide whether to convene a court-martial, and refer charges within their jurisdiction for trial. In certain cases, convening authorities have the discretionary authority to set aside findings of guilt and punishments after trial.

Courts-martial. The military’s three-tiered criminal court system. Generally, minor disciplinary offenses are referred to a summary court-martial; misdemeanor-level criminal offenses are referred to a special court-martial; and felony level criminal offenses are referred to a general court-martial.

Defense counsel. A judge advocate who advises and represents a service member accused of an offense under the Uniform Code of Military Justice (UCMJ). An accused service member is entitled to military defense counsel at no expense. A military defense counsel must be certified as competent to perform such duties by the service judge advocate general. Service members may hire civilian counsel at personal expense.

Ethics counselor. An attorney designated or appointed to assist in administering a command or agency ethics program and to provide ethics advice to Department of Defense personnel consistent with the Joint Ethics Regulation.

Good order and discipline. Generally, a condition or state of readiness that facilitates discipline, duty, and obedience to orders in the armed forces. The term, which is not defined in the Manual for Courts-Martial,[1] is entrusted to experienced military personnel to interpret under the circumstances in keeping with military customs and traditions.[2]

Joint Ethics Regulation. A single source of federal and military ethics standards and ethics guidance for Department of Defense personnel, including direction in the areas of financial and employment disclosure systems, post-employment rules, enforcement, and training.

Judge advocate. An officer of the Judge Advocate General’s Corps of the Army or Navy, an officer of the Air Force or the Marine Corps who is designated as a judge advocate, or a commissioned officer of the Coast Guard designated for special duty (law).

Manual for Courts-Martial. An executive order that implements the UCMJ with procedure, evidentiary rules, guidelines, and resources.

Nonjudicial punishment. Disciplinary proceedings under Article 15 of the Uniform Code of Military Justice used by commanding officers to address minor offenses.

Staff judge advocate. A designated service judge advocate who serves as the principal legal advisor for the command. Service regulations vary with respect to seniority and responsibilities. Staff judge advocates have a critical role in advising convening authorities about potential UCMJ violations before, during, and after each court-martial.

Trial counsel. A military prosecutor who advises and represents the government in the administration of military justice and enforcement of discipline. A military trial counsel must be certified as competent to perform such duties by the service judge advocate general.

Uniform Code of Military Justice. The military’s criminal and disciplinary code. The UCMJ establishes military criminal law and procedure and serves as the foundation for the administration of military discipline and justice.

____________

(1) Ghiotto A. Back to the future with the Uniform Code of Military Justice: the need to recalibrate the relationship between the military justice system, due process, and good order and discipline. North Dakota Law Rev. 2014;90:485. (2) Parker v Levy, 417 US 733 (1974).

The military justice system is the foundational cornerstone of military law and represents the most significant departure from civilian law. A separate system is needed to maintain good order and discipline, which are essential for mission readiness, efficiency, and effectiveness.[3] In recognition of the chain of command’s vital role in leading mission accomplishment, commanders have a central role in the military justice system[1]: “No question can be left open as to the right to command in the officer, or the duty of obedience in the soldier.”[4] Medical officers in all uniformed services must understand that fundamental legal differences apply to them as medical professionals serving in or with the military and become familiar with their critical roles in the military justice system.

This chapter will familiarize military medical officers (MMOs) with key concepts and issues involving military justice and administrative and civil law that they will address as military leaders. The chapter begins by examining key aspects of the Uniform Code of Military Justice (UCMJ), which provides the legal foundation for the military justice system and serves as the primary means for maintaining discipline in the US armed forces. The UCMJ serves as a multifaceted military criminal code and a flexible tool for maintaining good order and discipline. Next, a detailed explanation of how the military justice system works, including the roles that MMOs are often called upon to assume in the system, is provided. A brief overview of disciplinary rules unique to US Public Health Service (PHS) officers follows. The chapter then discusses military-unique medical malpractice protections under the Federal Tort Claims Act (FTCA). The chapter ends with a discussion of government ethics laws and requirements specific to those in military service, designed to familiarize MMOs with standards of professionalism they must uphold as leaders.

THE MILITARY JUSTICE SYSTEM

Historical Evolution of the UCMJ

The US court-martial system predates the Constitution, and is thus older than the courts created under the Constitution.[5] The Continental Congress adopted the first American Laws of War in 1775, based largely on the British Articles of War and Naval Articles.[6] Separate systems developed over time in the Army, Navy, and Coast Guard, with differences in both law and procedure. In 1948, responding to widespread complaints of systemic unfairness and calls for reform after World War I and World War II, the Senate Armed Services Committee asked the secretary of defense to submit a uniform code of military justice to apply across all military services in the newly created Department of Defense (DoD).[7]

Figure 5-1. Cover of the Manual for Courts-Martial.
US Department of Defense. Manual for Courts-Martial, United States. 2016 ed. Washington, DC: DoD; 2016. Reproduced from: http://jsc.defense.gov/Portals/99/Documents/MCM2016.pdf?ver=2016-12-08-181411-957].

Exercising its constitutional authority to regulate the armed forces, Congress enacted the UCMJ in 1950, bringing all services under one system with enhanced due process protections.[8] Sections in the UCMJ are referred to as “articles,” vestiges of the Articles of War and Naval Articles that served as the code’s historical basis. The UCMJ went into effect in 1951 after the president issued the Manual for Courts-Martial (referred to as the “Manual,” Figure 5-1), an executive order that implements the UCMJ by prescribing procedures (under “Rules for Courts-Martial”), evidentiary rules (“Military Rules of Evidence”), and punishments.[9] The UCMJ and Manual are reviewed annually and have been regularly updated and revised by Congress and the president.[10] The current edition of the Manual includes explanatory materials published by the DoD in conjunction with the Department of Homeland Security, and is supplemented by service regulations.

Jurisdiction: Those Covered by the UCMJ

Jurisdiction is covered in Article 2 of the UCMJ. Active duty military personnel are subject to the UCMJ at all times, even while off duty or in a leave status.[11] Other military personnel covered by the UCMJ at all times include cadets, aviation cadets, midshipmen, military prisoners serving a court-martial sentence, and prisoners of war. Reserve personnel are subject to the UCMJ only during active duty service periods and while in federal service on inactive duty training (Exhibit 5-2).[12] National Guard personnel are subject to the UCMJ only while serving in a federalized status; at other times they are subject to state law variations of the UCMJ.

Retired personnel of the regular components and members of the Fleet Reserve and Fleet Marine Corps Reserve are subject to the UCMJ. However, retirees from the reserve components are covered only when receiving hospital care from the armed forces. Medically retired service members are also subject to the UCMJ. Courts have long upheld UCMJ jurisdiction for those on the Temporary Disabled Retired List.13,14 In 2015, the Navy Marine Corps Court of Appeals found that jurisdiction also exists for those on the Permanent Disabled Retired List (Exhibit 5-3).[15]

PHS officers are subject to the UCMJ when assigned to and serving with the armed forces.[16] In this regard, the Public Health Service Act provides that “[o]fficers detailed for duty with the Army, Air Force, Navy, or Coast Guard shall be subject to the laws for the government of the service to which detailed.”[17] As a result, except in time of war or declared emergency, the policy of the Department of Health and Human Services is to detail a PHS officer to the armed forces only with that officer’s informed consent and acknowledgment that the UCMJ will apply.[18]

Given an increasing reliance by the US military on civilian personnel and contractors, it should be noted that certain groups of civilians serving with or accompanying the armed forces in the field in times of war or contingency operations are also subject to the UCMJ. However, under DoD policy, when offenses alleged to have been committed by civilians violate federal laws, the Department of Justice must be notified and offered the opportunity to exercise jurisdiction.[19] The Military Extraterritorial Jurisdiction Act[20] confers federal criminal jurisdiction for felony offenses committed abroad by federal employees and contractors supporting DoD missions. Several other groups are potentially subject to UCMJ jurisdiction, including prisoners of war in the custody of the armed forces (consult with your servicing military legal office when questions arise about jurisdiction).

EXHIBIT 5-2

RESERVE JURISDICTION

In United States v Phillips,[1] Patricia Phillips, a nurse serving as a lieutenant colonel in the Air Force Reserve, was ordered to active duty for 2 weeks of annual training in July 1999. On July 11th, Phillips traveled from her home in Pennsylvania to Wright Patterson Air Force Base in Ohio for the training, checked into visiting officer quarters, and knowingly consumed brownies laced with marijuana.

Phillips unsuccessfully tried to get another officer to provide a substitute urine sample for a urinalysis held the following week. The urinalysis detected marijuana usage, and Phillips was later convicted at a general court-martial of making a false official statement (Article 107), wrongful use of marijuana (Article 112a), and conduct unbecoming an officer (Article 133). She was sentenced to 45 days in confinement and dismissal from the service.

Phillips argued that jurisdiction was lacking because she consumed the marijuana on July 11th and annual training did not technically start until July 12th. The courts rejected her contention, noting that she traveled on orders, occupied government quarters, and received travel reimbursement on July 11th.

____________

(1) United States v Phillips, 58 MJ 217 (CAAF 2003).

EXHIBIT 5-3

MEDICALLY RETIRED PERSONNEL

The following two cases illustrate UCMJ jurisdiction over medically retired personnel. In 1994, Hospital Corpsman Third Class Walter Stevenson was discharged from the Navy and placed on the Temporary Disabled Retired List (TDRL) following recommendations of a Physical Disability Evaluation Board. Stevenson was awarded a 30% disability rating, which entitled him to receive military retired pay. However, after the Department of Veterans Affairs (VA) found him to be 100% disabled, he waived military pay in order to receive a higher amount from the VA.

Three years later, the Naval Criminal Investigative Service identified Stevenson, then living in Tennessee, as a suspect in the rape of a military family member in on-base housing in Hawaii in 1992. Stevenson was convicted at a general court-martial of rape (Article 120) and was sentenced to 3 years of confinement and a dishonorable discharge. The military trial and appellate courts found that the military retained an interest in good order and discipline for those on the TDRL because their disabilities are not permanent and they remain subject to recall. The Supreme Court declined to hear the case.[1]

Jurisdiction was also upheld in the court-martial of Charles Reynolds, a retired Marine first sergeant on the Permanent Disabled Retired List (PDRL). While on active duty, Reynolds joined a biker gang in violation of Department of Defense instructions. In January 2014, he conspired with two other Marines in the gang to assault a third Marine and participated in the assault. Two days later he was placed on the TDRL and transferred to the Fleet Marine Corps Reserve. Reynolds waived military retired pay in favor of higher payments from the VA. Later that year he physically assaulted his girlfriend.

In September 2015, Reynolds was placed on the PDRL, and continued to waive military pay in favor of VA compensation. The secretary of the Navy ordered Reynolds’s apprehension and confinement in late 2015 and authorized the exercise of court-martial jurisdiction over him. He was convicted of failure to obey a lawful general regulation (Article 92), conspiracy to commit assault (Article 80), and assault (Article 128) and sentenced to 270 days in confinement and a bad conduct discharge. In upholding jurisdiction over him, the Navy Marine Corps Court of Appeals relied upon his retired status, entitlement to retired pay, and the fact that he was not exempt from recall to active duty. The court distinguished Reynolds’s retired status from those who are completely discharged from service.[2]

____________

(1) United States v Stevenson, 53 MJ 257 (CAAF 2000), cert denied 555 US 816 (2008). (2) United States v Reynolds, No. 201600415 (NMCMR 2017).

OFFENSES UNDER THE UCMJ

UCMJ offenses (Articles 80–134) can be broadly grouped into three categories: “civilian” offenses, “uniquely military” offenses, and military “catchall” offenses.

“Civilian” Offenses

The UCMJ contains a wide range of “civilian” offenses commonly found in federal and state civilian criminal codes. These offenses include drunken or reckless operation of a vehicle, aircraft, or vessel (Article 111); wrongful use, possession, or distribution of controlled substances (Article 112a); murder (Article 118); rape and sexual assault (Article 120); and larceny (Article 121). Service members can reasonably be expected to understand that such acts are criminal in nature.

The potential exists for jurisdictional conflict and duplicative investigation and prosecution given that the UCMJ’s “civilian” offenses mirror those in federal and state criminal codes. Although the Constitution[21] and the UCMJ[22] prohibit double jeopardy, courts have interpreted that prohibition to limit only successive prosecutions by the same sovereign government under the “dual sovereignty doctrine.”23,24 Since federal and military authorities fall under the same federal sovereign, both cannot prosecute the same offense. Pursuant to interagency agreements with the Justice Department, most offenses involving DoD and Coast Guard service members on military installations or involving military operations are left to the military to investigate and prosecute.[3] However, matters of national significance are jointly investigated, and allegations of corruption are reserved for federal authorities.

States are separate sovereign governments and can prosecute offenses within their jurisdictions regardless of military prosecution, subject to state laws. However, the mere fact that actions occurred within a state does not necessarily confer jurisdiction on the state. In some cases, a state has no jurisdiction over an alleged offense if the act occurred on a military installation or facility that has exclusive federal jurisdiction. In other cases involving uniquely military offenses, there is no applicable state law. Protections against successive prosecutions are also found in military regulations that require high-level approval to prosecute a service member for the same offense previously tried in state courts.25(ch4)

Foreign courts generally have jurisdiction over crimes committed by US service members in other countries. However, the exercise of foreign jurisdiction is often limited by status-of-forces agreements, treaties, or other bilateral agreements with the United States, which normally confer primary jurisdiction on US military authorities. Nonetheless, such agreements can generate intense political discord in the host nation and erode public will, particularly when heinous crimes are committed by US personnel in the host nation involving host nation victims. Such incidents can threaten the stability of an alliance, which could result in a decision by military authorities to turn a service member over to host nation authorities.[26]

“Uniquely Military” Offenses

A second subset of UCMJ articles proscribe a number of offenses unique to military service for which there is no civilian equivalent. For example, whereas a civilian employee who misses work may be subject to adverse personnel actions, a service member who misses duty is subject to corrective training, administrative actions, progressive discipline, and even criminal penalties under the UCMJ. Similarly, unlike a civilian employee who does not commit a crime by publicly saying contemptuous things verbally or on social media about the company’s chief executive officer, a commissioned officer who uses contemptuous words against the president, the vice president, Congress, the secretary of defense, the secretary of a military department, the secretary of homeland security, or the governor or legislature of any state, commonwealth, or possession in which he or she is on duty or present faces possible criminal sanctions under the UCMJ. The fact that “uniquely military” offenses may not be obvious to those entering military service is one of the reasons that UCMJ training is required upon a service member’s initial entry into duty and periodically thereafter.[27]

This category of offenses includes, among others, absence without leave (Article 86); missing movement (Article 87); contempt toward officials (Article 88); disrespect toward a superior commissioned officer (Article 89); assaulting or willfully disobeying a superior commissioned officer (Article 90); insubordinate conduct toward a warrant officer, noncommissioned officer, or petty officer (Article 91); failure to obey an order or regulation and dereliction of duty (Article 92); cruelty and maltreatment (Article 93); mutiny or sedition (Article 94); misbehavior before the enemy (Article 99); aiding the enemy (Article 104); misconduct as a prisoner (Article 105); spies (Article 106); espionage (Article 106a); false official statements (Article 107); drunk on duty (Article 112); malingering (Article 115); conduct unbecoming an officer (Article 133); fraternization (Article 134); gambling with a subordinate (Article 134); and wearing unauthorized insignia, decoration, badge, ribbon, device, or lapel button (Article 134).

Article 92 of the UCMJ merits special examination because it incorporates three broad categories of offenses with clear significance for MMOs. First, Article 92 makes it an offense to violate or to fail to obey a lawful general order or regulation. Such orders and regulations are issued by a general court-martial convening authority, general, or flag officers in command, or are published at the service level. Knowledge of these orders and regulations is presumed, and therefore lack of knowledge is not a defense. This prohibition subjects service members to innumerable requirements generally related to standards of conduct and performance of duty. For example, many sections of the Joint Ethics Regulation (JER),[28] discussed at the end of this chapter, which exist to preserve the integrity of government operations by setting standards of conduct, are punishable as violations of Article 92. Likewise, participation in extremist organizations violates service regulations and is punishable under Article 92, UCMJ.29,30

Second, Article 92 makes violations of lawful orders punishable under the UCMJ. Such orders are issued directly by an individual that the service member has a duty to obey (Exhibit 5-4). This usually occurs within a service member’s chain of command, and could even arise in the context of medical treatment. For example, violation of an order to receive an immunization is subject to punishment under Article 92, UCMJ.[30]

Finally, Article 92 includes dereliction of duty as an offense, which potentially raises complex issues in the medical context. The offense is described as follows: “A person is derelict in the performance of duties when that person willfully or negligently fails to perform that person’s duties or when that person performs them in a culpably inefficient manner.”[3] This means that cases involving medical error potentially violate Article 92. This presents a friction point between professional self-regulation within military medicine and the UCMJ (Exhibit 5-5).

EXHIBIT 5-4

FAILURE TO OBEY A LAWFUL ORDER

In 2010, Lieutenant Colonel Terrence Lakin, an Army doctor with over 17 years of service, refused to deploy for a second tour of duty to Afghanistan due to his belief that then-President Obama was not born in the United States. Although the president had publicly released a copy of his birth certificate, Dr Lakin was unconvinced and felt the orders to deploy were not valid as a consequence. Another Army doctor had to deploy in Lakin’s place with little notice.

Dr Lakin, a flight surgeon who formerly served as chief of medicine at the Army’s Pentagon health clinic, ultimately pled guilty at a general court-martial to failing to obey a lawful order to deploy to Afghanistan (Article 92). The doctor who had to deploy in Lakin’s place, and that doctor’s wife, also an Army doctor, testified in sentencing proceedings about the difficulties the unexpected deployment caused them. Dr Lakin apologized, asked to remain in service and pledged to deploy in the sentencing phase of his court-martial. Nonetheless, he was sentenced to 6 months’ imprisonment and dismissal from the service. Dr Lakin lost any military retirement as a result.[1]

____________

(1) Hemmerly-Brown A. Lakin discharged, sentenced to six months. Army News Service. December 17, 2010. https://www.army.mil/article/49601/Lakin_discharged__sentenced_to_six_months/. Accessed November 20, 2017.

EXHIBIT 5-5

DERELICTION OF DUTY

Army Captain Michael Hamner, an anesthesiologist, pled guilty at a general court-martial in 2001 to false official statements regarding the administration of an antibiotic to a teenage patient who died in his care prior to routine surgery. At the time of the incident, in 1998, Hamner was a 3rd-year resident at the Walter Reed Army Medical Center.[1] Hamner was found guilty of dereliction of duty (Article 92) for improperly administering the antibiotic to a teenage patient and making false statements about the events. Hamner was sentenced to a dishonorable discharge.2,3

____________

(1) ABC News. Father seeks justice for daughter’s Army hospital death. ABCnews.go.com. November 22, 2004. http://abcnews.go.com/GMA/Health/story?id=272801&page=1. Accessed November 20, 2017. (2) Associated Press. Ex-Walter Reed doctor convicted in fatal malpractice case. Seattle Times. December 15, 2001. http://community.seattletimes.nwsource.com/archive/?date=20011215&slug=doctor15m0. Accessed November 20, 2017. (3) United States v Michael G. Hamner, No. 07-166, No. 07-0203/AR, petition for review denied (CAAF June 5, 2007).

Military “Catchall” Offenses

The UCMJ includes significant “catchall” offenses not specifically covered elsewhere in the UCMJ through Article 134’s General Article, including all disorders and neglects to the prejudice of (ie, those that cause a reasonably direct and obvious injury to31(p682)) good order and discipline in the armed forces (Article 134, Clause 1 [Exhibit 5-6]) all conduct of a nature to bring discredit upon the armed forces (Article 134, Clause 2); and certain state laws made applicable under the Federal Assimilative Crimes Act (Article 134, Clause 3). These broad “catchall” categories may not be used when a more specific offense listed in Articles 80 through 132 applies.

A detailed discussion of every punitive article is beyond the scope of this chapter. More information can be obtained from local servicing legal offices and the Manual for Courts-Martial, which provides detailed information about each offense in Part IV, including an explanation, a listing of the elements, and reference to any lesser included offenses.[3]

War Crimes

The law of armed conflict is established through international treaties and customary international law. The Geneva and Hague Conventions (discussed in Chapter 6, The Law of Armed Conflict and Military Medicine) establish the core of what is commonly referred to as the “law of war.”[32] However, it is left to states party to those conventions to investigate and prosecute violations under domestic law.

The UCMJ is the primary means by which the US prosecutes war crimes.[33] In some cases, such crimes are charged as specific UCMJ offenses, such as murder or rape. In others, suspected offenses are charged as conduct unbecoming an officer, and/or conduct prejudicial to good order and discipline. The federal criminal code can also be assimilated in charging war crimes for acts involving torture, genocide, terrorism, and certain uses of chemical, biological, or nuclear weapons. Those not subject to the UCMJ may be prosecuted under the War Crimes Act,[34] the Military Extraterritorial Jurisdiction Act,[35] and other applicable sections of the federal criminal code (Exhibit 5-7).

EXHIBIT 5-6

CONDUCT UNBECOMING AN OFFICER AND CONDUCT PREJUDICIAL TO GOOD ORDER AND DISCIPLINE

Howard Levy, a dermatologist from Brooklyn, New York, was drafted during the Vietnam War. His active duty service as an Army captain was delayed until he completed a civilian residency. While serving as the chief of dermatology at the military hospital at Ft Jackson, South Carolina, Levy refused an order to provide a course of instruction for Special Forces medics on dermatologic problems that might be encountered in the course of their counterinsurgency duties. Additionally, Levy publicly stated his opposition to the war, encouraged enlisted personnel not to participate in the war, and urged them to disobey orders, stating in part, “If I were a colored soldier I would refuse to go to Viet Nam and if I were a colored soldier and were sent I would refuse to fight. Special Forces personnel are liars and thieves and killers of peasants and murderers of women and children.”[1]

Levy based his refusal on his view of medical ethics and opposition to the war. He believed that Special Forces medics were primarily soldiers, and therefore any medical instruction he gave them would contribute to the war effort. As a physician, he felt providing this instruction would be unethical behavior. He was convicted of failure to obey a lawful order (Article 90), conduct unbecoming an officer (Article 133), and conduct prejudicial to good order and discipline (Article 134). Levy was sentenced to dismissal from the service, forfeiture of all pay and allowances, and 3 years of confinement at hard labor. Levy challenged the constitutionality of his convictions in federal court, claiming in part that the charges were vague and overbroad, and that the First Amendment protected his speech. Although a federal appeals court ruled in Levy’s favor, the Supreme Court reversed the opinion and reinstated his convictions and sentence.

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(1) Parker v Levy, 417 US 733 (1974).

EXHIBIT 5-7

WAR CRIMES PROSECUTIONS

In 2006, four soldiers from the 101st Airborne Division got drunk, left their guard post near Baghdad, entered a nearby home, and raped a 14-year-old girl. One of them, Private First Class Steven Green, then shot and killed the girl, her sister, and her parents in their home and set the girl’s body on fire. Green was discharged from the service before the four were linked to the crime. The other three soldiers were convicted at military courts-martial of rape and murder and sentenced to lengthy sentences under the UCMJ. However, since Green had separated from the service the UCMJ did not apply. Later in 2006, Article 3(a) of the UCMJ was changed to provide jurisdiction over former service members. Instead he was tried and convicted in federal court under the War Crimes Act, a federal law that allowed the former soldier to be charged under federal civilian law. Green was sentenced to life in prison without parole, and a federal appeals court upheld his conviction.1,2

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(1) United States v Steven D. Green, 654 F3d 637 (6th Cir 2011). (2) Frederick J. When a soldier murders: Steven Green gets life. Time. May 21, 2009. http://content.time.com/time/nation/article/0,8599,1900389,00.html. Accessed November 20, 2017.

The United States is not a party to the Rome Statute, a treaty that established the International Criminal Court (ICC), which became a permanent international criminal court in 2002 after ratification of the statute by 120 nations. The ICC was created to investigate and prosecute individuals “only if the State concerned does not, cannot or is unwilling genuinely to do so.”36,37 The court asserts jurisdiction over persons for the crimes of genocide, crimes against humanity, and war crimes. The United States rejects assertions of jurisdiction over US personnel by the ICC, although it maintains observer status and supports certain functions of the ICC.

HOW THE MILITARY JUSTICE SYSTEM WORKS

Command Discretion

Commanders have prosecutorial discretion under the UCMJ to determine how to handle alleged offenses under their authority. In this respect, commanders are charged with exercising their independent judgment, free from unlawful command influence by more senior commanders directing an outcome.[38] In most cases, the ultimate authority to dispose of more serious offenses, or those involving senior personnel, is withheld to higher level commanders.3(p401),39 Only commanders with authority to convene courts-martial or administer nonjudicial punishment have authority to finally dispose of allegations.[3]

Commanders have a wide range of options for dealing with alleged offenses. A basic tenet of the military justice system is to handle alleged offenses “at the lowest appropriate level.”[3] The Manual for Courts-Martial lists a number of significant factors for commanders to consider in this regard, “including, to the extent practicable, the nature of the offense, any mitigating or extenuating circumstances, any recommendations made by subordinate commanders, the interests of justice, military exigencies, and the effect of the decision on the military member and the command. The goal should be a disposition that is warranted, appropriate, and fair.”[3] The decision must be made with the advice and counsel of a judge advocate, an assigned military lawyer.

In most cases, medical commands fall under the ultimate UCMJ authority of a regional or command general court-martial jurisdiction administered by an operational unit commander. Jurisdiction is usually withheld to higher levels of command for allegations involving officers and senior enlisted personnel. Nonetheless, in many cases senior medical commanders are authorized to dispose of offenses. Even if medical commanders are not authorized to handle a case, the rules for court-martial give a service member’s chain of command an opportunity to recommend an appropriate disposition for an alleged offense. This is significant because the chain of command closest to the service member will have the best information to properly characterize the service member’s service record and rehabilitative potential, can best address any impacts of an alleged offense on the mission, and can point to other pertinent information.

Reports of UCMJ Violations

Allegations of UCMJ offenses come from a variety of sources, with varying levels of detail. Some reports originate outside the military, from civilian law enforcement or private citizens. Most allegations, however, rise through the chain of command based on direct observation within the military community. Investigations by military police and military criminal investigators are another frequent source of allegations of wrongdoing. In some cases, military medical personnel may be the first to discover signs of physical or other abuse in the course of their duties and may have an obligation to report the findings.

When handling these allegations, as in all situations involving potentially conflicting professional obligations, the MMO should seek guidance. For more information about authorizations or obligations to disclose protected health information for purposes of law enforcement or public health activities, consult with the local Health Insurance Portability and Accountability Act (HIPAA) or privacy compliance office, medical ethics office, or servicing legal office. Documents to consult include the following:

- 45 CFR, Part 164.512(k)(1), Uses and disclosures for which an authorization or opportunity to agree or object is not required;

- DoD Regulation 6025.18-R, DoD Health Information Privacy Regulation (January 2003);

- DoD Instruction 6490.08, Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members (August 17, 2011); and

- DoD Directive 6400.06, Domestic Abuse Involving DoD Military and Certain Affiliated Personnel (August 21, 2007).

Military healthcare providers have special reporting obligations relating to reports of sexual assault received from service members and adult military dependents.[40] In such cases, military healthcare providers must immediately notify designated military sexual assault response coordinators or sexual assault prevention and response victim advocates, who will advise the victim regarding restricted and unrestricted reporting options. Additionally, when restricted reports of sexual assault are first made at a military medical treatment facility, military medical personnel are relieved from state and local mandatory reporting obligations to law enforcement, except when necessary “to prevent or mitigate a serious and imminent threat to the health or safety of an individual.”[41] Only unrestricted reports are forwarded for investigation and reported to the chain of command. (However, when MMOs work off-duty for nonmilitary healthcare organizations, state and local requirements do apply and vary by state.)

Upon receiving a report alleging a UCMJ violation by a member of the command, a commander must consider the information, circumstances, and any applicable legal requirements before determining the next steps. Information should be obtained from the chain of command and consultation made with the servicing judge advocate. Depending on the allegation, immediate notification may need to be made to military criminal investigators (eg, sexual assault allegations, cases involving possible harm to persons, and those involving damage to or compromise of facilities, equipment, or systems).

Even though service members are presumed innocent until proven guilty, protective measures may be required or appropriate pending further investigation and resolution of the allegations. In some cases, in order to safeguard personnel, a commander may need to issue a “cooling off” order requiring that a service member reside in on-base government quarters, limit pass privileges, and/or have no contact with an alleged victim. In other cases, a commander may need to temporarily move a service member’s place of duty in order to avoid possible confrontations. It may be appropriate to temporarily restrict access to weapons and other dangerous materials. In the most extreme cases that present a danger to the service member or others or a possible flight risk, it may be necessary to pursue pretrial confinement. All such cases carry legal significance that could affect the outcome of the case. For example, certain forms of restriction may trigger speedy trial requirements.42,43 As a result, such measures must only be undertaken after consultation with the servicing judge advocate.

Protective measures may also be required or appropriate to protect government facilities, equipment, and information systems as an interim measure while additional facts are obtained. Allegations of a UCMJ violation may compel notification to information security personnel in order to protect information systems and classified information. To safeguard the integrity of government programs, it may be necessary to “flag” the service member and suspend favorable personnel actions while additional information is gathered and considered. Service regulations may require notification through human resources personnel channels to suspend favorable actions involving service members on a promotion list, selected for command, pending a change in duty station, or on retirement orders.

Investigations

The commander has a duty to gather “all reasonably available evidence bearing on guilt or innocence and any evidence relating to aggravation, extenuation, or mitigation.”[3] The circumstances will dictate the appropriate means and manner of inquiry or investigation. Commanders should consult with their servicing judge advocate for advice and counsel and to ensure legal compliance.

Low-level offenses may warrant no more than a request for information or statements from the service member’s chain of command. More serious offenses should be referred to criminal investigators or investigated under service regulations by an investigating officer (referred to as an “AR 15-6” [Army Regulation 15-6][44] investigation in the Army, a “JAGMAN” [Manual of the Judge Advocate General] investigation in the Navy and Marine Corps,[45] a command-directed investigation in the Air Force,[46] and administrative investigation in the Coast Guard[47]). Some allegations require special processing. For example, regarding sexual assault allegations, military criminal investigators will coordinate with sexual assault response coordinators and handle all aspects of investigating the allegations.[40]

Mental Health Evaluations and Sanity Boards

MMOs specializing in psychology and psychiatry may be asked to evaluate the mental health of service members under investigation for alleged UCMJ offenses. This usually occurs when a service member accused of an offense is believed to either lack mental responsibility for any offense[48] or lack the mental capacity to stand trial.[49] However, given the growing number of traumatic brain injuries and posttraumatic stress disorders experienced by service members since the attacks of September 11, 2001, mental health evaluations may already be underway in connection with fitness for duty and disability evaluations, which run concurrently with military justice proceedings.

Sometimes a forensic inquiry into mental responsibility or capacity takes place prior to a commander’s decision to prefer (formally initiate) charges under Rule for Courts-Martial 307 and may lead to a decision not to prefer charges. Usually, however, a court-martial convening authority orders qualified medical personnel to conduct a “sanity board” and to prepare detailed findings about the service member’s mental condition after charges have been preferred.[50] Such findings help to inform the commander’s decisions about the case, but do not compel an outcome.

Administrative Actions

Based upon the facts and circumstances, a commander may determine that an offense is best dealt with outside the traditional criminal justice context. In some cases, it may be appropriate to take no action based on the results of an inquiry or investigation that fails to establish wrongdoing. In many cases, it may be prudent to handle minor offenses progressively through a range of administrative actions, such as corrective training, counseling, revocation of pass privileges, admonition, censure or reprimand, and bar to reenlistment.[45]

Letters of concern or caution are occasionally used as a “wake up call” to underscore departure from accepted standards and encourage improvement. Essentially a formalized counseling statement, a letter of concern or caution does not, in and of itself, have long-term consequences. Rather, it is intended to rehabilitate the service member, and it is not permanently filed in official personnel records.45,51 Nonetheless, the underlying factual basis for the letter may be reflected in performance evaluations.45,52

Letters of reprimand are commonly used to memorialize more serious actions or omissions that reflect poorly on a service member’s “leadership ability, promotion potential, morals, and integrity.”[53] Such unfavorable information is considered pertinent to future personnel decisions that may result in selections for positions of public trust and responsibility, leadership positions, and continued service.

In some cases, reprimands must be issued for certain actions. For example, in the Army, driving while intoxicated or impaired or refusing to take a breathalyzer test requires an administrative reprimand regardless of any punitive actions.[54] The letter of reprimand process is streamlined, and the standard of proof is preponderance of the evidence. Service members must only be given notice and an opportunity to respond prior to final decisions on imposition and filing. In most cases, administrative reprimands can only be permanently filed in a service member’s official personnel files if directed by a general, a flag officer, or a general court-martial convening authority.

Service members may also be administratively eliminated from military service for a variety of reasons, including misconduct, professional dereliction, unsuitability for service, and conduct unbecoming an officer.55–57 The government’s standard of proof is lower in such cases than at courts-martial, and the rules of evidence generally do not apply. However, service members retain certain administrative due process rights in these cases, such as the right to present evidence and to be heard when an unfavorable discharge is possible. For example, medical evidence and testimony is often presented when the defense contends that an underlying medical condition caused or contributed to the actions or omissions that led to the administrative elimination action and supports retaining the service member. Additionally, when administrative elimination is warranted, the separation authority must determine whether the service member’s service should be characterized as “honorable,” “under honorable conditions,” or “under other than honorable conditions.” This characterization impacts eligibility for veterans’ benefits, including medical benefits, and may affect the service member’s future employment prospects.

Nonjudicial Punishment

Article 15 of the UCMJ offers an opportunity to resolve allegations of minor UCMJ violations through a disciplinary, nonjudicial measure that is more serious than corrective administrative actions but less serious than a court-martial.[3] Governed in part by service regulations, nonjudicial punishment is commonly referred to as an “Article 15” in the Army and Air Force, a “captain’s mast” in the Navy and Coast Guard, and “office hours” in the Marine Corps. It is generally appropriate for offenses that do not carry the possibility of a dishonorable discharge or more than 1 year of confinement.[3] Unless authority has been withheld by a senior commander or by law or service regulation, it falls within a commander’s discretion to determine whether nonjudicial punishment is appropriate in a given case after considering a number of factors, including the nature of the alleged offense, the service member’s record, the need for good order and discipline, and the effect of nonjudicial punishment on the service member and the service member’s record.

Once a commander decides to go forward with nonjudicial punishment proceedings, he or she must notify the service member of the intent to proceed, specify the alleged UCMJ violation involved, provide evidence showing that a violation occurred, and inform the service member about their applicable rights, including the right to consult with defense counsel. If the service member demands a trial by court-martial, nonjudicial punishment proceedings must be terminated unless the service member is attached to or embarked on a vessel, in which case they do not have this option. When a service member “turns down” nonjudicial punishment, the commander must decide whether to pursue a court-martial or to handle the situation through other means. A service member’s decision not to demand trial by court-martial reflects a decision to allow the commander to determine guilt or innocence, and if the service member is found guilty, to determine the appropriate punishment.

The service member can elect personal appearance at a hearing to present evidence in defense, extenuation, and mitigation both orally and in writing; request and question witnesses; and, in many cases, have a spokesman present. The chain of command is typically present at such hearings. The commander must consider all evidence presented and determine whether the service member committed one or more of the UCMJ violations alleged.

Significantly, the standard of proof to be found guilty varies by service for nonjudicial punishment.[58] The evidence must establish guilt by a preponderance of evidence (more likely than not) in the Navy, Marine Corps, and Coast Guard.45,59 In the Army, the evidence must establish guilt beyond a reasonable doubt.25(para3-16d4) The Air Force presently has no express standard of proof, but refers commanders to the beyond-a-reasonable-doubt standard at courts-martial, and suggests that nonjudicial punishment is inadvisable when the evidence fails to meet this standard.[60] If the commander concludes that the service member did not commit an offense according to the service-specific standard, the proceedings are terminated. If the commander concludes that the service member did commit an offense, the service member must be notified of the finding, the punishment imposed, and the right to appeal. This usually occurs at the time of any hearing.

Depending on the rank of the service member and the rank of the imposing commander, punishments can include extra duty, restriction, bread and water (for junior Navy enlisted personnel on vessels), reprimands, forfeitures of pay (up to half of one month’s pay for 2 months), and reduction in rank for enlisted personnel.[61] Field-grade and higher commanders are authorized to impose greater punishment than company-grade commanders. To incentivize rehabilitation, a commander may suspend any portion of the punishment on the condition that the service member not commit any further violation during the period of suspension. Suspended punishments are automatically remitted upon successful completion of a probationary period. However, further misconduct during the period of suspension empowers the imposing commander to summarily vacate the suspension.

Those found guilty have the right to appeal any finding of guilt, the punishment imposed, or both, to the next higher commander. On appeal, a commander can set aside a finding of guilt and reduce the punishment if deemed appropriate. Once final, the record of nonjudicial punishment is filed in the service member’s personnel file in accordance with service regulations, which can have considerable long-term consequences for assignment, promotion, and retention in service.

Most MMOs will have significant roles in the nonjudicial punishment process at some point during their service. Some will discover and report offenses, or they may conduct inquiries or investigations into reports of misconduct that serve as the basis for UCMJ action. Those in non-command supervisory positions will be called upon to recommend to command authorities whether nonjudicial punishment proceedings are appropriate for those under their supervisory authority. Others will be called upon to appear in person or by writing at a hearing to provide facts relevant to innocence, guilt, or punishment. A select number in command positions will administer nonjudicial punishment or decide appeals.

COURTS-MARTIAL

Preferral of Charges

Preferral of charges is the first step in the court-martial process. It involves a formal, written description of alleged UCMJ violations in a manner required by the Manual for Courts-Martial. Any person subject to the UCMJ can prefer charges, and in so doing must, under oath, state that the signer “has personal knowledge of or has investigated the matters set forth in the charges and specifications and that they are true in fact to the best of that person’s knowledge and belief” (Rule for Courts-Martial 307(b)).[3] In most cases, charges are preferred by a service member’s company level UCMJ commander after reviewing the investigation into the matter and consulting with the servicing judge advocate. Once preferred, charges are served on the accused service member and are immediately forwarded to the next higher commander for forwarding to the summary court-martial convening authority.

Levels of Courts-Martial

Summary courts-martial are at the lowest level. They apply only to enlisted personnel, are heard by one appointed officer rather than a military judge or panel members, have abbreviated procedural and evidentiary rules, and do not guarantee the right of the accused to be represented by a defense counsel at the hearing. The maximum punishments are limited to “one month of confinement and other relatively modest punishments.”[62] A service member must consent to have a case heard at a summary court martial. Generally, an O5-level commander (lieutenant colonel or equivalent rank) can convene summary courts-martial.

Special courts-martial are at the intermediate level, typically used for minor offenses that are generally equivalent to misdemeanors in civilian courts. Special courts-martial can try both officer and enlisted personnel. They include a military judge, defense counsel and military prosecutor, and court martial panel members. The maximum punishments include a bad conduct discharge and 1 year in confinement. Typically, designated commanders at the O6 level (colonel or equivalent rank) are authorized to convene special courts-martial and lower level summary courts-martial.

General courts-martial are the military’s felony-level courts. Like special courts-martial, general courts-martial include a military judge, defense counsel, military prosecutor, and court martial panel members. There is no sentence limitation at this level and appeal is automatic. General court-martial convening authority is normally reserved to designated general and flag officers, who are also authorized to convene special and summary courts-martial.

Article 32 Investigations

Unless waived by the service member, a preliminary hearing must be held in accordance with Article 32 of the UCMJ before a case can be referred to a general court-martial.63,64 This probable cause hearing, referred to as an Article 32 investigation, provides service members with substantially more rights than the civilian grand jury equivalent. An Article 32 investigating officer, often a military lawyer, must impartially hear the evidence and make the following specific determinations: whether there is probable cause to conclude that an offense or offenses have been committed, whether the accused committed it, and whether a court-martial would have jurisdiction over the offense and the accused. The investigating officer is also charged with considering the technical form of the charge and recommending how the charge should be handled (Exhibit 5-8).

Referral to Court-Martial

Court-martial convening authorities determine whether charges should be referred to a court-martial, and if so, at which level. Unless authority is withheld by a senior UCMJ convening authority or by law or service regulation, charges can be referred to courts within a convening authority’s level of authority. Otherwise, charges must be forwarded with recommendations to the next higher convening authority for similar determinations. Consultation with victims is also generally required prior to referral. Any decision to refer charges to a special or general court-martial must be informed by advice from the servicing staff judge advocate, a senior military attorney assigned to advise convening authorities on military justice matters.

EXHIBIT 5-8

ARTICLE 32 INVESTIGATIONS

In 2007, First Lieutenant Elizabeth Whiteside, an Army nurse, was charged with kidnapping, aggravated assault, assault upon a superior commissioned officer, reckless endangerment, willful discharge of a firearm, communicating a threat, and self-injury in a hostile-fire zone. The charges stemmed from an incident that occurred January 1, 2007, at Camp Cropper, Iraq.[1] According to press reports, Whiteside suffered a breakdown and as a result held a senior nurse against her will at gunpoint, threatened other soldiers, fired her weapon into the air, and ultimately shot herself.[2] Later, while undergoing treatment at the Walter Reed Army Medical Center, charges were preferred against her and an Article 32 investigation was conducted. A sanity board concluded that Whiteside lacked mental responsibility for her actions.[3] After reviewing the Article 32 report of investigation and recommendations from the investigating officer and the chain of command at the Walter Reed Army Medical Center, the general court-martial convening authority dismissed all charges without a trial.[1]

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(1) Boyce P. Court-martial convening authority dismisses all charges against lieutenant. US Army website. https://www.army.mil/article/7209/Court_martial_convening_authority_dismisses_all_charges_against_lieutenant/. Published January 30, 2008. Accessed November 20, 2017. (2) Priest D, Hull A. A patient prosecuted. Washington Post. December 2, 2007:A1. (3) Priest D, Hull A. Leniency suggested for officer who shot herself. Washington Post. December 11, 2007. http://www.washingtonpost.com/wp-dyn/content/article/2007/12/10/AR2007121001613.html. Accessed May 11, 2018.

Referred Cases

Once referred to trial at the special or general court-martial levels, the military judge takes effective control of the case. A substantial pretrial phase precedes any trial. Service members have many rights, including the right to counsel, to demand a speedy trial, to obtain witnesses and other evidence, to request and consult with experts, to litigate constitutional and procedural violations, and to raise motions to suppress evidence and dismiss charges; they also have discovery rights for evidence. At trial, service members also have substantial rights, including the right to challenge the judge and panel members for lack of impartiality, to challenge jurisdiction, to request trial by a military judge alone or trial by court members, to confront witnesses and challenge evidence, to call witnesses and present evidence, to raise defenses, to challenge the sufficiency of the evidence, and to remain silent.

Convening authorities continue to play important roles while charges are referred. For example, the convening authority must decide whether to accept a service member’s request for discharge in lieu of court-martial, if offered. Similarly, the convening authority must decide whether to accept any offer for a pretrial agreement, which often involves a sentence limitation in exchange for a guilty plea or trial by military judge alone. Additionally, the convening authority must ensure that court members are properly selected and made available.

Roles of Military Medical Officers in Courts-Martial

MMOs may be appointed to serve as court-martial panel members.[65] In this capacity, the officer essentially serves as a juror. Such duty takes precedence over other duties and any planned leave. MMOs are also commonly called as witnesses at courts-martial. In some cases, they are called to discuss direct observations about a medical condition or injury that may be relevant to guilt, innocence, or punishment. In other cases, as in state and federal courts, they may be asked to testify about statements that a patient made in the course of medical treatment in accordance with Military Rule of Evidence 803.[3] When mental responsibility or mental capacity are an issue at trial, qualified experts are called to testify.

Post-Trial

Shortly after trial, if requested by the service member, the convening authority must decide whether to defer any period of confinement. The convening authority’s action must be in writing and must state the reasons why any such request was denied. Similarly, the convening authority must respond in writing to a request by a service member to defer forfeitures of pay and state the basis for the decision. Additionally, the convening authority must also respond to any request to waive forfeitures of pay for a period not to exceed 6 months for the support of family member dependents.

EXHIBIT 5-9

APPELLATE REVIEW

In 1985, Commander Donal Billig, formerly a heart surgeon at the Bethesda Naval Medical Center, was charged with negligent homicide, involuntary manslaughter, and dereliction of duty in connection with the deaths of several patients and several other surgeries performed in 1983. Billig joined the Navy in 1982 while in his mid-50s, shortly after being dismissed by a private medical group in Pittsburgh. He had also been forced to leave a medical practice in New Jersey in 1980 after losing his operating privileges. Billig reportedly had not performed heart surgery for several years before joining the Navy, and suffered from poor vision. Dr Billig was found guilty of two counts of Article 119 (involuntary manslaughter), one count of Article 134 (negligent homicide), and 18 counts of Article 92 (dereliction of duty). He was sentenced to 4 years’ imprisonment and a dismissal from service. In 1988, the Navy-Marine Corps Court of Military Review was not satisfied of guilt beyond a reasonable doubt and threw out his convictions, released him from the confinement facility at Fort Leavenworth, and reinstated him in service with back pay.[1]

____________

(1) United States v Billig, 26 MJ 744 (NMCCMR 1988).

Once the record of trial has been prepared, it is forwarded to the staff judge advocate for review and advice to the convening authority regarding the proceedings. The staff judge advocate’s formal advice is served on the convicted service member and defense counsel, who have an opportunity to review it for errors and to submit information for the convening authority’s consideration. Crime victims also have the right to submit matters for the convening authority to consider in taking initial action on the findings and recommendations of the court-martial. The staff judge advocate must file an addendum to the initial advice addressing any legal error alleged.

Traditionally, convening authorities had broad discretion to disapprove findings of guilt and to approve, disapprove, commute, or suspend the sentence adjudged at trial. However, in 2013, Congress limited that authority. Pursuant to these changes, a convening authority may not dismiss a finding or approve a lesser included offense unless the offense carries a maximum punishment of 2 years’ confinement and the sentence adjudged does not include a punitive discharge or confinement greater than 6 months. No changes are authorized to findings of guilt in cases involving rape and sexual assault.

The convening authority’s initial action executes all portions of the sentence except for a dishonorable discharge, bad conduct discharge, dismissal, or death sentence. Appellate review is required in all such cases. Each service has a court of criminal appeals (Exhibit 5-9), and subsequent appeals go to the Court of Appeals for the Armed Forces. After that, a service member can petition the Supreme Court to hear the case on a petition for a writ of certiorari, which is rarely granted.

DISCIPLINARY RULES UNIQUE TO PUBLIC HEALTH SERVICE OFFICERS

Uniformed PHS officers are subject to administrative discipline, reduction in grade, and separation from service (termination of commission) for misconduct under regulations issued by the Department of Health and Human Services. These regulations cover both active and retired officers. The PHS retains the right to impose administrative discipline even when its officers are subject to the UCMJ (Exhibit 5-10).

EXHIBIT 5-10

US PUBLIC HEALTH SERVICE DISCIPLINE

In 2006, Dr Pearson “Trey” Sunderland, a Public Health Service Commissioned Corps officer and researcher at the National Institutes for Mental Health (NIMH), plead guilty to criminal conflict of interest in connection with his research activities. Sunderland had accepted nearly $300,000 as a consultant for a pharmaceutical company affected by his ongoing research activities at NIMH, and provided the company with thousands of samples from his research. He failed to seek approval or disclose the relationship and payments in ethics reports to the agency. Sunderland was sentenced to 2 years of probation, fined $300,000, and ordered to perform 400 hours of community service.[1] Sunderland’s Public Health Service disciplinary hearing was reportedly delayed at the request of the Department of Justice while the criminal case was underway.[2]

____________

(1) Rich E. NIH scientist pleads guilty in accepting $285,000 from Pfizer. Washington Post. December 9, 2006. http://www.washingtonpost.com/wp-dyn/content/article/2007/12/10/AR2007121001613.html. Accessed May 11, 2018. (2) Weiss R. NIH punishments criticized. Washington Post. September 14, 2006. http://www.washingtonpost.com/wp-dyn/content/article/2006/09/13/AR2006091302024.html. Accessed May 11, 2018.

Under PHS personnel instructions,[66] misconduct includes violation of the department’s standards of conduct regulations, and any other federal regulation, law, or official government policy, including the following:

1. disobedience of the lawful orders of an official superior;

2. negligence or carelessness in obeying orders or in performing official duties;

3. unauthorized use or consumption of controlled substances or alcohol while on duty, being under the influence of such substances or alcohol while on duty, or illegally possessing, transferring, or ingesting controlled substances at any time;

4. engaging in action or behavior of a dishonorable nature which reflects discredit upon the officer or PHS or both;

5. failure to honorably discharge just debts in a timely manner;

6. acts of insubordination or use of insulting or defamatory language or gestures disrespectful of, or displaying a contemptuous attitude toward, official superiors or other officers;

7. making any public statement that falsely impugns the professional competency or personal character of a superior or another officer;

8. waste of public funds or property, or knowingly permitting such waste;

9. conviction of a felony;

10. submission of false information in an application for appointment or in any other official document;

11. abusive treatment of subordinate officers, employees, patients, or program beneficiaries, or of members of the public in their dealings with the government; or

12. absence from his or her assigned place of duty without authorized leave.[66]

Like their military counterparts, PHS officers have administrative due process rights when misconduct is alleged, and adverse proceedings may result in disciplinary actions.66,67 Ultimately, when a board of inquiry finds that misconduct occurred and that the officer’s commission should be terminated as a result, as with military separations, the board must recommend an appropriate characterization of the discharge as “honorable,” “under honorable conditions,” or “under other than honorable conditions.”

THE FEDERAL TORT CLAIMS ACT AND THE FERES DOCTRINE

The overriding need for good order and discipline in the military has also contributed to an important difference between civil law rights and liabilities of service members versus civilians, which is of particular significance for the military and uniformed services medical community: active duty service members cannot sue the federal government, other service members, or civilian government employees for injuries that arise incident to service.[68] This means that active duty uniformed service members cannot sue uniformed service doctors for medical malpractice.

The Federal Tort Claims Act and the Military Claims Act

The United States enjoys sovereign immunity from lawsuits unless it consents to liability.[69] Historically, claims for redress and waivers of sovereign immunity were handled through private bills in Congress, an unpredictable process with uneven results.[68] In 1946, through the FTCA,[70] Congress provided a limited waiver of immunity for damages for personal injury, death, or property damage caused by the negligence of federal employees acting within the scope of employment. In FTCA cases, the United States is substituted as a party for the federal employee. Claims must be brought administratively before the agency involved and must follow detailed procedures prior to any lawsuit. Congress shifted adjudication of FTCA claims to the courts.

Notably, however, the law only applies in the United States. It also excludes “[a]ny claim arising out of the combatant activities of the military or naval forces, or the Coast Guard, during time of war.”[71]

For overseas claims, the Military Claims Act (MCA)[72] provides a limited waiver of immunity for those who are not active duty service members. The MCA relies entirely on administrative processes and does not allow lawsuits. As with the FTCA, combat-related claims are excluded from MCA coverage.

The Feres Doctrine

In 1950 the Supreme Court considered the FTCA’s application in Feres v United States[68] and two related cases in which the military was sued for alleged negligence that harmed a service member incident to service. Feres involved claims that negligence led to the death of a service member in a barracks fire. The two companion cases, Jefferson v United States[73] and Griggs v United States,[74] involved medical malpractice claims. In Jefferson, a former service member who had abdominal surgery while in the Army brought a suit for negligence when, in a subsequent operation after being discharged from service, a large towel marked “Medical Department US Army” was removed from his stomach. Griggs involved a suit brought by the widow of a service member who died after surgery, allegedly due to negligence by military surgeons. The Supreme Court ultimately held that all three cases were barred from going forward, finding that the FTCA does not waive sovereign immunity in such cases. Thus, the Feres doctrine was developed as a judicial exception to the FTCA.

The Supreme Court has relied on several rationales in support of the Feres doctrine: the court feared adverse impacts on good order and discipline and unit effectiveness if service members could sue the military or fellow service members for injuries incurred incident to service, involving the judicial branch in military affairs.[75] Additionally, the court noted that the military provides “simple, certain and uniform compensation for injuries or death of those in armed services,” which normally requires no litigation, applies regardless of negligence, and compares “extremely favorably” with civilian workers’ compensation.68,75 Finally, the court has observed that federal law properly governs the relationship of military personnel with the government and determined it would be unfair and inequitable to apply disparate state tort laws to acts or omissions committed in a state pursuant to military service.[68]

The Feres doctrine has also been applied to bar claims by active duty uniformed PHS officers,76–78 and it extends to the derivative claims of family members, as in the case of the death of a service member due to alleged medical malpractice. Nonetheless, family members and others may still file claims for medical malpractice that they allegedly suffer at the hands of uniformed personnel.

The Feres doctrine has been controversial since its inception, but has withstood numerous attempts to eliminate or modify its application.79–82 Congress has thus far declined to legislatively eliminate the Feres doctrine or to limit its application in medical malpractice cases. The Supreme Court has also refused to overrule Feres or declare that it does not apply in medical malpractice cases.[83] However, the court may reconsider the Feres doctrine in the future in the context of pre-birth cases, because some federal circuit courts of appeals disagree about its application in such cases.[84] Highly publicized cases continue to go before the court for review. In 2011, the Supreme Court denied a writ of certiorari in a well-publicized case in which the widow of an Air Force staff sergeant was barred from pursuing a medical malpractice claim against the Travis Air Force Base Medical Center after her husband was left in a vegetative state and later died after an appendectomy.[83] In 2017, after a monetary settlement was reached, the Supreme Court dismissed a petition for writ of certiorari in a case in which an Army captain having a scheduled caesarean section was given a drug that she was allergic to, causing her unborn child to be deprived of oxygen, which resulted in cerebral palsy.85,86

The Feres doctrine creates challenges for MMOs. In a litigious society, accountability for wrongs is often associated with a court verdict or negotiated settlement and monetary damages. The lack of an available civil law remedy for active duty service members may lead some to conclude that military medical personnel are not held accountable for errors and omissions that cause harm to their fellow service members. This misperception may be exacerbated by the fact that the military’s quality assurance program has statutory protections against disclosure of quality assurance investigations[87] and the fact that Privacy Act protections shield personnel matters from public view. This lack of transparency could ultimately lead to additional calls for a legislative “repeal” or judicial modification of the Feres doctrine. Others might increasingly turn to the UCMJ to investigate and adjudicate alleged medical negligence by medical personnel as a dereliction of duty. Military medicine leaders must ensure that medical quality assurance programs[88] are faithfully executed and that medical personnel are held accountable.

DEPARTMENT OF DEFENSE JOINT ETHICS REGULATION

Like all federal employees, military personnel must adhere to standards of conduct designed to ensure the integrity of government operations. Moreover, it is DoD policy that “[i]ndividual conduct, official programs and daily activities within DoD shall be accomplished lawfully and ethically ….”28(sec84.3f) From an organizational perspective, ethical failures can significantly derail important programs and acquisitions, and may result in substantial delays and unanticipated expenditures. Investigations and negative publicity may erode public and congressional confidence in agency operations. As noted earlier in this chapter, on an individual level, violations of many JER provisions may be punished under the UCMJ and the federal criminal code. Additional penalties include civil law and administrative actions. Military and uniformed medical officers must familiarize themselves with ethical requirements and principles, ensure compliance with ethics programs, and cultivate an organizational culture of ethical conduct.

For DoD personnel, comprehensive government ethics guidance is found in the JER. To help DoD personnel better understand and apply ethics rules to particular situations, the JER provides for attorneys appointed as ethics counselors28(sec84.4b2),89 under programs administered by designated service-level agency ethics officials. In fact, it is DoD policy that when any question exists about the propriety of an activity or action, DoD personnel are to consult with an ethics counselor.28(para1-212),89 Since ethics counselors represent the agency rather than individual employees, communications are not protected by the attorney-client privilege. Nonetheless, to incentivize preventive consultations with an ethics counselor, the JER rules out disciplinary action against those who rely on an ethics counselor in good faith, after full disclosure of pertinent facts, unless criminal conduct is involved. MMOs should therefore become familiar with the ethics counselor at their servicing legal office.

Fourteen general principles form the basis for the federal standards of conduct and the JER.[90] By becoming familiar with these principles, MMOs will be able to identify potential ethics issues for further resolution.

(1) Public service is a public trust, requiring employees to place loyalty to the Constitution, the laws and ethical principles above private gain.

(2) Employees shall not hold financial interests that conflict with the conscientious performance of duty.

(3) Employees shall not engage in financial transactions using nonpublic Government information or allow the improper use of such information to further any private interest.

(4) An employee shall not, except as permitted by subpart B of this part, solicit or accept any gift or other item of monetary value from any person or entity seeking official action from, doing business with, or conducting activities regulated by the employee’s agency, or whose interests may be substantially affected by the performance or nonperformance of the employee’s duties.

(5) Employees shall put forth honest effort in the performance of their duties.

(6) Employees shall not knowingly make unauthorized commitments or promises of any kind purporting to bind the Government.

(7) Employees shall not use public office for private gain.

(8) Employees shall act impartially and not give preferential treatment to any private organization or individual.

(9) Employees shall protect and conserve Federal property and shall not use it for other than authorized activities.

(10) Employees shall not engage in outside employment or activities, including seeking or negotiating for employment, that conflict with official Government duties and responsibilities.

(11) Employees shall disclose waste, fraud, abuse, and corruption to appropriate authorities.

(12) Employees shall satisfy in good faith their obligations as citizens, including all just financial obligations, especially those—such as federal, state, or local taxes—that are imposed by law.

(13) Employees shall adhere to all laws and regulations that provide equal opportunity for all Americans regardless of race, color, religion, sex, national origin, age, or handicap.

(14) Employees shall endeavor to avoid any actions creating the appearance that they are violating the law or the ethical standards set forth in this part. Whether particular circumstances create an appearance that the law or these standards have been violated shall be determined from the perspective of a reasonable person with knowledge of the relevant facts.[90]

A full discussion of the JER and government ethics laws is beyond the scope of this chapter. Nonetheless, certain questions that commonly arise in the context of military medicine deserve mention, including relations with non-federal entities; teaching, writing, and speaking; gifts; and outside employment.

Relations with non-federal entities. DoD personnel must not state or imply endorsement of a non-federal entity or its services, products, events, or enterprises.28(para3-209) However, special rules apply to the Combined Federal Campaign and specific military relief organizations. Additionally, consultation is needed with the servicing ethics counselor before participating in an official capacity with any non-federal entity, including as a speaker, panelist, or award recipient at non-federal entity events and conferences, or as a command representative or liaison to a non-federal entity’s management group. Certain groups have statutory authority for particular support, including the American Registry of Pathology, the Henry M. Jackson Foundation for Military Medicine, and the American Red Cross.28(para3-212),91

Teaching, writing, and speaking. The JER, as well as the Supplemental Standards of Ethical Conduct for Employees of the Department of Defense28(para3-305a),92 require DoD personnel to use prominent disclaimers when teaching, writing, or speaking on subjects related to agency matters. Public affairs and security reviews are also required for lectures, speeches, and writings that pertain to military matters, national security issues, or subjects of significant concern to DoD.28(para305b),93 Any offer of an honorarium in conjunction with teaching, writing, or speaking must be coordinated in advance with an ethics counselor to ascertain whether acceptance is possible.28(para3-305c)

Gifts. The JER and DoD’s Supplemental Standards of Ethical Conduct limit gifts from outside sources and between DoD employees. Generally, DoD personnel may not accept gifts given due to their official position, or given by an entity that does or seeks to do business with the agency. Certain exceptions permit limited gifts such as speaker mementos with little intrinsic value and modest items of food and refreshments. Gifts from subordinates are also normally prohibited, with limited exceptions allowing such gifts for significant life occasions such as weddings, retirement, and departure from the supervisory position. Nonetheless, the JER and DoD’s Supplemental Standards of Ethical Conduct limit the value of gifts that a group of subordinates can make to senior officials.

Any offer of travel, lodging, meals, or expenses in an official capacity in relation to participation in a non-federal entity conference or event compels advance consultation with the ethics counselor and requires proper approval by agency heads before acceptance.94,95 After-the-fact approval is not permitted for gifts of travel. Failure to comply subjects the traveler to possible fines and disciplinary action.

Outside employment. DoD’s Supplemental Standards of Ethical Conduct requires prior approval for outside employment and business activities for financial disclosure filers.[92] Furthermore, most commands require prior approval for any outside employment. In addition, federal law prohibitions against dual compensation and conflicts of interests bar active duty military personnel and government civilian employees who moonlight as healthcare practitioners from billing Tricare for fees generated from treating Tricare beneficiaries.96,97

Many MMOs, and those under their supervision, are required to file financial disclosure forms. The financial disclosure program is an important part of an agency ethics program because it enables supervisors to identify potential conflicts of interests before problems arise. This allows the supervisory chain of command and ethics counselors to fashion any necessary preventive steps to avoid conflicts so that no violations occur. Supervisors must carefully review financial disclosures because they are in the best position to understand each filer’s duties and responsibilities in order to flag potential conflicts of interests.

The DoD Standards of Conduct Office regularly updates the Encyclopedia of Ethical Failure,[98] a compendium of ethical lapses and failures committed by military and federal officials. While all of the ethical failure summaries provide useful lessons in government ethic laws for MMOs, some cases directly involve military medical personnel or military medicine. In one case, the director of a Navy health clinic repeatedly asked a subordinate for loans, and ultimately only repaid part of a $3,000 loan. A second case involves a civilian physician working at an Army health clinic who improperly obtained medical care, tests, and medication from the clinic. Another case involves a former Army officer who was responsible for procurement of a psychiatric services contract for an Air Force hospital while on active duty, and later, in retirement, improperly represented the same contractor to the government. The Encyclopedia serves as a useful training aid for all government personnel. Ethics counselors at local servicing legal offices can provide more information about government ethics and standards of conduct.

SUMMARY

MMOs in all of the uniformed services must understand the fundamental legal differences that apply to them as medical professionals serving in or with the military and become familiar with their critical roles in the military justice system. An enhanced understanding of key principles of military criminal and administrative law enables MMOs to better appreciate critical military legal systems and programs that maintain good order and discipline, advance military justice, and preserve standards of professionalism and the integrity of government programs. Greater knowledge also facilitates a fuller awareness of the essential roles that MMOs have as leaders in these systems. Finally, a better grasp of military law also provides greater insights into the varied roles that military lawyers play in each system and the enabling advice and services they can provide to MMOs.

The military justice system represents the most significant difference between military law and civilian law to develop since the days of the American Revolution. Service members are subject to a separate military justice system in addition to federal, state, and local criminal codes in recognition of the military’s unique mission, and the necessity to maintain good order and discipline throughout the armed forces. As the foundation of the military justice system, the UCMJ serves as both an instrument of justice and as a commander’s disciplinary tool for maintaining good order and discipline. By better understanding the UCMJ and the military justice system as a whole, MMOs will be more effective in their roles when disciplinary infractions and criminal offenses are alleged.

Administrative law principles and programs also impact the standards of professionalism and fitness for duty for medical personnel serving in the armed forces. An important legal difference in the context of military medicine is the FTCA bar on medical malpractice claims by active duty personnel. Notwithstanding this ban, as stewards of military medical quality assurance programs, MMOs have crucial roles in providing professional oversight and regulation for the military medical profession.

The JER and DoD’s Supplemental Standards of Ethical Conduct represent an additional area of departure from civilian norms. As leaders under military ethics programs, MMOs have important responsibilities to administer ethics programs and maintain the integrity of government operations.

As the foregoing discussion makes clear, the full extent of military law cannot be described in a single chapter. MMOs must engage in lifelong self-development, and should include military law topics in individual development plans for themselves and their subordinates. Local legal offices can assist with classes, training aids, materials, and presentations.

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91.   US Department of Defense. Procedures and Support for NFEs Authorized to Operation on DoD Installations. Washington, DC: DoD; 2008. DoD Instruction 1000.15.

92.   5 CFR, Part 3601, Supplemental standards of ethical conduct for employees of the Department of Defense.

93.   US Department of Defense. Security and Policy Review of DoD Information for Public Release. Washington, DC: DoD; 2014. DoD Instruction 5230.29.

94.   31 USC § 1353, Acceptance of travel and related expenses from non-federal sources.

95.   41 CFR, Part 304, Payment of travel expenses from a non-federal source.

96.   5 USC § 5536, Extra pay for extra services prohibited.

97.   32 CFR, Part 199.6a(3), Tricare-authorized providers.

98.   US Department of Defense, Standards of Conduct Office. Encyclopedia of Ethical Failure. Washington, DC: DoD; 2016.

Chapter 6

THE LAW OF ARMED CONFLICT AND MILITARY MEDICINE

MICHAEL H. HOFFMAN, JD*

INTRODUCTION

THE EVOLVING CONTEXT OF INTERNATIONAL LAW AND MILITARY MEDICINE

RESPONSIBILITIES AND PROTECTION OF MILITARY MEDICAL PERSONNEL

Application of the Law of Armed Conflict by Medical Officers

War Crimes

Intent of the Law of Armed Conflict in Relation to Military Medicine

Status of Military Medical Units and Personnel

Responsibilities and Protection of Military Medical Personnel and Units During Armed Conflict

Medical Operations Conducted in Cooperation With Coalition Partners

PROTECTION OF CIVILIAN MEDICAL STAFF AND HOSPITALS IN ARMED CONFLICT

APPLICATION OF INTERNATIONAL LAW IN PEACETIME MEDICAL DEPLOYMENTS

CONCLUSION

*Associate Professor, US Army Command and General Staff College; Assistant Professor, Uniformed Services University of the Health Science; Barden Education Center, Ft Belvoir, Virginia

INTRODUCTION

The positive humanitarian impact of compliance with the medical law of armed conflict is great. The negative human, legal, political, and military impact of noncompliance can be even greater. Military medical officers (MMOs) need to understand not only the key humanitarian obligations of military medical personnel and units in armed conflict, but also their rationale, in order to ensure the law is effectively applied in varied, uncertain, and sometimes rapidly changing operational settings. In addition to the suffering that follows if the law is not applied, there can be serious legal consequences for medical personnel who fail to apply it—and long-lasting damage to the honor and credibility of the United States and the nation’s armed forces.

To help impart the level of insight required to mesh medical operations with international law, this chapter provides a conceptual overview of key responsibilities and legal protection requirements for military medical personnel during armed conflict. It is not a detailed guide for implementation of the Geneva Conventions, nor a manual attempting a comprehensive survey of the wide and varied range of medical issues that may arise under the Geneva Conventions. Readers who want to explore these issues in depth can find guidance on additional resources later in this chapter. It is essential for MMOs to work closely with a staff judge advocate legal advisor in all phases of the planning and execution of the military medical mission. The legal requirements in all military operations must be considered with great care and implemented accordingly.

THE EVOLVING CONTEXT OF INTERNATIONAL LAW AND MILITARY MEDICINE

International law is less familiar to most people than the rules found in national, state, and local law. However, international law plays a behind-the-scenes role shaping daily interactions that many people take for granted. It provides the framework for routine international travel, communications, trade, and cultural exchange. It is more challenging to apply international law during armed conflict, but there is a well-developed system of treaties and customary practice that applies to regulate war as well.

Customary international law is the earliest form of the law of armed conflict. It has been in use for centuries. The customary law of armed conflict (most widely known as the customary law of war) is made up of any “consistent practice of states” that comes to be accepted as a binding legal norm even if it has not been formalized in a written agreement.[1] The United States has implemented the law of war beginning with the application of customary law during the American Revolution. To seal the decisive American victory at Yorktown in 1781, General Washington negotiated an elaborate customary surrender process with General Cornwallis, and US military medical services have continuously honored the national commitment to the law of armed conflict by providing medical treatment for enemy prisoners of war into the modern age.2–4

The modern, treaty-based law of armed conflict first significantly emerged with the adoption of the first Geneva Convention for the Wounded and Sick in 1864. The principles embodied in that treaty still guide its signatories in the 21st century. Though President Lincoln and Secretary of State Seward were reluctant to commit to these Geneva negotiations during the American Civil War, they did send a senior diplomat and a representative from the US Sanitary Commission, a major nongovernmental organization caring for the wounded and sick in the ongoing US conflict, to serve as observers at the conference.[5] The United States ratified the first Geneva Convention in 1882, and has ratified each of the Geneva Conventions that followed in later generations (see Chapter 1, History of the Military Medical Officer, Exhibit 1-2, for more background on the chronological development of the Geneva Conventions).

The modern law of armed conflict is primarily treaty based. The four Geneva Conventions of 1949 establish the responsibilities, status, and protection afforded to medical personnel; the wounded, sick, and shipwrecked members of armed forces; prisoners of war; and civilians under the law of armed conflict. Accordingly, they are the main focus of this chapter and are also explored in further detail in the Department of Defense (DoD) Law of War Manual.[6]

The terms “law of war,” “law of armed conflict” (sometimes abbreviated as LOAC), and “international humanitarian law” (frequently abbreviated as IHL) tend to be used interchangeably.[7] Though there is some disagreement on whether each term applies to precisely the same set of rules, for this chapter they can be considered identical. The focus for MMOs will be on the Geneva rules. (Sometimes a distinction is drawn between “Geneva law” for humanitarian protection, and “Hague law” for regulation of the means and methods of war, meaning rules governing targeting and the weaponry employed. MMOs fulfill Geneva law in their duties.)

The law of armed conflict has evolved from a specialized field known only to a handful of legal practitioners and scholars to one receiving constant, widespread media coverage and intense scrutiny by human rights organizations. Failure to implement the law of armed conflict raises the possibility of prosecution under the Uniform Code of Military Justice (see also Chapter 5, Military Law and Ethics) and opens the door to accusations that MMOs have breached medical ethics. Such failure—even mistaken or deliberately false accusations of violations of the law of war—might spur political backlash and international condemnation, undermining prospects for success in a military campaign.[8]

The DoD Law of War Manual includes the following cautionary observations: “For example, violations of the law of war in counter-insurgency operations may diminish the support of the local population. Violations of the law of war may also diminish the support of the populace in democratic States, including the United States and other States that would otherwise support or participate in coalition operations. Violations of the law of war committed by one side may encourage third parties to support the opposing side.”[9] By impartially and firmly carrying out humanitarian medical obligations for all protected persons under Geneva law, MMOs also protect the credibility of the armed forces and the nation as a whole.

RESPONSIBILITIES AND PROTECTION OF MILITARY MEDICAL PERSONNEL

Application of the Law of Armed Conflict by Medical Officers

The Geneva Conventions are a legal foundation for quiet, successful implementation of the law of armed conflict on an ongoing basis. For example, many prisoners of war around the world regularly receive protective visits to ensure their safety and well-being.[10] MMOs are responsible for successful implementation of the medical dimensions of the law of armed conflict. They are expected to fulfill this role both through direct leadership and indirectly through leadership by moral example. MMOs exercise such leadership in concert with other military and civilian leaders at all levels of the US government.

The United States’ commitment to application of the law of armed conflict takes many forms. US commanders are responsible for the law’s implementation. Alleged violations are investigated for possible prosecution or (depending on the level of severity of the alleged offense) for other disciplinary or corrective action. Judge advocates at all levels of command furnish legal advice on interpretation and implementation of the law of armed conflict.[11] Although every actual or potential enemy will not apply them in whole or even in part, US MMOs need to understand the rules and apply them regardless. It bears repeating that MMOs lead by example, and not only when serving in command assignments. They must not express cynicism about the law of armed conflict in any circumstances, regardless of how they may feel about enemies who commit war crimes. Any hint of such cynical or negative views about the law of armed conflict may help provoke negative action and conduct by other medical personnel.

War Crimes

While US MMOs need to focus on the mission—including implementation of the medical requirements of the law of armed conflict—situational awareness requires some understanding of the scope and characteristics of war crimes as envisioned in international law. MMOs have a solemn responsibility to help ensure that the medical dimensions of the law of armed conflict are fully implemented in their command. This requires strong direct leadership and leadership by example. It requires careful monitoring to help ensure that US military and civilian personnel fulfill their obligations under the Geneva Conventions in all situations, including those where feelings may run high in the face of reports and evidence of war crimes.

Medical personnel may encounter evidence of war crimes in the field, or treat patients who are traumatized survivors of war crimes. Higher headquarters must be notified immediately if such issues or evidence should arise. Despite careful attention to the protection of medical units and personnel under the Geneva Conventions, urgent force protection requirements demand awareness that some enemies will deliberately target medical facilities, personnel, transport, patients, and supplies.

A sense of the potential scale and gravity of such challenges is presented by systematic, continuing violations of the law of armed conflict in Syria during the civil war. The Syrian government has deliberately targeted medical personnel in the ongoing conflict in that country. As reported in The Lancet, “The weaponisation of health care—a strategy of using people’s need for health care as a weapon against them by violently depriving them of it—has translated into hundreds of health workers killed, hundreds more incarcerated or tortured, and hundreds of health facilities deliberately and systematically attacked.”[12] These crimes are not limited to the battlefield. The Syrian government has also used a network of hospitals, and hospital staff, to systematically torture, mutilate, and murder captives on a mass scale.[13] As one consequence, medical activities have been driven underground to avoid deliberate attack by the Syrian authorities. Efforts to provide medical care are driven by logistically challenging and costly requirements to set up very limited underground facilities.[14]

Some enemies may not only be willing to engage in deliberate attacks on protected medical sites, personnel, and patients, and to appropriate medical facilities to commit horrific crimes, they may even remain contemptuous of international law when efforts are made to provide them with the medical services they should receive after being captured. Dating back to at least the Korean War, US medical personnel have sometimes encountered situations where captured enemy wounded, rather than cooperating in their clinical care, have continued hostile conduct even in a medical setting.[15]

Application of the law in the face of war crimes committed by the enemy comports well with the ethos expected of physicians. In peacetime, fully professional application of the healing arts is expected, even when this benefits the most reprehensible members of society. The same principle applies by analogy in wartime. Addressing such challenges, maintaining situational awareness, and fostering a command climate in which medical personnel will unfailingly apply the Geneva Conventions, even in the face of understandable outrage and extreme provocation, requires some understanding of the international law of war crimes. A brief survey of the law is provided here, followed by a more extensive review of the rules that are positively applied by US medical personnel in all situations involving armed conflict.

There is no universal definition of war crimes, but one that focuses on medical issues comes from Geneva Convention I of 1949. Under this Convention, particularly serious war crimes, known as grave breaches, are described as follows:

Grave breaches … shall be those involving any of the following acts, if committed against persons or property protected by the Convention: wilful killing, torture or inhuman treatment, including biological experiments, wilfully causing great suffering or serious injury to body or health, and extensive destruction and appropriation of property, not justified by military necessity and carried out unlawfully or wantonly.[16]

A pattern of war crimes may constitute a distinctive category of offenses known as crimes against humanity. There is no universally accepted definition for such crimes, but MMOs must be alert in the field for medical evidence that points towards such systematic crimes. Though the United States has not ratified the Rome Statute of the International Criminal Court, the definition found in that treaty is a useful point of reference for these crimes:

For the purpose of this Statute, “crime against humanity” means any of the following acts when committed as part of a widespread or systematic attack directed against any civilian population, with knowledge of the attack:

(a) Murder;

(b) Extermination;

(c) Enslavement;

(d) Deportation or forcible transfer of population;

(e) Imprisonment or other severe deprivation of physical liberty in violation of fundamental rules of international law;

(f) Torture;

(g) Rape, sexual slavery, enforced prostitution, forced pregnancy, enforced sterilization, or any other form of sexual violence of comparable gravity;

(h) Persecution against any identifiable group or collectivity on political, racial, national, ethnic, cultural, religious, gender as defined in paragraph 3, or other grounds that are universally recognized as impermissible under international law, in connection with any act referred to in this paragraph or any crime within the jurisdiction of the Court;

(i) Enforced disappearance of persons;

(j) The crime of apartheid;

(k) Other inhumane acts of a similar character intentionally causing great suffering, or serious injury to body or to mental or physical health.[17]

Genocide, the war crime potentially most far reaching, can also take place in peacetime. Genocide is a crime that was identified, defined, and expressly prohibited in a treaty adopted in 1948. The UN Convention on the Prevention and Punishment of the Crime of Genocide defines this crime as follows:

In the present Convention, genocide means any of the following acts committed with the intent to destroy, in whole or in part, a national, ethnical, racial or religious group, as such:

(a) Killing members of the group;

(b) Causing serious bodily or mental harm to members of the group;

(c) Deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part;

(d) Imposing measures intended to prevent births within the group;

(e) Forcibly transferring children of the group to another group.[18]

Some physicians were complicit in crimes on the scale of genocide and crimes against humanity during World War II. Some of the most shocking crimes ever documented in a courtroom were those involving vicious, lethal experimentation on human beings by doctors who supported the Nazi regime. The first in the series of trials of senior level Nazi officials that took place in Nuremburg, following World War II, is known as the “Doctors’ Trial.” It resulted in a number of convictions, and the presiding judges in this trial developed the Nuremberg Code, which remains an essential foundation for regulation of human medical experimentation into the 21st century. The war crimes and crimes against humanity committed during World War II were the impetus for adoption of the Geneva Conventions of 1949. Subsequent sections of this chapter will cover the basic medical protections addressed in those treaties and discuss some of the challenging settings in which the rules are applied.

Intent of the Law of Armed Conflict in Relation to Military Medicine

The Geneva Conventions of 1949, which established the extensive modern-day rules on the roles and responsibilities of medical personnel during armed conflict, included four treaties:

- The Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field of 12 August 1949 (GC I)

- The Geneva Convention for the Amelioration of the Condition of Wounded, Sick and Shipwrecked Members of Armed Forces at Sea of 12 August 1949 (GC II)

- The Geneva Convention relative to the Treatment of Prisoners of War of 12 August 1949 (GC III)

- The Geneva Convention relative to the Protection of Civilian Persons in Time of War, of 12 August 1949 (GC IV)

The United States is a party to the Geneva Conventions of 1949, which have been ratified by the US Senate, and therefore the nation is bound by the provisions of these treaties. Text from the Geneva Conventions is quoted frequently in this chapter to highlight key rules and concepts.

Though they have not been ratified by the United States and are therefore not binding on this country, it is worth noting that widely known legal instruments called the Protocols Additional to the Geneva Conventions were adopted at a diplomatic conference in Geneva in 1977. A number of countries, including the United States, participated in this conference for the purpose of adopting these Protocols to enhance and update the 1949 Geneva Conventions. They are known formally as the Protocols Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), of 8 June 1977, and the Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of Non-International Conflicts (Protocol II), of 8 June 1977. This chapter makes reference to the Protocols where awareness of them could be useful in work with the armed forces of states that have ratified them.

The Geneva Conventions in their entirety “shall apply to all cases of declared war or of any other armed conflict which may arise between two or more of the High Contracting Parties, even if the state of war is not recognized by one of them.”[19] Requirements for MMOs are clear. “Members of the DOD Components comply with the law of war during all armed conflicts, however such conflicts are characterized, and in all other military operations.”[20] This means MMOs must apply this Geneva law during armed conflict without exception. It is irrelevant to individual MMOs, and to their mission, as to whether or not a state of war or armed conflict is formally declared or recognized. The Geneva Conventions apply regardless.

The fastest route to understanding the ethos and functional purpose of the Geneva Conventions of 1949 is to read the concise provisions of the famous “Common Article 3,” which sets out the absolute minimum protections that must be applied in any armed conflict[21]:

ART. 3. In the case of armed conflict not of an international character occurring in the territory of one of the High Contracting Parties, each Party to the conflict shall be bound to apply, as a minimum, the following provisions:

1) Persons taking no active part in the hostilities, including members of armed forces who have laid down their arms and those placed hors de combat by sickness, wounds, detention, or any other cause, shall in all circumstances be treated humanely, without any adverse distinction founded on race, colour, religion or faith, sex, birth or wealth, or any other similar criteria.

To this end, the following acts are and shall remain prohibited at any time and in any place whatsoever with respect to the above-mentioned persons:

a) violence to life and person, in particular murder of all kinds, mutilation, cruel treatment and torture;

b) taking of hostages;

c) outrages upon personal dignity, in particular humiliating and degrading treatment;

d) the passing of sentences and the carrying out of executions without previous judgment pronounced by a regularly constituted court, affording all the judicial guarantees which are recognized as indispensable by civilized peoples.

2) The wounded and sick shall be collected and cared for.

An impartial humanitarian body, such as the International Committee of the Red Cross, may offer its services to the Parties to the conflict.

The Parties to the conflict should further endeavour to bring into force, by means of special agreements, all or part of the other provisions of the present Convention.

The application of the preceding provisions shall not affect the legal status of the Parties to the conflict.[22]

Article 3 is an exception to the other text found in each treaty of the four Geneva Conventions because it applies in all cases of armed conflict “not of an international character occurring in the territory of one of the High Contracting Parties.”[22] This means that Article 3 applies during civil wars and other forms of armed conflict taking place within the borders of a single country. All other articles of the Geneva Conventions of 1949 apply in their entirety during international armed conflict (meaning military conflict between two or more states, as countries are termed under international law), and MMOs must apply the provisions of the treaties in full, rather than the more limited provisions of Common Article 3.

Though Common Article 3 lacks the detailed guidance found in the other articles of the full Conventions, if read carefully, it provides a distillation of the core principles of the law of armed conflict. Common Article 3 should be read to provide MMOs an orientation to the basic purposes of the law of war. Then, studying the detailed description of the more complete medical requirements of the Geneva Conventions, which apply during international armed conflict, will provide a fuller picture of the MMO’s professional responsibilities.

Status of Military Medical Units and Personnel

During international armed conflict, the Geneva Conventions for Wounded and Sick (GC I), and for Wounded, Sick, and Shipwrecked (GC II) identify “[f]ixed establishments and mobile medical units” of military medical services as the principal providers of medical assistance.[23] Hospital ships are authorized to provide these services at sea subject to requirements for advance notification of their status.[24] Medical aircraft “exclusively employed for the removal of wounded and sick and for the transport of medical personnel and equipment” are recognized as protected under the Geneva Conventions. The same protection applies for aircraft transporting the shipwrecked.[25] (For further information, see Joint Publication 4-02.[26]) Activities essential for medical support are protected as well. On land, these include “transports of wounded and sick or of medical equipment.”[27] At sea, ships chartered “to transport equipment exclusively intended for the treatment of wounded and sick members of the armed forces or for the prevention of disease” are also protected if advance notice of their voyage is provided.[28]

Within military medical units, those medical personnel “exclusively engaged in the search for, or the collection, transport or treatment of the wounded or sick, or in the prevention of disease, staff exclusively engaged in the administration of medical units and establishments, as well as chaplains attached to the armed forces” hold protected status under the law of armed conflict.[29] The same status is provided for “religious, medical and hospital personnel of hospital ships and their crews”[30] and for the same category of personnel serving on other ships.[31] Coastal rescue craft are to be respected on the same terms “so far as operational requirements permit.”[32]

MMOs should keep in mind that under the Geneva Conventions, the only military personnel entitled to continuous medical standing, privileges, and protection are those “exclusively engaged” in medical duties as described above. Other military personnel “specially trained for employment, should the need arise, as hospital orderlies, nurses or auxiliary stretcher-bearers, in the search for or the collection, transport or treatment of the wounded and sick shall likewise be respected and protected if they are carrying out these duties at the time when they come into contact with the enemy or fall into his hands.”[33] To ensure continued protection of medical units, personnel, and activities, all staff should be managed in a manner that ensures no blurring of distinctions between work carried out by medical and other military personnel (cautionary guidance on activities that exceed medically protected roles is provided in Joint Publication 4-02[26]).

Though (if recent history is any guide) civilian volunteers and aid societies are unlikely to be recruited to assist US military medical units in care for the wounded and sick of US and friendly forces, this contingency is provided for by the Geneva Conventions. Given the changing context of military medicine in war zones, it is not beyond question that such assistance may someday be requested again. Medical status is provided for “staff of National Red Cross Societies and that of other Voluntary Aid Societies, duly recognized and authorized by their governments” providing the same support as full-time military medical personnel and also “subject to military laws and regulations.”[34] Analogous humanitarian support is also addressed in the maritime domain. “Hospital ships utilized by National Red Cross Societies, by officially recognized relief societies or by private persons” have the same protection as military hospital ships if commissioned for that role, and the same notification procedures that apply for military hospital ships would be complied with as well.[35]

Less formal relief efforts by civilians are also contemplated in Geneva law and have historical precedent. During the American Civil War, for example, individual and organized groups of civilians rendered extraordinary assistance to wounded and sick soldiers on and off the battlefield.[36] Under the Geneva Conventions, military authorities “may appeal to the charity of the inhabitants voluntarily to collect and care for, under their direction, the wounded and sick, granting persons who have responded to this appeal the necessary protection and facilities.”[37] Similarly, an appeal may be made to “the charity of commanders of neutral merchant vessels, yachts or other craft” to assist with rescue of the wounded, sick, and shipwrecked at sea. Protection will be provided to such vessels and others that render such assistance.[38]

Responsibilities and Protections of Military Medical Personnel and Units During Armed Conflict

The units and personnel identified for protection under the Geneva Conventions assume challenging humanitarian responsibilities. They commit to strict limitations on their scope of activities. The scope of permitted duties is considered here in relation to potential harm that may follow if these requirements are not met.

The Geneva Conventions apply for protection of all wounded and sick “Members of the armed forces of a Party to the conflict as well as members of the militias or volunteer corps forming part of such armed forces.” There are also detailed provisions on other categories of combatants covered by the protections of the Geneva Conventions.[39] MMOs must, therefore, be ready for missions that differ conceptually in scope from their peacetime support for US military personnel and their families. In addition to those continuing responsibilities, they must expand their medical support paradigm to render medical assistance to all combatants, including captured enemy wounded.[40]

The broad scope of medical assistance set out in the Geneva Conventions warrants verbatim inclusion here, as set out in GC I:

Members of the armed forces and other persons mentioned in the following Article, who are wounded or sick, shall be respected and protected in all circumstances.

They shall be treated humanely and cared for by the Party to the conflict in whose power they may be, without any adverse distinction founded on sex, race, nationality, religion, political opinions, or any other similar criteria. Any attempts upon their lives, or violence to their persons, shall be strictly prohibited; in particular, they shall not be murdered or exterminated, subjected to torture or to biological experiments; they shall not wilfully be left without medical assistance and care, nor shall conditions exposing them to contagion or infection be created.

Only urgent medical reasons will authorize priority in the order of treatment to be administered.

Women shall be treated with all consideration due to their sex.

The Party to the conflict which is compelled to abandon wounded or sick to the enemy shall, as far as military considerations permit, leave with them a part of its medical personnel and material to assist in their care.[40]

The Geneva Conventions also highlight the extension of an MMO’s professional obligations beyond the wounded, sick, and shipwrecked members of armed forces. Though the Geneva Conventions focus on the role of military medical personnel and units in connection with medical care for these categories of personnel, there are also important provisions requiring medical treatment and careful attention to the public health needs of other categories of people as well. In fulfillment of those obligations, MMOs may be tasked to assist with public health needs and medical treatment for enemy who are prisoners of war, civilian detainees, civilians living under military occupation, and civilians who are wounded, sick, infirm or pregnant.[41] Other important humanitarian obligations set out in the Geneva Conventions relate to notification, disposition of human remains, and return of personal effects when a patient has died.[42]

Military medical units and establishments are protected from attack in order to ensure that medical work can be carried out for all wounded, sick, and shipwrecked combatants without distinction. “Fixed establishments” and “mobile medical units” of military medical services “may in no circumstances be attacked, but shall at all times be respected and protected” by all sides in the conflict.[43] Military hospital ships bear the same protection, and sick bays on other military ships “shall be respected and spared as far as possible.”[44]

Medical services of armed forces are authorized to use a specific identifying emblem recognized under the provisions of the Geneva Conventions. Accordingly, the Red Cross or Red Crescent emblem, displayed on a white ground, may be employed for this purpose.[45] A Red Crystal emblem was also authorized more recently. Israel employs a Red Shield of David in lieu of a Red Cross or Red Crescent emblem. (The complex background to the development and use of these emblems is summarized in the DoD Law of War Manual.[46]) If a medical facility, establishment, or activity is known to the other side, it should be respected and thus spared from attack even if a protected emblem is not in use.[26] Military medical personnel covered by the Geneva Conventions are also identified by wearing, “affixed to the left arm, a water-resistant armlet bearing the distinctive emblem, issued and stamped by the military authority.”[47]

The “medical personnel exclusively engaged in the search for, or the collection, transport or treatment of the wounded or sick, or in the prevention of disease, staff exclusively engaged in the administration of medical units and establishments, as well as chaplains attached to the armed forces”[29] are not deemed to be prisoners of war if captured. They are “retained personnel” and held “only in so far as the state of health, the spiritual needs and the number of prisoners of war require.”[48] Medical hospital ships (“built or equipped … specially and solely with a view to assisting the wounded, sick and shipwrecked”) may not be attacked or captured. Other hospital ships can also acquire protection where they have been authorized for such service and notice provided to all parties.[49] Similar status, authority to continue medical work, and provision for release apply to military medical personnel captured while serving at sea as applies to medical personnel serving on land.[31]

There are, however, strict requirements that must be met for medical personnel to sustain protected status. The Geneva Conventions anticipate situations in which protection may be lost. “The protection to which fixed establishments and mobile medical units of the Medical Service are entitled shall not cease unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy. Protection may, however, cease only after a due warning has been given, naming, in all appropriate cases, a reasonable time limit and after such warning has remained unheeded.”[50] The same restrictions apply to employment of hospital ships and sick bays of other vessels.[51]

This discussion inevitably raises questions about practical security of military personnel and medical establishments and facilities. The law of war recognizes armed security requirements. Medical personnel may be armed for their own defense and that of their patients. Armed security for the unit or establishment may be posted by orderlies, sentries, picket, or escort. None of these measures jeopardize the legal protection of medical units or establishments.[52] Armed security is also authorized on hospital ships (and sick bays of other vessels), and it does not deprive them of protected status.[53]

Medical Operations Conducted in Cooperation With Coalition Partners

The US armed forces have worked with international partners since the American Revolution, but this practice has accelerated in the 21st century. MMOs should expect many and perhaps most of their deployments to take place in partnership with the armed forces of international partners. Some of these forces have worked with US forces on a sustained basis in formal, treaty-based alliances. In such instances, there may be longstanding combined operational experience and logistical standardization. Other, less formal cooperative operations are called coalitions and often include newer partners. In either instance, important law of war responsibilities apply in armed conflict.

If enemy wounded and sick are transferred to an ally or coalition partner by US military authorities, the United States remains responsible for correction of any important medical or other failures of proper treatment when such are brought to the attention of US personnel. In fact, such transfer can only take place if the party receiving the enemy prisoners of war is itself a party to the applicable GC III on prisoners of war and has shown its “willingness and ability” to apply that treaty. If such deficiencies are not corrected, then the United States must request and secure return of the prisoners.[54] More nuanced issues may also arise that involve differing approaches to appropriate standard of care under the law of armed conflict.[55]

US military medical capabilities in most instances exceed those of allies and coalition partners. However, it should be kept in mind that though the United States has not ratified Additional Protocol I to the Geneva Conventions of 1977, sometimes allies and coalition partners have. For example, this protocol merges the concept of wounded and sick to include military wounded, sick, and shipwrecked under GC I and GC II with civilians in need of medical care under GC IV.[56] US medical officers should be aware that differences of interpretation may consequently arise in some circumstances regarding medical requirements and standards of care.[55] In some instances, the United States considers provisions of the Protocols Additional to reflect principles of customary law, and such customary principles are implemented.[57]

PROTECTION OF CIVILIAN MEDICAL STAFF AND HOSPITALS IN ARMED CONFLICT

Historically, the missions of military medical units have overlapped with those of civilian medical staff and facilities only on an incidental basis. Greater expectations for coordinated care now exist, and deploying MMOs must be prepared for cooperation with healthcare professionals who are treating civilian patients.[58] As previously discussed in the War Crimes section, and as can be seen from monitoring world news, civilian hospitals and staff sometimes face extremely dangerous conditions in which medical staff and patients are deliberately targeted.[59]

During international armed conflict, civilian medical staff are protected in their work under GC IV on terms analogous to those that apply to military medical staff and facilities. During armed conflicts internal to a country, such as a civil war, civilian medical practitioners and activities are entitled at a minimum to the protections afforded by Common Article 3. During international armed conflict, under GC IV, “Civilian hospitals organized to give care to the wounded and sick, the infirm and maternity cases, may in no circumstances be the object of attack, but shall at all times be respected and protected by the Parties to the conflict.”[60]

Regarding hospital staff, “Persons regularly and solely engaged in the operation and administration of civilian hospitals, including the personnel engaged in the search for, removal and transporting of and caring for wounded and sick civilians, the infirm and maternity cases, shall be respected and protected.”[61] Such hospitals shall be marked by a protective emblem if authorized by a state that is party to the armed conflict, and authorized medical personnel shall wear on the left arm an armlet displaying a protected emblem “while carrying out their duties.”60–62 Protections for such civilian hospitals “shall not cease unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy. Protection may, however, cease only after due warning has been given, naming, in all appropriate cases, a reasonable time limit, and after such warning has remained unheeded.”[62]

Other special protection arrangements can be made under GC IV. This treaty authorizes, by mutual agreement of all sides, the establishment of “hospital and safety zones and localities so organized as to protect from the effects of war, wounded, sick and aged persons, children under fifteen, expectant mothers and mothers of children under seven.”[63] GC IV also provides that belligerents may agree to the establishment of “neutralized zones intended to shelter from the effects of war the following persons, without distinction:

(a) wounded and sick combatants or non-combatants;

(b) civilian persons who take no part in hostilities, and who, while they reside in the zones, perform no work of a military character.”[64]

MMOs may also come into contact with the International Committee of the Red Cross, a humanitarian organization recognized under the Geneva Conventions as bearing special responsibility to provide protective assistance to prisoners of war, civilians, and the wounded, sick, and shipwrecked during armed conflict.[65] Officially chartered and recognized National Red Cross and Red Crescent Societies, as well as other relief societies, sometimes broadly referred to as nongovernmental organizations (or NGOs or PVOs [private voluntary organizations]), may also provide civilian relief “subject to temporary and exceptional measures imposed for urgent reasons of security … ”[66]

APPLICATION OF INTERNATIONAL LAW IN PEACETIME MEDICAL DEPLOYMENTS

The medical dimensions of international law are most developed in relation to services provided for combatants and civilians during armed conflict. The extensive guidance and rules on medical operations contained in the Geneva Conventions of 1949 have no medical equivalent in treaties that apply in peacetime. However, some fundamental human rights and humanitarian law protections must always be taken into account.

International human rights law provides important peacetime human rights protections and is a dynamic, developing field. Of particular note in connection with peacetime deployments is the Universal Declaration of Human Rights,[67] a resolution adopted by the United Nations (UN) General Assembly in 1948. This resolution and the UN treaty called the International Covenant on Civil and Political Rights of 1966[68] are landmark instruments establishing a foundation for human rights protection that imposes rules on governments for their treatment of human beings.

Human rights treaties all apply in peacetime, and some of them apply in times of armed conflict as well. Prior reference was made to one such treaty, the UN Convention on the Prevention and Punishment of the Crime of Genocide. Torture is also prohibited, in both peacetime and wartime, by the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment of 1984, as it is during armed conflict by the Geneva Conventions.69,70

A full survey of international human rights law exceeds the scope of this chapter. However, it should be kept in mind that governments have international legal obligations to treat their populace humanely and ensure their human rights in peacetime as well as during armed conflict. Just as the law of armed conflict never excuses states from their obligation to fulfill humanitarian obligations in wartime, international human rights law similarly obligates them to do the same for their population during peacetime disasters and emergencies in which MMOs may deploy as part of a foreign humanitarian assistance mission.

MMOs must be highly alert for situations in which individuals or groups might face persecution, discrimination, or mistreatment at the hands of host nation authorities, or may find themselves deprived of assistance by their government during medical and humanitarian relief operations. Higher headquarters must immediately be notified if such issues or evidence arises. The tragedy inherent in the consequential human suffering, and loss of life, could also further aggravate festering social and political problems and magnify security challenges. Additionally, potential goodwill could be thwarted through guilt by association. Just as a wartime crime by a coalition partner can tarnish the credibility and reputation of the United States, the same could happen if a host nation abuses or neglects all or portions of its population, or individuals who have been singled out, during a peacetime emergency.

Less traumatic but important issues may arise pertaining to the Constitution of the World Health Organization, which promises a “right to health,” and to a treaty that was widely ratified (but not by the United States to date) that “recognizes the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”71,72 The term “right to health” is interpreted to mean “the highest attainable standard of health.”[73] However, interpretations of the full scope of the meaning and implementation of a right to health may vary. Allies and coalition partners in medical development initiatives may have differing views on what this means and promises.

CONCLUSION

MMOs are responsible for ensuring medical personnel and units maintain protected legal status and fulfill service delivery requirements that the US government tasks to them in accordance with the Geneva Conventions. These are solemn national commitments that MMOs and other military medical personnel have fulfilled for generations. To continue this tradition, new MMOs should be able to visualize the medical dimensions of the law of armed conflict as an essential component of the mission—a medical form of commander’s intent.

MMO leadership in ensuring compliance with the medical aspects of the Geneva Conventions serves a high calling that exceeds patient needs and the national commitment to honor these rules. By implementing medical ethics in wartime, MMOs help ensure the continued viability and credibility of the law of armed conflict for the present time and the generations to follow.

REFERENCES

1.   US Department of Defense, Office of General Counsel. Department of Defense Law of War Manual. Washington, DC: DoD; June 2015 (updated December 2016): section 1.8.

2.   Wright JW. Sieges and customs of war at the opening of the eighteenth century. Am Hist Rev. 1934;39(4):629–644.

3.   US Army Medical Department, Office of Medical History. Extract from Medical Department, US Army. Preventive Medicine In World War II. Vol. IX, special fields. http://history.amedd.army.mil/booksdocs/wwii/EPWs/EPWs.htm. Accessed May 11, 2018.

4.   Reister F. Hospitalization in Korea. In: Battle Casualties and Medical Statistics, U.S. Army Experience in the Korean War. http://history.amedd.army.mil/booksdocs/korea/reister/ch4.html. Accessed May 11, 2018.

5.   Maxwell WQ. Lincoln’s Fifth Wheel: The Political History of the United States Sanitary Commission. New York, NY: Longmans, Green and Co; 1956: 271–276.

6.   US Department of Defense, Office of General Counsel. Department of Defense Law of War Manual. Washington, DC: DoD; June 2015 (updated December 2016): sections 4.9-4.13, 7.1-7.20.

7.   US Department of Defense, Office of General Counsel. Department of Defense Law of War Manual. Washington, DC: DoD; June 2015 (updated December 2016): sections 1.3.1, 1.3.2.

8.   Wright DP, Reese TR. The United States Army in Operation Iraqi Freedom, May 2003–January 2005: On Point II: Transition to the New Campaign. Ft Leavenworth, KS: Combat Studies Institute Press; 2008: 346.

9.   US Department of Defense, Office of General Counsel. Department of Defense Law of War Manual. Washington, DC: DoD; June 2015 (updated December 2016): section 18.2.3.

10.   International Committee of the Red Cross. Annual reports, 2002–2016. https://www.icrc.org/en/annual-report. Accessed May 12, 2018.

11.   US Department of Defense, Office of General Counsel. Department of Defense Law of War Manual. Washington, DC: DoD; June 2015 (updated December 2016): sections 18.4.1–18.5.3.

12.   Fouad M, Fouad MD, et al. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet-American University of Beirut Commission on Syria. Lancet. doi: http://dx.doi.org/10.1016/S0140-6736(17)30741-9. http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)30741-9/fulltext. Published March 14, 2017. Accessed October 20, 2017.

13.   Loveluck L, Zakaria Z. “The hospitals were slaughterhouses”: a journey into Syria’s torture wards. Washington Post. https://www.washingtonpost.com/world/middle_east/the-hospitals-were-slaughterhouses-a-journey-intosyrias-secret-torture-wards/2017/04/02/90ccaa6e-0d61-11e7-b2bb-417e331877d9_story.html?utm_term=.93835e7b6fa9. Published April 2, 2017. Accessed October 20, 2017.

14.   McKay H. Syria’s secret caves serve as hospitals in a final lifeline to save victims. FoxNews.com. http://www.foxnews.com/world/2017/04/06/syria-s-secret-caves-serve-as-hospitals-in-final-lifeline-to-save-victims.html. Published April 6, 2017. Accessed October 20, 2017.

15.   Weintraub S. War in the Wards. San Rafael, CA: Presidio Press; 1976.

16.   Geneva Convention I, article 50. International Committee of the Red Cross. The Geneva Conventions of 12 August 1949. https://www.icrc.org/eng/assets/files/publications/icrc-002-0173.pdf. Accessed May 11, 2018.

17.   Rome Statute of the International Criminal Court, Part 7. United Nations website. http://www.un.org/law/icc/index.html. Accessed October 20, 2017.

18.   UN Convention on the Prevention and Punishment of the Crime of Genocide, 1948. United Nations website. http://www.un.org/ga/search/view_doc.asp?symbol=a/res/260(III). Accessed October 20, 2017.

19.   Geneva Convention I, article 2; Geneva Convention II, article 2; Geneva Convention III, article 2; Geneva Convention IV, article 2.

20.   US Department of Defense. DoD Law of War Program. Washington, DC: DoD; May 9, 2006. DoD Directive 2311.01E.

21.   US Department of Defense, Office of General Counsel. Department of Defense Law of War Manual. Washington, DC: DoD; June 2015 (updated December 2016): section 3.1.1.2.

22.   Geneva Convention I, article 3; Geneva Convention II, article 3; Geneva Convention III, article 3; Geneva Convention IV, article 3.

23.   Geneva Convention I, article 19.

24.   Geneva Convention II, article 22.

25.   Geneva Convention I, article 36; Geneva Convention II, article 39.

26.   US Department of Defense. Joint Health Services. Washington, DC: DoD; December 11, 2017: appendix H: Impacts of the law of war and medical ethics, H-11. Joint Publication 4-02. http://www.jcs.mil/Portals/36/Documents/Doctrine/pubs/jp4_02.pdf. Accessed May 11, 2018.

27.   Geneva Convention I, article 35.

28.   Geneva Convention II, article 38.

29.   Geneva Convention I, article 24.

30.   Geneva Convention II, article 36.

31.   Geneva Convention II, article 37.

32.   Geneva Convention II, article 27.

33.   Geneva Convention I, article 25.

34.   Geneva Convention I, article 26.

35.   Geneva Convention II, article 24.

36.   Ernst KA. Too Afraid to Cry: Maryland Civilians in the Antietam Campaign. Mechanicsburg, PA: Stackpole Books; 2007: 168–181.

37.   Geneva Convention I, article 18.

38.   Geneva Convention II, article 21.

39.   Geneva Convention I, article 13; Geneva Convention 11, article 13; Geneva Convention III, article 4.

40.   Geneva Convention I, article 12; Geneva Convention II, article 12.

41.   US Department of Defense, Office of General Counsel. Department of Defense Law of War Manual. Washington, DC: DoD; June 2015 (updated December 2016): sections 7.16, 9.14.1–9.14.4, 10.14.1–10.14.1.3.

42.   US Department of Defense, Office of General Counsel. Department of Defense Law of War Manual. Washington, DC: DoD; June 2015 (updated December 2016): sections 7.7.2–7.7.5.1.

43.   Geneva Convention I, articles 19, 28.

44.   Geneva Convention II, articles 22, 28

45.   Geneva Convention I, article 38; Geneva Convention II, article 41.

46.   US Department of Defense, Office of General Counsel. Department of Defense Law of War Manual. Washington, DC: DoD; June 2015 (updated December 2016) sections 7.15.1–7.15.1.4.

47.   Geneva Convention I, article 40; Geneva Convention II, article 42.

48.   Geneva Convention I, article 28.

49.   Geneva Convention II, articles 22, 24, 25.

50.   Geneva Convention I, article 21.

51.   Geneva Convention II, article 34.

52.   Geneva Convention I, article 22.

53.   Geneva Convention II, article 35.

54.   Geneva Convention III, article 12.

55.   Office of General Counsel. Department of Defense Law of War Manual. Washington, DC: DoD; June 2015 (updated December 2016): sections 7.20.1–7.20.3.

56.   Additional Protocol I to the Geneva Conventions of 1977, article 8(a). International Committee of the Red Cross. Protocols Additional to the Geneva Conventions of 12 August 1949. https://www.icrc.org/eng/assets/files/other/icrc_002_0321.pdf. Accessed May 11, 2018.

57.   US Department of Defense, Office of General Counsel. Department of Defense Law of War Manual. Washington, DC: DoD; June 2015 (updated December 2016): section 1.8.1.

58.   US Department of Defense. Joint Health Services. Washington, DC: DoD; December 11, 2017: appendix J, Section B, Health Services Checklist for Stability Operations. Joint Publication 4-0, http://www.jcs.mil/Portals/36/Documents/Doctrine/pubs/jp4_02.pdf2. Accessed May 11, 2018.

59.   United Nations Office for the Coordination of Humanitarian Affairs. Reliefweb. https://reliefweb.int/. Accessed May 14, 2018.

60.   Geneva Convention IV, article 18.

61.   Geneva Convention IV, article 20.

62.   Geneva Convention IV, article 19.

63.   Geneva Convention IV, article 14.

64.   Geneva Convention IV, article 15.

65.   Geneva Convention I, article 9; Geneva Convention II, article 9; Geneva Convention III, article 9; Geneva Convention IV, article 10.

66.   Geneva Convention IV, article 63.

67.   Universal Declaration of Human Rights. United Nations website. http://www.un.org/en/universal-declaration-human-rights/. Accessed October 20, 2017.

68.   United Nations High Commissioner for Human Rights. International Covenant on Civil and Political Rights. http://www.ohchr.org/en/professionalinterest/pages/ccpr.aspx. Accessed May 11, 2018.

69.   United Nations High Commissioner for Human Rights. Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. http://www.ohchr.org/EN/ProfessionalInterest/Pages/CAT.aspx. Accessed May 11, 2018.

70.   US Department of Defense, Office of General Counsel. Department of Defense Law of War Manual. Washington, DC: DoD; June 2015 (updated December 2016): section 1.6.3.4.

71.   World Health Organization. Constitution of the World Health Organization. http://www.who.int/governance/eb/who_constitution_en.pdf. Accessed October 20, 2017.

72.   United Nations High Commissioner for Human Rights. International Covenant on Economic, Social and Cultural Rights, article 12. http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx. Accessed May 11, 2018.

73.   International Committee of the Red Cross. Health Care in Danger: The Responsibilities of Health-Care Personnel Working in Armed Conflicts and Other Emergencies. Geneva, Switzerland: ICRC; 2013: 37. https://www.icrc.org/en/publication/4104-health-care-danger-responsibilities-health-care-personnel-working-armed-conflicts. Accessed May 11, 2018.

Chapter 7

THE NATIONAL SECURITY STRUCTURE

JONATHAN WOODSON, MD*

INTRODUCTION

PROFESSIONALISM AND MILITARY VALUES

THE MILITARY MEDICAL OFFICER AND THE NATIONAL SECURITY STRUCTURE

The National Command Authority and National Security Council

Congress and Oversight of the Department of Defense

THE DEPARTMENT OF DEFENSE

Organization of the Office of the Secretary of Defense

Combatant Commands

Goldwater-Nichols Department of Defense Reorganization Act

Joint Chiefs of Staff and Joint Staff

Joint Doctrine

ORGANIZATION OF THE MILITARY MEDICAL SERVICES

Army Medical Department

Bureau of Medicine and Surgery

Air Force Medical Service

Uniformed Services University of the Health Sciences

DEFENSE HEALTH AGENCY

Tricare

Multiservice Markets

DEPARTMENT OF DEFENSE BUDGETING PROCESS

THE UNIFIED MEDICAL PROGRAM AND THE DEFENSE HEALTH PROGRAM

LOOKING TO THE FUTURE

*Professor of Surgery, Department of Surgery, Boston University, Boston, Massachusetts; formerly, Assistant Secretary of Defense (Health Affairs)

INTRODUCTION

The military medical officer (MMO) is a unique professional who performs his or her duties in an increasingly complex environment. In order to be successful in both roles as a medical professional and a military officer, it is necessary for the MMO to have a comprehensive understanding of the organizational environment in which they will work, lead, and contribute to solving problems and advancing the tools of their profession. This chapter outlines key elements of the national security structure, including the national command authority, the Department of Defense, combatant commands, the military services, and the Defense Health Agency. In addition, the chapter provides an overview of budgeting and financial controls, which are important to the sustainability and success of the military medical mission.

PROFESSIONALISM AND MILITARY VALUES

The MMO is a member of two professions. A professional may be defined as a person who belongs to an occupational group that lives by an ethos, professional discipline, and set values, and that generates new knowledge to advance the profession, usually to the benefit of society. In turn, society generally grants the profession some autonomy and preferred status. Professionals begin with formal education, but progressive skill development and competence are the hallmarks of a professional.

Medical professionals are driven by compassion to heal and relieve suffering. In pursuit of these core values, they commit to putting the patient first, conducting research to improve the evidence base for care, and developing new strategies to broaden access and efficiency of care for all who may need services. In addition to providing treatment, medical professionals promote health and prevention of disease by counseling patients or sharing knowledge, which should benefit them as individuals. Although these are ideals, providers should constantly work to make them a reality. This is how providers maintain their respected status in the eyes of their fellow citizens and humanity.

The very essence of professionalism is a community of people who agree on standards and practice. A profession exercises some degree of autonomous control of the community because society recognizes the community has skills and knowledge that others, without professional education, do not generally understand. Therefore, the professional is bound by the standards of the profession. Although professionals may work to change some standards, while the standards are in force, professionals are bound by them. How the rules are made and who makes them are therefore critical aspects of professional knowledge. Healthcare professionals must be aware of standards of care, who their colleagues on the hospital staff are, and who controls the licensing and credentialing authority in their community.

The MMO is also a professional whose occupation is values based (see Chapter 3, Officership and the Profession of Arms in the 21st Century). Each of the military services expresses core values that officers are expected to embody and exhibit in their daily behavior. Deepening an understanding of these values throughout one’s professional career provides the platform for solid senior leadership roles. In fact, absent a deep understanding of core values, leaders are likely to fail. Loyalty and a commitment to upholding the Constitution (and its values) is an oath all MMOs make. The commitment to the Constitution is the basis for understanding the professional work of soldiers. The mission of defending the nation requires selflessness, just as does putting the patient first. Putting the “mission above self” is supported by a sense of duty or commitment to doing the job whenever and wherever required, doing it well, and improving skills and competence throughout one’s career.

Military officers value honor. Closely related to honor is the value of integrity, an essential part of the character of a military officer, which is the reflex to do the right thing—even when no one is watching. Personal courage is a cornerstone attribute for the fully developed military officer. This attribute is clearly important in battle, but it needs to be honed to ensure leaders exhibit moral as well as physical courage whenever and wherever it is needed. Leaders frequently fail because they do not defend what is right or stand up to peers or others who foster climates of intimidation, disrespect, or discrimination.

The military services have a responsibility to develop leaders and promote good leadership. Leadership is the ability to establish a vision for a future that is better than today. It requires leaders to communicate, aspire, inspire, and motivate others. Leaders need to know how to build effective teams. Leadership is active and never passive. It requires energy and willingness to solve anticipated or unanticipated problems. Thus, leaders need to know themselves and know how to recharge and create balance in their lives. Leadership is the ultimate attribute that defines military officers because it incorporates the military ethos, defines competence, and is selfless and driven by mission. One aspect of leadership is resource development and utilization. Whether in a civilian medical system or the military, understanding the administration and management of the system is a key leadership qualification.

Careful evaluation of the ideal attributes of the medical professional and the military officer reveals that the optimal qualities of each profession are wholly congruent and mutually reinforcing. Individuals who do not fully understand the values underpinning the core attributes of a military officer question whether the medical ethos runs counter to the values of the military officer, which is clearly not true. Characteristics such as leadership, loyalty, duty, honor, and courage serve medical professionals and patient care very well. Understanding compassion and relief from suffering provides the military leader with mature skills needed to care for subordinates. MMOs therefore have a robust supportive framework to guide their development. True commitment to developing one’s self as a military officer pays dividends as a medical professional. Part of that commitment is understanding the framework of the military profession just as medical providers understand the framework of the medical profession.

THE MILITARY MEDICAL OFFICER AND THE NATIONAL SECURITY STRUCTURE

The intent of this chapter is to lay the foundation for junior medical officers to understand the context in which they will function and mature as MMOs, and prepare them to assume increasing levels of responsibility and accountability throughout their careers. It charts a broad course for guiding personal development and provides a general introduction to the important elements of the national security structure impacting an MMO’s career.

The MMO operates throughout his or her career within the special context of the US government’s national security structure in support of the National Security Strategy (NSS), National Defense Strategy (NDS), and National Military Strategy (NMS) (Exhibit 7-1). The NMS[1] increasingly calls for joint operations, and thus it is important for MMOs to understand the broad organizational structure of sister services and how each may contribute to joint operations, particularly during joint medical support to a spectrum of operations. This spectrum runs from conventional war to stabilization, post-conflict host nation support, and global health engagement.

EXHIBIT 7-1

DEFINITIONS

The National Security Strategy (NSS) is a document prepared periodically by the executive branch of the US government for Congress and other audiences. It outlines the major national security concerns of the United States and how the administration plans to deal with them. The legal foundation for the document is spelled out in the Gold-water-Nichols Act. The document is purposely general in content (contrast with the National Military Strategy [NMS]), and its implementation relies on elaborating guidance provided in supporting documents (including the NMS).

The National Defense Strategy (NDS), issued by the secretary of defense in response to the NSS, provides guidance for the chairman of the Joint Chiefs of Staff in developing the NMS, and also provides a foundation for the Quadrennial Defense Review (QDR). The NDS and the QDR provide strategic guidance from the secretary of defense on priority defense missions and associated strategic goals. These goals are used by the strategic planning community to assess newly emerging goals and to develop specific performance measures. The QDR report also serves as the Department of Defense’s strategic plan, consistent with the Government Performance and Results Act of 1993.

The National Military Strategy (NMS) is issued by the chairman of the Joint Chiefs of Staff as a deliverable to the secretary of defense that briefly outlines the strategic aims of the armed services. The chairman of the Joint Chiefs of Staff, in consultation with the other members of the Joint Chiefs of Staff, the commanders of the unified combatant commands, the Joint Staff, and the Office of the Secretary of Defense, prepares the NMS in accordance with 10 USC, Section 153. Title 10 requires that not later than February 15 of each even-numbered year, the chairman must submit to the Senate Committee on Armed Services and the House Committee on Armed Services a comprehensive examination of the NMS. This report must delineate an NMS consistent with the most recent NSS prescribed by the president; the most recent annual report of the secretary of defense submitted to the president and Congress; and the most recent QDR conducted by the secretary of defense.

The 2015 NSS[2] for the first time explicitly stated that “the spread of infectious diseases constitutes a growing risk” to national security. The strategy acknowledged the national security imperative behind the US government’s efforts in “leading a global effort to stop the deadly spread of the Ebola virus at its source.” The 2015 NMS defines requirements to provide for globally integrated military operations across the spectrum of US military engagements, including maintaining a stabilizing presence, conducting stability operations, supporting civil-military authorities, and providing humanitarian and disaster response. Each of these functions has implications for employment of medical forces to accomplish the mission.

Increasingly, MMOs are required to participate in interagency work, either as part of international crisis response or policy development work groups, in pursuit of a “whole US government” organized effort. Thus, the MMO must have a broad understanding of the mission and capabilities of other important US government agencies and how the military “supports or is supported by” those agencies.

Medical care has become increasingly more complex in terms of technology, science, and organizational design. Medical care is a key enabler for the success of military operations and is an important reflection of national values and respect for human life. The expectations for the delivery of high quality care, good outcomes, and efficient systems that can be rapidly deployed anywhere in the world are the hallmark of distinction that defines the US military health system (MHS). As the world becomes more volatile and complex, the MHS must evolve and prepare its leaders to provide strategic leadership in this environment.

The development of the military medical leader is iterative and must proceed in a parallel course with development of clinical skills. Neither attribute can be neglected if the MHS is to meet its mission and remain relevant. At senior levels of responsibility, the leadership ability of MMOs is actually more important than their clinical skills. Line officers, senior civilian officials, allies, and foreign governments will increasingly rely on MMOs’ ability to integrate the specific requirements of delivering medical care with geopolitical, logistical, and cultural concerns, and to evaluate the strategic impact of medical operations.

The National Command Authority and National Security Council

The president is the commander-in-chief of the US armed forces. In exercising this responsibility, lawful orders need to be published. The national command authority refers to the source of lawful orders and comprises the president (and his or her designee, the vice president) and the secretary of defense (and his or her designee, the deputy secretary of defense).

The National Security Act of 1947[3] established the White House National Security Council. It functions to advise and assist the president on national security and foreign policy issues and to coordinate these policies among government executive agencies. The standing (statutory) members of the National Security Council include the president (chair), vice president, secretary of state, secretary of defense, and secretary of energy. Regular invited attendees include the chairman of the Joint Chiefs of Staff (CJCS), the director of the National Intelligence Agency, and the director of national drug control policy. Other White House staff and executive-level participants include the national security advisor, deputy national security advisor, homeland security advisor, attorney general, and White House chief of staff.

Congress and Oversight of the Department of Defense

The Constitution of the United States provides for the legal authority to organize and fund military forces to defend the country. Article I, Section 8, gives Congress the authority “To lay and collect taxes … to pay the debts and provide for the common defense … To raise and support armies … To provide and maintain a navy.”[4]

However, the organization of the armed forces dates to the Second Continental Congress, which established the US Army (June 14, 1775); the US Navy (October 13, 1775); and the US Marine Corps (November 10, 1775). After the Revolutionary War, Congress established the Department of War (the predecessor of the Department of Defense [DoD]), on September 29, 1789. (Exhibit 7-2 elaborates on the role of the Congress in shaping national defense policy and structures.)

The US Congress consists of the House of Representatives and the Senate. Each body of Congress exercises its oversight responsibilities through the organized activities of specific committees. In the House, the House Armed Services Committee is the duly constituted committee to conduct oversight of the DoD and the armed forces. This committee develops the legislation to authorize the DoD and each service to enact programs and personnel actions (eg, troop limits). The Subcommittee on Military Personnel is responsible for personnel policy, military healthcare, and military education, among other issues.

The Senate counterpart is the Senate Committee on the Armed Services, established under standing rules of the Senate. It has jurisdiction over the DoD, military services, and military research and development, as well as pay, promotion, and the selective service system. As in the House, the Senate Armed Services Subcommittee on Personnel is charged with leading most of the Senate’s defense oversight work in regard to active and reserve military personnel issues, including a focus on pay, military healthcare, education, morale and welfare, and military justice.

EXHIBIT 7-2

CONGRESS AND NATIONAL SECURITY REFORMS

The original War Department had responsibility of the naval forces as well as the land forces of the new nation, but after the Revolutionary War, the naval forces were almost nonexistent. In 1794 a separate executive department was established to build and oversee the naval forces; the new Navy and Marine Corps were managed separately from the Army, although efforts to collaborate were subsequently made during wartime.

During World War II, substantial difficulties arose in establishing priorities for campaigns and operations, as well as resourcing the services, in part because of competition between the services, the relative independence of the services, and an unclear chain of command. Following the war, President Truman proposed establishing a unified Department of (National) Defense, bringing together the Department of War (Army) and the Department of the Navy.

The National Security Act of 1947 created the “National Military Establishment” (renamed Department of Defense in 1949), and placed it under the authority, direction, and control of the secretary of defense. The National Security Act of 1947 also created the Joint Chiefs of Staff, the National Security Council, and the Central Intelligence Agency. Furthermore, the act established the US Air Force as a separate service from its predecessor, the Army Air Corps. During the second half of the 20th century, the structures within the services and Department of Defense changed several times, but the broad structure established in 1949 remains: four services within three departments under the overall direction of the secretary of defense.

Under Article 1, Section 9, Clause 7 of the Constitution, “No money shall be drawn from the treasury but in consequence of appropriation by law.” In both the House and the Senate, legislation that authorizes programs is separate from legislation that provides the appropriation or money to pay for the programs. Both are required in order to establish and sustain new programs. US military spending is the largest part of discretionary spending by the government. As a result, the Senate and House appropriations committees and their defense subcommittees play a crucial part in the defense budgeting process and acquiring needed resources to meet military and defense strategies. Using the combined authorization and appropriation authorities, Congress plays at least a partnership role and many times leads in efforts to reform national security structures.

THE DEPARTMENT OF DEFENSE

The DoD is an executive agency of the US government whose mission is to provide the military forces needed to deter, fight, and win the nation’s wars and to protect the security of the country (Figure 7-1). The DoD employs over 2.8 million civilians, active duty military forces, reserve component forces, and contractors. Established after World War II as a distinct agency to supervise and coordinate national security and the armed forces, the DoD is headquartered at the Pentagon, in Arlington, Virginia, but has many offices throughout the National Capital Region and the United States.

The secretary of defense is a cabinet-level appointee who reports to the president and has authority, direction, and control over the DoD. The DoD has three component military departments: Department of the Army, Department of the Navy (and Marine Corps), and Department of the Air Force. In addition, the DoD has oversight for the Defense Intelligence Agency, the Defense Advanced Projects Agency, the National Security Agency, the National Geospatial Intelligence Agency, and the National Reconnaissance Office. Other DoD agencies include the Defense Logistics Agency, the Defense Health Agency (DHA), the Missile Defense Agency, the Defense Threat Reduction Agency, the Defense Security Agency, and the Pentagon Protection Force Agency.

Organization of the Office of the Secretary of Defense

The secretary of defense provides civilian control over the military services in accordance with the Constitution. In order to execute these responsibilities, the Office of the Secretary of Defense is organized to provide a senior civilian staff to carry out the secretary of defense’s authorities and manage the DoD (Figure 7-2).

Figure 7-1. Organization of the Department of Defense.

Figure 7-2. Organization of the Office of the Secretary of Defense.

In addition to the secretary of defense, key civilian personnel (appointed by the president with the advice and consent of the Senate) include the deputy secretary of defense; three service secretaries (Army, Navy, Air Force); and six undersecretaries (for acquisition and sustainment [A&S]; research and engineering [R&E]; comptroller/chief financial officer; personnel and readiness [P&R]; policy; and intelligence). The National Defense Authorization Act of 2017 restructured the undersecretary for acquisition, technology, and logistics into two distinct roles: the undersecretary for research and engineering (chief technical officer), with the mission of advancing technology and innovation, and the undersecretary for acquisition and sustainment. A number of assistant secretaries, who are also civilian, support the undersecretaries. The assistant secretaries are also appointed by the president with the advice and consent of the Senate. Other key staff include the general counsel, deputy chief management officer, director of administration, and director of operational test and evaluation.

Space does not permit coverage of all of the roles and responsibilities of key leaders within the Office of the Secretary of Defense, which are delineated in several DoD publications. However, a few relationships, roles, and responsibilities are important for the medical officer to understand.

The military service secretaries function as the chief executive officers for their respective service and report to the secretary of defense. Reporting to the service secretaries are the service chiefs (ie, the chief of staff for the Army and the Air Force, the chief of naval operations for the Navy, and the commandant of the Marine Corps). With advice and consultation of the senior leadership of the service, the service secretaries are responsible for service plans, policies, budgets, and programs. They also have specified responsibilities under the Uniformed Code of Military Justice.

The undersecretary for personnel and readiness is the principal advisor to the secretary and deputy secretary of defense for total force management as it relates to personnel requirements, readiness, reserve component affairs, health affairs, training, equal opportunity, morale, welfare, and quality of life issues. The assistant secretary of defense for health affairs, while the principal advisor to secretary of defense for health-related matters, reports to the undersecretary for personnel and readiness.

The assistant secretary of defense for health affairs (ASD[HA]) has broad roles, responsibilities, and authorities as a principal agent of the Office of the Secretary of Defense. As delineated in DoD Directive 5136.01:

The ASD(HA) is the principal advisor to the Secretary of Defense and the Under Secretary of Defense for Personnel and Readiness (USD (P&R)) for all DoD health and force health protection policies, programs, and activities, and for the Integrated Disability Evaluation System (IDES). The ASD(HA) ensures the effective execution of the DoD medical mission, providing and maintaining readiness for medical services and support to members of the Military Services, including during military operations; their families; those held in the control of the Military Services; and others entitled to or eligible for DoD medical care and benefits, including those under TRICARE. In carrying out these responsibilities, the ASD(HA) exercises authority, direction, and control over the DoD medical and dental personnel authorizations and policy, facilities, programs, funding, and other resources in the DoD.[5]

In the process of developing health-related policies, the ASD(HA) coordinates with the services and the Joint Chiefs of Staff (JCS), usually with the service surgeons general and joint staff surgeons as the points of contact. Additionally, the ASD(HA) has authority, direction, and control over the Uniformed Services University of the Health Sciences, including the Armed Forces Radiobiology Research Institute, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, and the Armed Services Blood Program. The ASD(HA) executes his or her responsibilities with the assistance of five functional leads:

1. The principal deputy assistant secretary of defense fulfills all of the functions and duties of the ASD(HA) when he or she is absent and provides direct oversight of the deputy assistant secretaries.

2. The deputy assistant secretary for health services policy and oversight serves as the principal staff assistant and advisor to the ASD(HA) for clinical policies and programs, including oversight of quality assessment/quality improvement, patient safety, and population-based healthcare management across the MHS.

3. The deputy assistant secretary of defense for health readiness policy and oversight directs development of deployment medicine and force health protection policy, medical research and development strategy and policy, international health agreements and policy, and domestic federal interagency and nongovernmental partnerships to serve DoD missions and medical readiness.

4. The deputy assistant secretary for health resources, management, and policy is responsible for overall financial policy and programs for the Defense Health Program (DHP). DHP is the name given to the actual budget groups that financially support the DHA, the MHS, and Tricare. The DHP maintains the financial portfolio that both funds and promotes the MHS’s strategic imperatives, including research, education, administration, health information technology, direct care in military hospitals and clinics, and payment for private sector healthcare.

5. The director of the DHA directs the execution of 10 joint shared services including Tricare, pharmaceuticals, health information technology, research and acquisition, education and training, public health, medical logistics, facility management, budget and resource management, and contracting. The DHA administers Tricare, which provides worldwide medical, dental, and pharmacy benefits to more than 9.4 million uniformed service members, retirees, and their families.

Combatant Commands

Unified combatant commands (COCOMS) were created as an outgrowth of the Second World War and codified under the authorities of the National Security Act of 1947 and Title 10 of the US Code. During World War II, a unified command structure was created to synchronize American and British war efforts under the Combined Chiefs of Staffs, which planned and executed the military campaigns. The Supreme Headquarters Allied Expeditionary Force for the European Theater was one example of a joint command structure. Following the war, unified commands underwent several iterations, originally overseen by one of the service chiefs as an executive agent of the JCS.

Unified COCOMs are 4-star joint commands organized on a geographical (area of responsibility) or functional basis and are constituted by forces from multiple military services.[6] COCOMs provide command and control of US military forces and conduct peacetime and wartime operations. They are established in accordance with the Unified Command Plan, a directive approved by the president that defines command relationships for operational forces globally. The military services, under Title 10 authorities and responsibilities, train, organize, and equip the armed forces. The services are responsible for providing trained forces to COCOMs when needed for ongoing operations. COCOMs are extremely important to providing strategic situational awareness, contingency planning, regional agility, unity of effort, and forward presence to support the NDS and NMS. Each of the COCOMs has an assigned command surgeon to provide healthcare and force health protection advice to the combatant commanders.

The current geographical commands are the European Command (EUCOM, Stuttgart, Germany); Africa Command (AFRICOM, Stuttgart, Germany); Central Command (CENTCOM, MacDill Air Force Base, FL); Pacific Command (PACOM, Camp H.M. Smith, HI); Southern Command (SOUTHCOM, Doral, FL); and Northern Command (NORTHCOM, Peterson Air Force Base, CO). Figure 7-3 maps the geographic area of responsibility for each of these commands.

Figure 7-3. Map of the US unified geographic combatant commands.

Specified commands are functional in organization and operate across the globe. They have specialized, ongoing missions in support of unified commands and geographical combatant commanders. The US Transportation Command (USTRANSCOM, Scott AFB, IL); US Special Operations Command (USSOCOM, MacDill Air Force Base, FL); and US Strategic Command (USSTRATCOM, Offutt Air Force Base, NE) are the current specified commands. Congress recently directed the establishment of an additional functional combatant command, Cyber Command, which currently is organized under STRATCOM. Periodically different stakeholders have advocated for the establishment of a unified medical command as an additional functional command. The president, with the advice and assistance of the secretary of defense and CJCS, can establish additional specified or geographical commands as necessary.

Goldwater-Nichols Department of Defense Reorganization Act

The Goldwater-Nichols Department of Defense Reorganization Act of 1986 defines the current military command relationships, roles, and responsibilities, specifically, the chain of command for the unified command that flows from the president through the secretary of defense to combatant commander.7,8 The CJCS facilitates this line of authority but has no command authority over the COCOMs or the forces assigned.

The Goldwater-Nichols Act produced significant changes in the command alignment and organization of the DoD. The intent of the legislation was to further address the interservice competition that impeded effective defense and military strategy planning and execution. Despite the creation of the DoD (in 1947), when the services began reporting to a single secretary, the military services remained independent and organized along individual service chains of command. There remained duplication of effort (eg, procurement), lack of efficiency, and problems planning for and conducting combined arms/service operations.

The Goldwater-Nichols Act clarified the role of the CJCS as the principal military advisor to the president, National Security Council, and secretary of defense. The act provided a platform for the CJCS to lead the development of the overall NMS, and it provided for clear command authority for unified and specified combatant commanders. The services report to their respective service chiefs and are responsible for “training, manning and equipping” the forces required or requested by the COCOM (subject to approval of the secretary of defense). The combatant commanders have full command of forces provided to them by the services, and they have freedom to plan and conduct joint operations with the assigned multiservice (air, ground, naval, and special operation) forces. In addition, the changes implemented under the Goldwater-Nichols Act provided for unity of effort and efficiencies in procurement, interagency collaboration, and planning. The act also set forth the requirements for joint professional military education for career progression to admiral (flag) or general officer rank. MMOs have generally been exempted from this joint professional military education provision, although compliance with this requirement creates an increasingly competitive edge for individual medical officers.

Joint Chiefs of Staff and Joint Staff

The National Security Act of 1947, in part to institutionalize the joint chiefs structure created during World War II, constituted the JCS. Its membership includes the CJCS, vice chairman of the JCS, the service chiefs, and the chief of the National Guard Bureau. The JCS provides advice to the president, secretary of defense, and National Security Council through the CJCS (who is the designated principal military advisor) and assists the CJCS in carrying out his or her duties. The JCS, pursuant to the Goldwater-Nichols Act of 1986, does not have operational command authority. Each service chief works for his or her respective service military department secretary.

The Joint Staff refers to the complement of civilians and military personnel (from all five armed services) who work to support and execute the responsibilities of the JCS and CJCS. In carrying out this effort, the Joint Staff coordinates extensively with the staff of the secretary of defense, staffs supporting the military service chief and secretaries, and staffs of combatant commanders and other government agencies as needed. Joint Staff functions follow a typical structure common in higher military headquarters, as noted in Figure 7-4, with the designation “J” before the numbered staff function. The director of the Joint Staff is a 3-star general or flag officer responsible for oversight and coordination.

Like many headquarters, the Joint Staff has special staff officers assigned. The Joint Staff surgeon is assigned to the J-4 (logistics) cell and is the chief medical advisor to the CJCS and the COCOMs. The Joint Staff surgeon coordinates all issues related to health services, including operational medicine, force health protection, and readiness, working with the ASD(HA) and the military services.

Joint Doctrine

The Joint Staff publishes a series of joint publications to educate US military forces in joint doctrine:

Joint doctrine presents the fundamental principles that guide the employment of US military forces in coordinated and integrated action toward a common objective. It promotes a common perspective from which to plan, train, and conduct military operations. It represents what is taught, believed, and advocated as what is right (ie, what works best). It provides distilled insights and wisdom gained from employing the military instrument of national power in operations to achieve national objectives.[6]

Figure 7-4. Organization of the Joint Chiefs of Staff.

These publications range across the spectrum of staff operations, planning, and operational requirements for the joint force. Joint Publication 1[6] provides doctrine for unified action by US armed forces, including command relationships, military authority guidance for command and control, and organizing and equipping joint forces. It provides the doctrinal basis for interagency coordination and US military employment in multinational and interagency operations. It should be a familiar resource for all MMOs.

In 2015, the Joint Staff surgeon championed the development and approval of the Joint Concept for Health Services,[9] which describes “the CJCS vision for what the future Joint Force will need to have from the collective military medical enterprise to support full spectrum global integrated Operations. This includes interoperable service capabilities, common standards, procedure, and tailorable expeditionary capability to operational and strategic requirements.” It provides a framework for joint healthcare for combatant commands, military services, the DHA, and the Joint Staff to achieve unity of effort in the provision of health service support.

Seven core supporting ideas are described in the Joint Concept for Health Services:

1. Integrated joint requirements in medical force development that mitigate threats to health services specifically, and the joint force generally, in contested environments.

2. Global synchronization of health services that plan, integrate, and sustain medical resources efficiently and quickly on a global scale.

3. Modular and interoperable medical capabilities that meet a core set of joint standards and requirements while also conforming to service-specific requirements.

4. A global network of health service nodes that incorporate mission partners and are flexible enough to rapidly mobilize and deploy medical capabilities and resources.

5. Tailored medical forces and operations that reduce lift requirements, sustainment requirements, and physical presence while improving quality of care.

6. Leaders integrating joint medical capabilities who are adaptive, skilled, and can synchronize multiple efforts across multiple domains to ensure unity of health service efforts.

7. Improved performance through an appropriate balance between sustainment of current readiness through healthcare delivery in medical beneficiary markets, targeted warfighting clinical education and training, and investment in future capabilities.

ORGANIZATION OF THE MILITARY MEDICAL SERVICES

The Army, Navy, and Air Force operate independent medical services in support of their parent military organization. The Marine Corps receives medical support from the Department of the Navy. As a result, the chain of command flows from the service secretary to the respective service chief to the respective service surgeon general. The Army and Navy surgeons general both have command responsibilities in addition to their principal service senior staff roles. The Army surgeon general is commander of the US Army Medical Command. The Navy surgeon general is commander of the US Navy Bureau of Medicine and Surgery (BUMED). The Air Force surgeon general functions as the principal medical advisor to the chief of staff of the Air Force, but has no similar command responsibilities.

Army Medical Department

The Army Medical Department (AMEDD) is the oldest organized US military medical support activity and dates its lineage to the Continental Army in 1775. The AMEDD is organized into six special officer corps and an enlisted medical corps. The Army Medical Corps (physicians) is the oldest corps and, like the AMEDD, dates to the Continental Army. The other corps are the Army Nurse Corps, the Dental Corps, the Veterinary Corps, the Medical Service Corps, and the Medical Specialist Corps. The Medical Service Corps represents a group of professional capabilities including pharmacists, medical evacuation pilots, operations officers, health administration officers, social workers, podiatrists, and several other disciplines. The Medical Specialist Corps consists of commissioned officers holding professional degrees who serve as clinicians in several disciplines such as physician assistants, physical and occupational therapists, and dieticians.

There are 24 enlisted medical specialties (eg, behavioral health specialist, dental specialist) that augment the AMEDD’s professional capability. These specialists receive their training in a joint educational environment, the Medical Education and Training Campus, in San Antonio, Texas. The military standards are set and overseen by the AMEDD Academy of the Health Sciences, which educates and trains medical personnel as part of the AMEDD Center and School. The Center and School is also the proponent for Army medical organization, doctrine, and tactics.

The AMEDD executes its responsibility for staffing the services with qualified medical professionals through several educational strategies. Professionals such as doctors and nurses can receive primary professional training through civilian professional schools supported by scholarships (eg, the Health Professions Scholarship Program) or be directly commissioned into the service at later stages of their careers.

Bureau of Medicine and Surgery

The BUMED is the Navy’s executive agency for training, staffing, and provision of health services and health policy for the Navy and Marine Corps. Commanded by the Navy surgeon general, BUMED has about 63,000 personnel assigned. BUMED’s subordinate commands are Navy Medicine East, Navy Medicine West, the Education and Training Command, the Naval Research Center, the Naval Medical Logistics Command, the Navy Medicine Information Systems Support Activity, and the Navy and Marine Corps Public Health Center. Navy Medicine East and Navy Medicine West have oversight of 19 hospitals and 9 clinics as well as 3 dental battalions.

Air Force Medical Service

The Air Force Medical Service (AFMS) was established in 1949, two years after the Army Air Corps became its own service as the US Air Force. Like its sister services, the AFMS is organized into a series of medical professional corps, including the Medical Corps, Nurse Corps, Biomedical Science Corps, Dental Corps, and Medical Service Corps. Additionally, there is an Enlisted Medics Corps. Unlike the Army and Navy, Air Force hospitals and clinics fall under the command of wing commanders rather than the AFMS.

Uniformed Services University of the Health Sciences

The Uniformed Services University of the Health Sciences (USUHS) and its F. Edward Hebert School of Medicine were established by an act of Congress on September 21, 1972. The mission of USUHS is “to educate, train and comprehensively prepare uniformed services health professionals, scientists and leaders to support the Military and Public Health Systems, the National Security and National Defense Strategies of the United States and the readiness of our uniformed services.” USUHS is a key source of career military medical physicians and graduate dental and nursing personnel. It is a joint organization, supporting all services. The ASD(HA), the three military surgeons general, and the US surgeon general are members (ex officio) of the USUHS Board of Regents.

DEFENSE HEALTH AGENCY

Since 1947, there have been 19 studies, commissions, and reports to evaluate the propriety of having separate military service medical systems. The majority of these reports have recommended combining the medical services to improve efficiency, reduce costs, and reduce the size of medical headquarters. A few studies have recommended a “Joint Medical Command.” Most of these recommended changes have been resisted by the services.

In 2011, after a decade of war in which joint medical operations prevailed and costs spiraled, the Office of the Secretary of Defense formed a task force to review the long-term governance options of the MHS. Additionally, the 2005 Base Realignment and Closure Commission had recommended co-locating the Army, Navy, and Air Force medical headquarters in the same building. This set the stage for examining core duplicative health system functions that could be better managed as MHS shared services or enterprise support activities. The task force, conducted under the auspices of the undersecretary of defense (personnel and readiness) and the ASD(HA), produced a report recommending the establishment of a joint DHA to assume management of 10 shared business processes or core business activities and any other activities identified by the secretary of defense. The shared services included Tricare; health facilities management; budget and resource management; health information technology; medical logistics; education and training; research and development; pharmacies; public health; and procurement and contracting. The National Defense Authorization Act of 2017 directed the DHA to assume control of all military treatment facilities beginning October 1, 2018.

The overarching mission of the DHA is to support and maintain a medically ready force and a ready medical force at all times while creating a better, stronger, more efficient and agile MHS. The DHA assumed initial operating capability on October 1, 2013, and matured to full operating capability on October 1, 2015. The DHA is also designated as a combat support agency and in this role is responsible to the CJCS for delivering key combat service support capabilities to support the NMS. The DHA is also responsible for oversight of National Capital Region medical assets, which include the Walter Reed National Military Medical Center in Bethesda, the Fort Belvoir Community Hospital, the National Museum of Health and Medicine, the Joint Pathology Center, the National Capital Region multiservice market (see below), and the Pentagon clinic. The DHA director, a 3-star admiral or general, reports directly to the ASD(HA). The ASD(HA) has authority, direction, and control over the DHA and DHP.

Tricare

When the DHA was established in 2013, it assumed control and oversight of the Tricare management activity functions, responsible for administering Tricare health benefits. Tricare is a congressionally defined health benefit service for active duty military personnel, their family members, retirees and their family members, reserve component service members, and eligible survivors of service members who died on active duty.

DoD health benefits for dependents have undergone significant evolution over time, but their origins date to the passage of the Dependents Medical Care Act of 1956, which permitted the secretary of defense to contract with civilian healthcare providers to provide medical care for active duty military family members. Prior to this time healthcare for families of service members and retirees was provided on a “space available” status in military medical treatment facilities (MTFs). The expansion of the armed forces during the Cold War, the increase in employer-provided insurance, and the increased sub-specialization and remote locations of some military bases created access problems for military families, prompting Congress to act.

In 1966 the act was updated and renamed the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). At that time, the benefit for civilian healthcare was extended to retirees and their families. During the 1980s and 1990s, medical care throughout the United States experienced escalating costs. The CHAMPUS program was no exception. In the late 1980s, in an effort to control costs, improve access, and increase beneficiary satisfaction, a demonstration program known as the CHAMPUS Reform Initiative (CRI) was introduced in California and Hawaii. The CRI was the DoD’s first foray into a “managed care” model for managing the defense health benefit. It included a health maintenance organization (HMO) model of care delivery along with preferred provider organization (PPO) networks. Like in the civilian setting, the HMO option provided for primary care physician approved (“gatekeeper”) referrals to specialists, but with lower beneficiary cost contributions.

In 1994, through provisions in the DoD authorization and appropriations legislation, Congress required the nationwide implementation of the CRI model. Today’s Tricare program evolved out of this legislatively required reform, which established 12 Tricare regions in the country, serviced by 7 managed care support contracts. An additional overseas contractor was later added. Subsequent evolution and revisions of the managed care support contracts have reduced the number of contracts to two, divided into east and west regions (as of 2017). The independent overseas managed care support contract remains separately managed.

The Tricare health benefit has been enhanced progressively over the years. In 2001, Congress directed the DoD to add Tricare for Life, a supplemental “wraparound” health insurance benefit for Medicare-eligible beneficiaries (mostly those aged 65 years and older). These beneficiaries must be eligible for Medicare Part A and enrolled in Part B. Tricare Reserve Select is an optional health benefit available to reserve component service members and their dependents. It gives access to the full Tricare options, but reserve component service members pay 28% of premium costs. Tricare Retired Reserve gives full access to Tricare health benefits to retired members of the reserve components, but the beneficiary pays 100% of the premium cost (no government cost sharing). Tricare Young Adult was created in response to the Patient Protection and Accountable Care Act or Affordable Care Act (ACA) of 2010 (also known as “Obamacare”). The ACA allowed (along with other benefits) for young adults to stay on their parents’ health insurance plans up to the age of 26 (under defined conditions). Tricare Young Adult created the same provisions within Tricare, but at additional premium costs equivalent to the actuarially projected cost for the coverage. Other enhancements of Tricare included dental and vision insurance and home delivery of pharmaceuticals.

In 2016, Congress again directed reforms of Tricare, aimed at simplifying the program as well as introducing modestly higher enrollment and user fees for military families and retirees. Tricare Select, which became effective January 1, 2018, replaced Tricare Extra (the PPO plan) and Tricare Standard (the fee-for-service plan). These benefits remain a subject of continuing congressional interest and will possibly change as American healthcare undergoes change.

Multiservice Markets

The provision of comprehensive health service to military service members, family members, and retirees in the 21st century is complex and influenced by many of the driving forces promoting calls for reforms in the civilian health sector. The MHS has the additional responsibility of maintaining readiness of its medical forces. The MHS must balance costs, efficiency, productivity, quality of care, and utilization of medical services in the direct care system (MTFs) against expenditures, costs, access, and quality in the purchased care markets acquired through Tricare. Optimal utilization of the direct care system contributes to military medical force readiness, which is paramount. Additionally, new strategies to improve healthcare such as “value-based care” challenge the MHS organizational structure. MHS leaders increasingly view military communities with large beneficiary populations and large direct military healthcare capacity as providing the best opportunities to maintain clinical skills needed for the military mission.

A multiservice market is a geographical region in which two or more military medical services operate (eg, the National Capital Region, where elements of Army, Navy/Marine Corps, and Air Force all operate MTFs). Uncoordinated, independent service efforts to optimize the use of their facilities and budgets can lead to competition between military services and overall suboptimized DoD health expenditures from the DHP. The multiservice market management structure provides for coordinated investments and medical services under a single market manager. Under this program, medical productivity is enhanced because the market manager has the ability to move (with consent of the parent military service) medical personnel (to create more capacity) and referrals (to improve access and productivity) to MTFs where needs exist. This in turn reduces the number of referrals to the private healthcare sector and reduces Tricare expenditures.

In addition to the National Capital Region, large multiservice markets exist in the Tidewater region, Virginia; Colorado Springs, Colorado; San Antonio, Texas; Puget Sound region, Washington; and Oahu, Hawaii. The need to create an optimum enterprise management strategy in these large multiservice markets was one of the imperatives leading to the establishment of the DHA.

DEPARTMENT OF DEFENSE BUDGETING PROCESS

Mission, resources, and strategy are inseparably linked. It has been said that without resources, there is no mission, and strategy often needs to be changed to fit the resources available. This section refers specifically to financial resources because most other resources (personnel, equipment, and to some extent time) depend on the amount of money available to fund all requirements. It is important to emphasize that the DoD budget is tied to other national priorities and thus subject to the priorities set by the president and Congress. Under the provisions of the US Constitution, Congress has the ultimate responsibility for authorizing and appropriating the national budget, and specifically for providing the funds for the armed services and DoD. Thus, Congress is integral to the DoD budget process.

The planning, programing, budgeting, and execution (PPBE) system is the DoD’s multiyear resource allocation process.[10] Phases of the PPBE process, which are distinct but overlapping (Figure 7-5), occur throughout the year, addressing both the current year budget execution and future year defense programs. The planning phase examines alternative strategies as well as changing conditions (including threats and economic and technology issues). The programing phase analyzes the resource implications of force structure, weapon systems, and other support elements as well as potential alternatives. The budgeting phase examines the first 1 to 2 years of the budget to justify and formalize execution and budget control. The execution phase results in funds distribution, year of execution budget assessment and adjustment, audit controls, and fiscal year closeout.

Figure 7-5. The Department of Defense planning, programing, budgeting, and execution process.

The NSS, NDS, and NMS, together with recommendations from the services, the CJCS, and the COCOMs, provide input to the secretary of defense’s planning guidance (DPG). The DPG is fiscally constrained guidance that establishes priorities for the DoD (modernization, readiness, forces structure, sustainability) and its support infrastructure and business processes. The DPG informs DoD components on capabilities needed to support the NSS, NDS, and NMS. From this guidance, the undersecretary of defense (comptroller), in coordination with the Office of Defense Cost Assessment and Program Evaluation, issues fiscal guidance, and DoD components develop proposed programs or program objective memoranda. Program objective memoranda are the result of systematic analysis of missions, objectives, resources, and alternatives. Based on fiscal guidance and program objective memoranda, a budget estimate submission is developed. The CJCS directs a chairman’s program assessment, which, along with the budget estimate, is further reviewed. Major budget conflicts that surface are resolved by the issuance of resource management decisions. This document informs the president’s budget through a process of communication and interaction with the Office of Management and Budget (during October through December).

Following the submission of the president’s budget (which includes DoD requests) to Congress in early February of each year, Congress holds a series of engagements and hearings to clarify the DoD’s fiscal concerns and requests. Based upon independent congressional assessment, Congress may (and often does) modify the requested budget. The Senate and House adjudicate differences in their recommended budgets through a conference committee process before approving it and sending it back to the president to sign. Ideally, this process is completed before the coming fiscal year (which begins October 1). In recent years, federal budget negotiations have often remained unresolved by October 1, and the government is funded through a series of continuing resolutions, or shut down, until Congress reaches an agreement approved by the president.

THE UNIFIED MEDICAL PROGRAM AND THE DEFENSE HEALTH PROGRAM

The DoD’s medical mission is to support the nation’s defense by providing health services support. This is a key enabler for combat and other operations. The overall budget for defense health is captured in four separate budget lines: the DHP operation and maintenance (O&M) appropriation; military medical personnel; military medical construction; and the Medicare-Eligible Retiree Health Care Fund. When these four types of costs are added together, the combined budget is referred to as the Unified Medical Program.

DHP O&M funds provide for worldwide medical and dental services to active forces and other eligible beneficiaries for care delivered in military hospitals and clinics as well as civilian care delivered through Tricare. The DHP also provides funds for medical headquarters, veterinary services, and occupational and industrial healthcare. Military medical personnel costs are funded through the military departments with all other military personnel costs, but medical personnel costs are identified for accounting purposes. Similarly, military medical construction costs are funded along with other military construction, but medical construction is specifically identified and funded as a distinct line item.

The Medicare Eligible Retiree Health Care Fund is an accrual fund administered by the secretary of the treasury that finances, on an actuarially sound basis, future liabilities of the Tricare For Life benefit (dual-eligible, DoD, and Medicare beneficiaries). The DoD makes annual contributions to this fund according to a formula determined by an independent board of actuaries.

The escalating costs of the MHS throughout the 1980s and 1990s was fueled by many factors. Many issues were similar to those that plagued the private sector and included expansion of subspecialty medical care, an aging population, enhanced use of medical technology and health information technology, and increased costs for pharmaceuticals, facilities, and personnel. For the DoD, rising healthcare costs were exacerbated by an expansion of health benefits, which were largely borne by the DoD, while beneficiary out-of-pocket costs were reduced (the opposite trend of what was unfolding in the private sector). Military healthcare budgets became harder to predict and manage. Shortfalls in year-of-execution budgets to provide medical care for beneficiaries through the DHP required reprogramming of funds from the military services’ O&M accounts.

Congress established the DHP in 1991 to provide a stronger financial management structure. The DHP is a separate budget appropriation from the military services under the authority, direction, and control of the ASD(HA). Budget activity groups, often called BAGs (eg, for MTFs and private sector care or Tricare) within the DHP allow for greater insight into accelerated growth in costs. However, the establishment of the DHP in and of itself did not produce better cost control. From 2001 to 2011 the DHP budget more than doubled, from $19 billion to $54 billion. Most of the increase in costs were in the budget activity groups associated with payment of healthcare for beneficiaries (during this period, several new programs such as Tricare for Life were added).

The DHP’s budgeting process follows the PPBE process. It is important to note that the DHP, while a separate appropriation within the DoD budget, contributes to the DoD’s overall budget request. When the total DoD budget is constrained, as it was by the Budget Control Act of 2011, which imposed mandatory ceilings and reductions, unrestrained growth in the DHP produces critical fiscal issues for the DoD. The rise in costs of the DHP competes with the military services’ funds to train, staff, equip, and modernize the forces. This situation emphasizes the need for fiscal accountability, efficiency, and innovation within the DHP and MHS to support the overarching strategic objectives and mission of the DoD.

LOOKING TO THE FUTURE

The MMO has a unique profession. MMOs are members of both the medical and military professions, with mutually reinforcing ethos. The critical nature of their work, the importance of the mission, and the contribution of their profession to society mandate the requirement for disciplined improvement in skill and competency.

The world in general and medical care specifically are becoming more complex. New technologies and digitization are driving rapidly evolving ways of delivering healthcare. From the micro level (cellular, genomics, proteomics, nanotechnology) to the macro level (robotics, internet of medical things), advancing information is creating new possibilities for personalizing care. The adaption of these technologies to benefit service members and other MHS beneficiaries is the province of the MMO. Senior leaders will need to determine how to invest critical resources and leverage new technologies to drive the MHS to greater efficiency.

In addition, technology and digitization are rapidly changing warfare. Non-state actors can now extend their reach and influence in ways and magnitudes unimagined a few decades ago. These changes are producing challenges for military medicine as they are for other aspects of the defense establishment (eg, cyber security).

The first decade of the 21st century saw the United States involved in a two-theater war of mixed conventional and unconventional varieties. The second decade brought a proliferation of individual terrorist acts around the world and the resurgence of competition from old adversaries such as Russia and China. The MHS performed well throughout this fluid warfare environment, but it must remain ready to engage in the full spectrum of operations that may be required of US armed forces. These may include rapid deployments to deter and defeat enemies, as well as postconflict stability and nation-building operations. To be sure, the MHS will be globally engaged, requiring its officers to develop a set of professional competencies commensurate with the evolving challenges.

Combined arms, joint, and multinational coalition operations are likely to prevail. In fact, many nations will look to the US military to provide full spectrum medical deployment platforms, which can support their niche capabilities (see Chapter 13, Combined Health Services Support Operations). The MHS must work to continually improve the Joint Trauma System, which has matured and served the operational force well during the past 2 decades. This system, based upon rapid-cycle analysis of data and implemented change, has saved lives. As the variety and sources of data increase, leaders must use information management systems effectively and develop analytic tools to drive decision-making and needed changes. At the same time, the MHS must lead efforts to produce higher levels of medical readiness and force health protection. Force health protection, anchored in public health strategies, has been the foundation of military medicine since the Revolutionary War. In fact, force health protection initiatives have saved more lives and returned more soldiers, sailors, airmen, and marines to the fight than more advanced technology. The MMO’s career is exciting but challenging, and requires great personal commitment to career development. This has been the heritage and will be the future of US medical officers.

REFERENCES

1.   Joint Chiefs of Staff. The National Military Strategy of the United States of America, 2015. Washington, DC: JCS; June 2015. www.jcs.mil/Portals/36/Documents/Publications/2015_National_Military_Strategy.pdf. Accessed October 23, 2017.

2.   National Security Strategy. Washington, DC: The White House, February 2015. Obamawhitehouse.archives.gov/sites/default/files/docs/2015_national_security_strategy.pdf. Accessed October 23, 2017.

3.   The National Security Act of 1947, amended by Pub L no. 115-31 (May 5, 2017).

4.   US Constitution, art 1, sec 8.

5.   US Department of Defense. Assistant Secretary of Defense for Health Affairs (ASD[HA]). Washington, DC: DoD; September 30, 2013. DoD Directive 5136.01. http://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodd/513601p.pdf?ver=2017-08-10-151523-060. Accessed October 23, 2017.

6.   US Department of Defense. Doctrine for the Armed Forces of the United States. Washington, DC: DoD; May 31, 2013. Joint Publication 1. www.dtic.mil/doctrine/new_pubs/jp1.pdf. Accessed October 23, 2017.

7.   The Goldwater-Nichols Department of Defense Reorganization Act of 1986. Pub L no. 99-433. www.history.defense.gov/Portals/70/Documents/dod_reforms/Goldwater-Nichols.

8.   Joint Chiefs of Staff. Joint Concept of Health Services (JCHS). Washington, DC: JCS; August 31, 2015. http://dtic.mil/doctrine/concepts/joint_concepts/joint_concept_health_services.pdf. Accessed October 23, 2017.

9.   US Department of Defense. The Planning, Programing, Budgeting and Execution Process. Washington, DC: DoD; January 25, 2013, incorporating change 1, August 29, 2017. DoD Directive 7045.14. http://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodd/704514p.pdf?ver=2017-08-29-132032-353. Accessed October 24, 2017.

10.   US Department of Defense. Health Service Support. Washington, DC: DoD; July 26, 2012. Joint Publication 4-02. www.dtic.mil/doctrine/new_pubs/jp4_02.pdf. Accessed October 23, 2017.

Chapter 8

THE MEDICAL OFFICER ON THE COMMANDER’S STAFF

JUSTIN WOODSON, MD, MPH,* AND SAMUAL SAUER, MD, MPH†

INTRODUCTION

THE STAFF OFFICER

THE COMMANDER

CHARACTERISTICS OF AN EFFECTIVE STAFF OFFICER

DUTIES OF THE COMMAND SURGEON

DUALITY OF THE MEDICAL OFFICER

THE COMMANDER’S EXPECTATIONS OF THE MEDICAL OFFICER

SUMMARY

ATTACHMENTS

*Colonel, Medical Corps, US Army; Associate Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Colonel (Retired), Medical Corps, US Army

INTRODUCTION

The quintessential feature of competent military medical officers is successful integration of their medical leadership within the military line unit. This is crucial for all types of organization, whether it is the air squadron, ship’s company, or ground battalion. Early in the rise of the modern military, medicine struggled with its contextual role in operational units. Military surgeons paved the way in the Napoleonic Wars, and later the Continental military strived to establish the structure and function of the medical elements delivering care to the warfighter.

A Civil War era ambrotype of Major Jonathan Letterman (Figure 8-1) demonstrated the successful integration of the command surgeon within his unit. As the Army of the Potomac’s lead surgeon, he stands with General McClellan as he addresses President Lincoln during a briefing on the battlefield at Antietam. Major Letterman’s efforts in overhauling the medical services in the Army of the Potomac at this key turning point in the war, stand out as a benchmark in the evolution of modern military medicine. It was Major Letterman’s service as an advisor, innovator, and medical planner that solidified the importance of the medical officer in successful military operations. Not only was this command–staff relationship an intimate one, but it was one of practical importance. Major Letterman understood that in order to be successful in a staff function, he had to garner the support of his commander. With that support, he was able to write medical capability requirements into orders and keep the force ready and prepared to serve effectively in battle. He understood that integration of the medical plan with the battle plan from the very beginning was crucial for mission success. Major Letterman’s efforts marked the beginning of modern military medicine, in which a command surgeon is appointed at every level.1,2 Modern medical officers must understand the role of the command surgeon and its relevance to the unit’s mission. Incoming medical officers should embrace this role when arriving to a new unit to gain the respect and confidence of the commander and the members of the unit whose health is ultimately entrusted to their care.

THE STAFF OFFICER

The first task is to understand the structure and function of the command team. Junior medical officers will plug into the commander’s staff and be one of many staff officers. While focusing within a single lane of expertise, staff officers work together to enable the unit to complete the mission successfully. Military staffs are generally organized across predictable lines (Figure 8-2). There are many commonalities that are true across all units in the military, regardless of service or branch. However, the unit’s mission requirements or capability may require specific variations to meet these needs.

Effective execution of the military unit commander’s mission requires complex and diligent coordination of direct line functions and support activities. While the commander directly controls maneuver elements to execute an assigned mission, he or she cannot function without combat support and combat service support functions. The commander is provided with a number of officers and noncommissioned officers (NCOs) to coordinate these functions and to prepare the unit for the mission. This personnel group is referred to as the “command staff.” While the commander is responsible for what the unit accomplishes and fails to accomplish, he is highly dependent on the staff to provide sound recommendations. Without a staff, the commander would quickly be overwhelmed and be rendered ineffective by the minute details in the execution of the mission.[3] The staff support the commander’s decision-making process by understanding his intent, understanding the operational environment, and using that information to formulate recommendations, implement the commander’s intent, and direct the unit under the commander’s supervision. Each staff officer and their team has the primary task of advising the commander in their own technical functional areas. Most commonly, staff officers will be delegated decision-making authority along their lines of expertise. This delegation of authority frees commanders from the burden of routine decisions while allowing them to maintain focus on critical tasks. The commander’s staff is divided into basic groups as follows:

- coordinating staff

- special staff

- personal staff

The Coordinating Staff

The coordinating staff is the commander’s principal group of advisors who advise, plan, and coordinate actions for the unit. Standard from unit to unit, across military services, and in the joint operational environment, they address common functions required by nearly all types of units. While they may have different names, the functions remain similar. This structure allows a predictable division of labor in functional areas, which has been tested over time. The staff can then efficiently address the normal decision points and informational lines encountered during routine operations. This structure also supports the training of personnel to enable appropriate expertise and experience within specific functional areas. Table 8-1 shows the typical coordinating staff groups and their functions. They are part of the larger staff group, which includes personal and special staff groups (see Figure 8-2).

Figure 8-1. Jonathan Letterman with General McClellan and the president at Antietam. Photograph by Gardner A.
Reproduced from Library of Congress Digital Collections. LC-DIG-cwpb-04352. https://www.loc.gov/item/2018666256/. Accessed November 21, 2018.

Functional areas and corresponding staff offices are relatively standard across units and military services, but can be tailored to the individual unit’s needs. Standard staff sections include Personnel (S-1), Intelligence (S-2), Operations (S-3), Logistics (S-4), Plans and Civil Affairs (S-5), and Communications (S-6). A principal officer is routinely assigned as the chief of each section, which consists of a robust team to aid in accomplishing assigned and identified tasks within that functional area. Sections do not work in isolation and in order for the unit to be successful, they must constantly communicate with each other both informally and in scheduled staff meetings.

Figure 8-2. The general commander’s staff structure typically includes personal, coordinating, and special staff. This structure may be modified to fit specific missions or units.

The Special Staff

While the coordinating staff group covers the necessary functions to address unit plans and operations, there are often required specialized technical functions that may be assigned to a unit. For example, there may be a need to address air operations and coordination with aviation authorities for the area of operations. In this case, a separate special staff section is established as the air liaison officer section. It functions as a separate staff group, normally headed by an aviator who understands the intricacies of air operations. The nature of the mission dictates the unique structure of each individual unit’s staff. There is no specific array of special staff officers that may be present in any given unit, however a surgeon and a medical section are almost universally authorized depending on the level of command.[3] Additional special staff groups may include safety, transportation, chemical, fire support, liaisons, and many others.

TABLE 8-1

STANDARD COORDINATING STAFF GROUP FUNCTIONS

Designation*

Title

Function

G1 (S1)

Personnel

Addresses all matters concerning human resources both military and civilian including manning, personnel services, personal support, and headquarters management.

G2 (S2)

Intelligence

Gathers and analyzes information on enemy, terrain, weather, and civilian considerations.

G3 (S3)

Operations

Coordinates movement and maneuver war fighting functions for the unit. Also oversees training, plans, and force development.

G4 (S4)

Logistics

Oversees sustainment plans and operations, supply, maintenance, transportation, services, and operational contracts.

G5 (S5)

Plans/future operations

Oversees operations beyond the scope of the current order. This section often works in conjunction with G3 (S3).

G6 (S6)

Signal/communications

Oversees all matters concerning radio and network operations, information services, and spectrum management within the unit’s area of operations.

*The commander’s staff is designated as “G staff” if commanded by a general or flag officer and as “S staff” if commanded by a lower ranking officer. Additional coordinating staff sections may be assigned based on the type of unit and level of command.
Source: US Department of the Army. Mission Command: Command and Control of Army Forces. Washington DC: DA; 2003. Field Manual 6-0.

The function of special staff officers is to coordinate and often assume direct responsibility for their specific technical functions. In most cases, special staff officers will be the only members of the unit with the requisite knowledge or skill set to direct operations in that specific functional area or to advise the commander on decisions within that arena. Special staff officers will normally be granted a wide berth of freedom to operate within their lane of expertise, as long as they maintain the trust of the unit and of the commander. Accordingly, the commander may frequently delegate limited decision-making authority to special staff officers within their own lane, assuming that they closely follow guidance from the command team. Special staff officers routinely coordinate with multiple coordinating staff officers and their functions typically cross lines among core functions such as operations, intelligence, and logistics. Special staff officers normally report to the commander indirectly through one of the coordinating staff officers or through the executive officer (XO) or deputy commander.

The Personal Staff

The third staff group bears special consideration. The personal staff have a unique relationship with the commander and work under his or her immediate control. While many personal staff officers have additional special staff functions, they are placed in a position of intimacy with the commander that is established and protected by law and regulation. This gives them a direct line to the commander and allows them to advise the commander directly on potentially sensitive issues without involving the remainder of the coordinating and special staff or subordinate commanders. This relationship provides a degree of confidentiality and a conduit for critical information that in many cases may affect the overall morale of the unit. In other cases, it offers a mechanism by which the commander can solve personal and private problems with individual members of the unit or interactions outside of the unit.

The unit surgeon is an example of a personal staff officer who has both a special staff responsibility and also the privilege of a personal staff relationship with the commander. This relationship offers an opportunity to address health concerns within the unit without violating the confidentiality of patients. Other examples of personal staff include the senior enlisted advisor, the chaplain (responsible for the religious support within the unit), and the safety officer (oversees safety programs within the command). The commander places special trust in his personal staff officers as they are in unique positions to enhance his situational awareness about the well-being of his service members.

THE COMMANDER

To truly understand the role of the military staff officer, the reader must also understand the unique role of the commander. Legal and binding guidance provided by the Uniform Code of Military Justice (UCMJ) is unique to military service.[4] The commander’s authority is derived from the UCMJ.5,6 The commander is charged with a tremendous amount of responsibility that accompanies this authority and is enforced by law. A military medical officer must understand the difference between command authority and general military authority to function effectively.

Command Authority

Command authority derives ultimately from the Constitution, is codified in 10 USC §164[4] and the UCMJ, and begins with the president as commander in chief (or National Command Authority).6,7 Commanders are appointed to specific organizations that are designated as commands and are given command authority within that organization. Staff officers operate under the direction of the commander and on behalf of the commander. They serve as an extension of command authority, which is inherent in the decisions and work performed by the staff. Inherent command authority is present in all military leadership assignments by virtue of the leaders being placed in a position with subordinate units or service members. Command authority establishes the commander as the sole authority under the UCMJ for legal and disciplinary actions under military law. This is the basis for the importance of the commander’s guidance. Every action, every decision, and every plan made by a staff officer must take into account the commander’s guidance, as ultimately it is the commander who is responsible for those decisions or actions.

General Military Authority

General military authority also derives from the Constitution, 10 USC §164[4] and the UCMJ, and begins with the president as commander in chief (or National Command Authority).6,7 General military authority is authority extended to all service members to take action and act in the absence of a unit leader or other designated authority. It derives from oaths of office, federal law, rank structure, traditions, and regulations. This authority is delegated to officers and NCOs to preserve good order and discipline.

Command Responsibility

The commander cannot delegate responsibility that is inherent in his command, but rather remains responsible for everything that the staff does or fails to do.[3] Moreover, the commander is also responsible for everything that the unit does and everything the unit fails to do.[8] There are myriad statutory and regulatory requirements imposed upon the commander, who is legally (and morally) required to demonstrate integrity, disciplined performance, professional competence, and exemplary conduct.[9] The commander is responsible for training and equipping the unit and for ensuring its readiness for the mission. The commander is responsible for establishing an effective command climate and for attending to the professional development of the members of the command. The take-home message is simply to understand that while commanders do carry the absolute authority within the unit, there is seemingly no limit to their responsibilities. It should be clear that the military medical officer’s role is to make the best possible recommendations in support of the commander’s decisions and to provide the best possible support for the members of the unit within the medical functional area. Doing so requires a thorough understanding of the commander’s intent, consistent communication with the commander, and diligence to the medical officer’s responsibilities as a special and personal staff officer.

Technical Authority

While not often clearly delineated in Department of Defense documents and regulations, technical authority is a form of delegated command authority; dependent and intertwined with a command surgeon’s personal licensure. Medical officer technical authority is derived from the aggregation of federal and state law, rules, regulations, other jurisprudence, and policies contributing to the sub-allocation and subdivision of powers that delegate physicians the legitimacy to lawfully control and deliver healthcare within the Department of Defense. It recognizes the command surgeon’s special competencies of accumulated knowledge, skills, attributes, and formal education in medicine. Accordingly, technical authority provides the commander, through the command surgeon, the legal authority to clinically supervise subordinate physicians, advanced practice providers, and para-professional medical personnel. When assigned as a command surgeon, the medical officer becomes accountable for the technical control of all medical activities in the command and is responsible for coordinating healthcare efforts between the command and other medical organizations. These duties include the approval, training, and supervision of all patient care activities as well as establishment and enforcement of the standard of care within the unit, and the critical component of establishing and maintaining quality and safety assurance programs.

CHARACTERISTICS OF AN EFFECTIVE STAFF OFFICER

Experience as a staff officer and service in a military unit is a core competency for all military officers. Good staff officers have great influence on success of the mission, as commanders cannot effectively run their units without them. Serving on a command staff is both exhilarating and highly satisfying. Without minimizing the importance and impact of direct one-on-one patient care, there is a unique opportunity in the unit to influence the health of our warfighters on a larger scale through effective mission planning and program management within the unit. Effectively integrating with the staff is vitally important for success in executing the medical mission within the unit.

Field Manual 6-0, Commander and Staff Organization and Operations, identifies several routinely recognized and common characteristics found in effective staff officers, such as the following[10]:

- competence

- initiative

- creativity

- flexibility

- confidence

- loyalty

- team player

- effective manager

- effective communicator

Striving to incorporate these into a personalized approach to the job will assist team integration and provide added value to the mission.

Good staff officers will also avoid certain attitudes and behaviors that can undermine their effectiveness or cause outright failure. According to US Army Captain Nate Stratton, there are several ways a staff officer can fail[11]:

- Forget that you’re still a leader.

- Treat subordinate units as the enemy.

- Treat higher headquarters as the enemy.

- Don’t take the time to get to know your organization.

- Undermine the Headquarters and Headquarters Company (HHC) chain of command.

- Hide behind your desk (where it’s not raining).

- Get fat.

Competence

First and foremost, staff officers must be competent within their area of expertise and also within the context of military operations. Skills related to service as a staff officer are particularly important. The command surgeon is assumed to be a good doctor, but must also provide value as a good staff officer.

New medical officers should understand that they are joining a team of professionals who may have upwards of 15 years’ experience as military leaders. Those professionals have trained and have often previously served as staff officers at a variety of command levels and in a variety of missions. Many have operated in complex, challenging, and demanding environments. They are well aware of military operations and are well versed on the methods of staff functions and unit operations. As a member of this team, the medical officer is expected to perform at the same level of competence and can rely on his or her fellow staff officers as effective mentors. This competence extends well beyond clinical medicine and direct patient care.

Military medical officers must begin with an understanding of the operational environment, the unit mission, and the way it operates. Beyond understanding the latest diagnosis and treatment for a medical condition, they should also understand the relevant regulatory guidance for the disposition of a soldier with that condition. Medical officers must make informed and consistent recommendations to help commanders decide if a service member can deploy, train, or go to war. These recommendations will affect the careers of individuals and the unit’s readiness for combat. Medical officers must know the reporting requirements for a condition and its impact on the mission. Additionally, they would be expected to have appropriate medical supplies and pharmaceuticals on hand to manage the condition within the aid station if possible, to avoid unnecessary evacuations to higher roles of care.

Applying medical skills and knowledge to the mission is an art form that requires development of individual staff officer skills. The ability to integrate military operational awareness with clinical knowledge is a hallmark of the competent medical staff officer.

Help the Commander “See” the Battlefield

Recall that the primary role of the staff officer is to continually provide information to the commander in order to help him visualize his operational environment. The effective staff officer serves as a conduit of information, channeling observations from the subordinate commands and the environment outside the unit to the commander to influence the decisions of the command team appropriately. This requires that the staff officer is informed on policy and regulations within his area of expertise and remains up-to-date on the latest developments outside of the command, particularly at the next higher levels of command. This also implies that the staff officer has positioned himself to be able to “see” outside the command throughout the area of operations. Specifically, the command surgeon must be aware of medical threats in the area of operations.

Understanding the recognition, treatment, and prevention of diseases and environmental or occupational threats prevalent within the area of operations is critical. Translating that understanding into effective prevention strategies will help ensure that the unit remains combat effective. Maintaining awareness of the medical status of members of the unit is also part of ongoing analysis. The effective medical staff officer will have established a regular forum for communication to the commander and key staff members. It is the staff officer’s job to interpret development of medical events, to develop alternative courses of action, and ultimately to implement a plan to address these threats with the commander’s guidance in mind.

Initiative

Historical analysis relates different opinions about the role of the staff officer, such as those found in the works of Jomini[12] and Clausewitz.[13] Jomini served in the French Army under Napoleon and Clausewitz served in the Prussian Army under Frederick and their writing reveals an enlightening discussion on the role of the staff officer. Inherent in these writings is a difference of opinion about the degree of freedom and initiative that subordinate staff officers should have.

The Prussian staff officer was often handicapped by a lack of authority to make independent decisions without the commander’s direct involvement. In contrast, modern US military doctrine has adopted a model more consistent with the Napoleonic (French) model, which allowed freedom for the staff officers to make independent decisions based on the guidance of a superior commander. The staff officer should anticipate the commander’s needs and do the analysis before being asked to do so.[3] Taking the initiative to recognize problems and develop courses of action is a highly valued characteristic of the staff officer today. Many analysts attribute the success of the US military largely to this characteristic, which derives from delegated authority.

In military medicine, the awareness of the medical threats is often limited to the command surgeon who must take initiative to address these problems before they come to the attention of the command. The implication is that the effective command surgeon is forward leaning, constantly observing his or her unit, and anticipating opportunities to improve the medical readiness of his or her warfighters. More importantly, the command surgeon must be willing to make a decision that will favorably impact the health of the command without violating the commander’s intent.

Creativity and Creative Thinking

In addition to contributing to a common operational picture, it is the commander’s staff’s job to solve the problems encountered by the unit. The individual officer who enjoys the challenge of solving problems will be well suited for this job because military operations are prone to presenting unique problems. “As critical thinkers, staff officers discern truth in situations where direct observation is insufficient, impossible, or impractical.”[3] Given the reality of military operations and resource limitations, the staff officer is often faced with the challenge of creating the “impossible solution” which can only come with creative, out-of-the-box thinking.

Medical planners should develop problem solving capability by playing games, participating in simulations, and attending courses and military training that take them out of their comfort zone and expose them to solving problems outside of medicine. It should also be noted that physicians have the potential to make particularly good staff officers because, inherent in their training is an ability to diagnose and solve problems. This includes formal education and demonstrable competency in the scientific method which relies on the systematic observation, measurement, formulation, and testing of solutions to solve problems. The difference is that while most medical problems are algorithmic in nature, most military problems are not. Accordingly, their solutions will require true creativity.

Flexibility

There is no greater truth than the reality that military operations are defined by ambiguity. Constantly changing situations require staff officers to maintain consistently adaptable minds. Plans serve as starting points; however, changes in the situation must be addressed. Unfortunately, it is quite common for the medical officer to develop a plan to address a particular problem within the unit and fail to recognize the need to change course midstream as the plan begins to fall apart.

Effective medical staff officers will be required to manage a high degree of simultaneous workflows and must maintain the flexibility not only to change plans, but also to readjust priorities as the situation evolves. This does not mean that they should not commit to a plan, but rather that they must maintain enough situational awareness to recognize that assumptions regarding a specific plan may well have changed in such a way as to invalidate that plan altogether.

Remaining married to a failing plan is a certain way to fail. Communicating those critical points when plans must change to the commander and other key staff is an important part of contributing to a flexible command staff. Plans must be nurtured to fruition with vigilance and purposeful engagement.

Confidence

Staff officers must remain confident in their skills and contributions to the mission. The task is to continually develop creative plans. They must, however, remember that they do not operate in a vacuum. Other creative officers also develop creative plans. Frequently the medical officer’s ideas will not be incorporated into the final plan. The task within the planning cell is not to “win” by having a particular plan selected, but to participate in developing a comprehensive and functional plan. Even in those times when recommendations are declined or disregarded, staff officers must stay confident and continue recognizing problems and providing recommendations for their solutions. Confidence derives from competence which engenders credibility.

Effective staff officers know their lane, know their staff responsibilities, and maintain a committed effort towards the mission even when in the minority, or knowing that their recommendations are unlikely to be accepted. Doing the “right thing” requires confidence and discipline.

Loyalty to the Team

One of the main challenges for new medical officers coming into a command staff for the first time is to understand the structure of the team and their role on the team. This isn’t quite as simple as it seems, and physicians must recognize that there is a distinct departure from their original environments. Within the medical treatment facility, the center of operations revolves around the patient. Physicians and their input into diagnosis and treatment decisions are center stage. Within the military unit, the center of operations revolves around the mission and focuses on the subordinate maneuver units (eg, the companies within a battalion).

Medical staff officers serve in a support role whose primary job is to make life easier for the subordinate units and for the commander. Attachment 8-1 provides a real-world example that illustrates this important point. They are one of many staff officers who must all have a similar outlook on the job. Medical officers should endeavor to garner the trust of their fellow staff officers in order to enable effective collaboration. To this end, it is important to engage in training and planning meetings, routinely communicate with the other staff sections (which requires conscious effort), and socialize with them in order to get to know them and fully integrate into the team. Mastery in understanding the differences between operating in supported versus supporting assignment is key to operational integration.

Management

Staff officers are both leaders and managers. Leadership is defined as “influencing people by providing purpose, direction, and motivation. It is the sum of the qualities of intellect, human understanding, moral character to enhance the motivations, cognitions, and behaviors of individuals and groups to accomplish the assigned mission.”14,15

In contrast, management consists of “controlling a group or a set of entities to accomplish a goal.”[16] Inherent to staff work is the management of specific programs and initiatives within the mission. Staff officers must effectively monitor and control the programs in their functional areas. Administrative overhead is inherent in the management of a battalion, squadron, or other military unit and the management responsibility falls directly on the shoulders of the staff officers within that unit.

Despite the need to manage within the unit, staff officers cannot forget that they are leaders above all else. The staff’s primary function is to provide direction to unit members, incorporating the commander’s guidance. While the staff may assist, it is ultimately the commander’s responsibility to inspire and motivate. The commander cannot do so effectively without an effective staff.

Speak the Language of the Staff Officer

To be effective, the staff officer must be an effective communicator.[3] Central to the work of the staff officer is intensive written and verbal communication. Staff officers are expected to routinely brief not only the commander and other senior leaders, but also the unit, individual teams, and individual members of the unit. Common types of briefings include the following:

- information briefings (to provide technical knowledge),

- decision briefings (to provide information that facilitates an answer or decision), and

- mission briefings (to provide detailed instructions and information regarding the conduct and execution of a mission).

Medical officers should adopt the common language of the staff officer in order to establish credibility and ensure that communications are effective. Just as effective doctor-patient communication is key to building a therapeutic bond, a medical officer’s ability to communicate effectively is key to success within the command. It is the communicator’s responsibility to adapt their style to ensure that the LISTENER heard and understood the message as it was intended. Every audience is different, and in military units listeners may range from junior enlisted members to senior officers. One thing they all have in common is a standard military vernacular, one which physicians are often not accustomed to hearing. The new command surgeon has a very powerful opportunity during his or her first briefing to either gain or forfeit credibility based on the language, style, and format of the briefing. Therefore, understanding the culture of the unit is vitally important, and using the appropriate language can make the difference between understanding and confusion.

Another aspect of the communication challenge is to understand that staff officers in a military unit are accustomed to using specific tools during their planning process. Knowing and using them can greatly facilitate transfer of information. Specifically, briefing formats (Attachments 8-2 and 8-3) report structure, the military decision-making process, military and technical terminology, and other accepted processes could greatly streamline your collaborative efforts for the accomplishment of the mission. Often specific formats are prescribed for various reports and orders and can be found in instructions, regulations, field manuals, and joint publications. You should begin by simply asking the question of your predecessors, mentors, NCOs, or fellow staff officers for the normally accepted formats, procedures, or tools for a given task. Fortunately, with Internet access, it is easy to find answers and get links to the appropriate publications.

Learning to use these tools effectively takes time and focused effort, and is part of an individual’s professional development as a military medical officer. The Uniformed Services University military medical practice curriculum, professional military education courses, and additional short military courses in planning and staff work are available to those who take the initiative to enhance their capacity as a staff officer. The command surgeons’ capability to ensure quality care is completely dependent on their ability to communicate to the command and the commander.

DUTIES OF THE COMMAND SURGEON

A command surgeon is designated at all levels of command. Typically, that includes commands that begin at the battalion or squadron level, and are normally commanded by an Army or Air Force Lieutenant Colonel or Navy Commander (O-5 grade) serving hundreds of service members, and extends upwards to those commanded by general or flag officers serving thousands. The junior medical officer coming directly out of graduate medical education may be assigned as a battalion surgeon or squadron surgeon, or possibly as a deputy surgeon in a larger higher level command. This assignment will likely be exciting, but also intimidating as the new medical officer begins to grasp the breadth of the job. Many are surprised by the number of broad-based responsibilities accompanying the position of command surgeon. Becoming proficient across the full spectrum of responsibilities of the command surgeon position is paramount to success.

The command surgeon will often directly lead a team of medical personnel, which will range from one or two NCOs or medics/corpsman and possibly a physician assistant to a much larger medical platoon that may include 30 to 40 personnel or more. Resources may include combat medics/corpsmen, preventive medicine NCOs or officers, medical service corps officers, nurses, medical practitioners, psychologists, radiology technicians, or other specialty technicians or providers depending upon the type of command. One of the first tasks upon arriving to the unit is determining available personnel and equipment as well as a general medical capability, which varies among commands and locations. Establishing daily proprietorship of the medical officer’s direct report medical personnel and equipment is paramount to mission accomplishment.

New command surgeons should reach out to the command before reporting in to the unit. He or she should contact the commander and senior staff (eg, the executive officer, to whom the command surgeon will likely report), as well as the current or outgoing command surgeon and medical section senior NCO. This begins the process of integrating into a unit and learning about the mission and resources. This conversation will also help to identify key issues ahead of time and what knowledge or skills might be useful to gain before going into the position. Making a good first impression with the command team including the senior enlisted advisor can go a long way towards paving the path for success.

The command surgeon is responsible for supervising and managing a wide array of functions and services within the command, including the following:

- Advise the commander on the health of the command.

- Advise the commander on all aspects of medical interest in the area of operations (AO).

- Oversee preventive medicine plans, programs, and recommendations to the commander.

- Develop the Health Service Support (HSS) portion of operation plans (OPLANs) and operation orders (OPORDs).

- Deliver healthcare (treatment).

- Synchronize HSS efforts with next higher medical authority.

- Task organize HSS personnel and units.

- Evaluate medical epidemiological data and develop recommendations for the commander.

- Provide medical intelligence.

- Oversee medical evacuation with air or ground resources in coordination with aeromedical evacuation (AE) or medical evacuation (MEDEVAC) personnel.

- Develop local medical policies as needed.

- Interpret and implement medical policies from higher organizations.

- Supervise, plan, and execute within all medical functional areas.

These medical functions generally apply to individual service and joint organizations, but are best described in Army doctrine as Health Service Support planning considerations,[1] which provides the basis for the command surgeon’s job description. While the level of involvement in each functional area will vary based on the level of command, it is incumbent on the command surgeon to attend to these functional areas, in many cases providing direct services and in other cases simply integrating these considerations into the planning process for the command. The unit’s mission will determine the requirements for the specific situation.

Clinical Capabilities and Medical Logistics Support in the Unit

The medical officer is responsible for providing basic medical care for the members of the unit. Patient survival may often depend on availability of the required supplies and equipment being co-located with the patient at the time of need. It should be obvious that medical providers cannot function clinically without equipment and medical supplies. This is described in the context of the health support planning considerations as “clinical capabilities” and requires a medical logistics (MEDLOG) support program. A unique task within the unit is to ensure that there is a steady resupply of medical supplies (class VIII) to sustain the basic medical mission. There is typically no dedicated logistics team taking care of this process in small organizations. Often in the medical treatment facility, medical officers become dependent on what appears to be an invisible process working behind the scene to keep the supply cabinets in the emergency rooms, clinics, wards, or operating suites stocked with the supplies and pharmaceuticals required in the daily delivery of medical care. In the operational environment, these supplies simply will not be available without the daily, routine attention of the medical section to the MEDLOG function.

Preventive Medicine and Health Surveillance

Through the landmark work of pioneering early American patriot physicians John Morgan and Benjamin Rush,[17] and 18th century British physicians Richard Brocklesby[18] and Sir John Pringle[19] and later reinforced by Dr Jonathan Letterman[2] in the American Civil War and others, we understand that a critical component of successful military operations is maintaining the health of the force and control of disease within the military camp. Accordingly, a significant effort of the command surgeon is dedicated to preventive medicine and health surveillance.

Regulations require the commander of the unit to ensure that his service members maintain medical readiness in the form of periodic health assessments, medical examinations, occupational surveillance, and immunization programs. Responsibility for these requirements naturally falls to the command surgeon. Attention to these programs can occupy a tremendous amount of the command surgeon’s time, who should expect to be asked to brief the commander on a regular and on-demand basis regarding the medical readiness status of the members of his unit. Failure to meet medical readiness standards could render the unit unqualified for deployment. Therefore, the commander will place command emphasis on ensuring that all medical requirements such as immunizations remain current. And, while delivering the full spectrum of quality healthcare is paramount, particular attention and diligent effort must be made to minimize or eliminate medical, organizational, non-value-added barriers to issues tracked by higher headquarters. Tracked issues signal senior command emphasis, which is a surrogate marker of system or organizational importance and value, such as medical readiness.

The command surgeon should utilize the commander’s legal command authority by working carefully with the coordinating staff to incorporate immunizations and other medical readiness programs into the unit’s training schedule on a regular basis to ensure that members of the unit are up-to-date. The command surgeon’s duty is to provide broad, open, available, and flexible technical means to accomplish medical readiness while the unit’s subordinate commanders are responsible for accepting this support. In doing so, it inherently implies that the surgeon’s office is adequately tracking readiness status. Fortunately, well-established service-wide tools are available to unit surgeons to facilitate tracking of medical readiness items.

Clearly, medical readiness tracking is a critical task for the medical officer (see Chapter 30). Command surgeons should be familiar with and ensure that they and their team have access to these systems including the Medical Readiness Reporting System (MRRS) for the Navy and Marine Corps, the Medical Protection System (MEDPROS) for the Army, and Aeromedical Services Information Management System (ASIMS) for the Air Force. Additional information is available on the Military Health System website at https://health.mil/Military-Health-Topics/Health-Readiness/Immunization-Healthcare/Immunization-Tracking-Systems.

Prior to deployments and periodically, the medical officer will be expected to conduct systematic reviews of medical readiness status for the members of the unit. One key nuance for the reader is the term systematic. Often referred to as SRP (soldier readiness program) or PDR (pre-deployment readiness) exercises, these events provide an opportunity to close gaps in readiness but require planning and coordination with the command and staff in order to execute effectively. Members of the unit will be required to attend while medical team personnel review medical records and provide immunizations, hearing exams, eye exams, dental exams, and other medical readiness items as needed. While the medical elements of these programs are dominant, coordination with the S1 (personnel) shop will often include additional legal, financial, and administrative readiness requirements in the process as well. Projecting the timing of the SRP and coordinating with the S3 (operations) to place these events on the training schedule will help to ensure their success and will ultimately save the command surgeon a tremendous amount of frustration.

Prevention of Stress Casualties

Doctrine and current situation concerns require mental health services to be provided within the unit. New medical officers are often surprised by the amount of attention required to care for unit members and manage the program. In the operational environment, a combination of factors amplify the already inherent behavioral health challenges that service members carry with them. Some of these factors include the following:

- separation from home and family,

- the stress of the operational combat environment,

- long hours, and

- close living quarters and working environment.

The command surgeon is in a unique position, along with the chaplain, to be available to address individual and collective mental health problems within the unit. Command surgeons are expected to have extensive knowledge of behavioral health issues and act as the conduit between command and external behavioral health activities. Accordingly, wise medical officers will seek to expand their behavioral health competencies as commanders will often turn to them to identify morale issues, which may originate from individual mental health conditions. Additionally, in the routine course of healthcare delivery within the units, members may confide in their surgeon regarding the emotional challenges they are facing during the course of a deployment or long stint of training. Attentive medical officers who recognize, diagnose, and treat mental health disorders may be able to make the greatest impacts on individual soldiers by working closely with the command and the chaplain in order to best support affected individuals during difficult times.

Unfortunately, it is rare that medical training programs in residencies or medical schools adequately prepare their graduates for psychiatric care. For this reason, the curricula in programs that routinely prepare medical officers for operational assignments (eg, the flight surgeon training programs in the Army, Navy, and Air Force) include significant time addressing psychiatric disposition and management. It can be very helpful if the medical officer thoroughly understands the dynamics of interpersonal interactions that are likely to result from various personality disorders or psychiatric conditions and can recognize these if they surface within the social dynamics of the unit.

Figure 8-3. There are many functional areas comprising health support that must be considered when planning a mission. Although not all functions are relevant for all missions or at all levels of command, using this or a similar graphic or checklist can help ensure nothing is missed.

When these situations arise, they can often be disproportionately distracting from the mission and medical officers may be the only member of the unit with the background and training to understand the factors contributing to these interpersonal issues. In the role as a personal staff officer, medical officers must be able to appropriately advise the commander in ways that can minimize the distractions and de-escalate situations before they become out of control.

Medical officers can also anticipate the need to manage routine combat stress reactions to operations in the military environment and should be prepared to provide immediate treatment and referral. At a very minimum it will be incumbent upon the command surgeon to establish a coordinating relationship with combat stress control resources within the area of operations in order to ensure that appropriate services are available for members of the unit when needed.

Medical Planning

Another important role that command surgeons play is as principal medical planner for the commander. While in some units command surgeons may have the luxury of an assigned medical planner, this is not a universally available asset.

The specific health support planning responsibilities of the command surgeon are numerous. Figure 8-3 shows functional areas that must be considered during medical planning for operations. In the planner role, medical officers will be expected to incorporate functions such as medical intelligence and threat analysis, patient movement, mass casualty planning, and host nation support into operational planning. Other planning and coordination may be required as well, depending on the mission. Integrating these considerations into the operational plan from the earliest phase is critical to mission success as has been observed throughout history in military operations.

Figure 8-4. The joint operational planning process is used in its entirety during deliberate planning, but may be modified by the commander for crisis action (time constrained) planning. Staff sections work through this process using commander’s guidance and available information products. The ultimate goal is to produce an effective military plan or order to accomplish the command’s mission.
Reproduced from: US Department of Defense. Joint Planning. Washington, DC: DOD; 2017. Joint Publication 5-0, Figure V-1.

The Army Medical Department (AMEDD) in the Continental Army during the American War for Independence was born out of the recognition that military mission success was in large part dependent upon medical support. The fighting force needed to understand that if they were injured, systems would be in place to provide for their effective evacuation, treatment, and rehabilitation. A key contribution of Dr Jonathan Letterman to military medicine was his understanding that medical planning had to be incorporated into the commander’s military orders to ensure medical care was provided through every phase of the operation on the battlefield.

In the modern military, every operation requires a written or verbal order describing the details for the execution of that mission. The command surgeon is responsible for writing the medical annex to that order, incorporating all of the relevant medical planning considerations. Medical planning and orders production is an art form and skill which takes time to acquire and is not adequately taught in most training programs. During officer indoctrination programs, pre-commissioning programs, military coursework, and at the Uniformed Services University, officers have the opportunity to learn details about the medical planning process and orders production, often practicing medical planning in simulated exercises. However, it is not until medical officers are assigned to the operational unit and integrated into the medical planning process that they discover the complexity and criticality of military planning.

The Joint Planning Process and Military Decision-Making Process (Figure 8-4) are described in publications such as Joint Publication 5-0, Joint Operation Planning and Field Manual 6-0, Commander and Staff Organization and Operations. These references are valuable resources to have on hand when beginning to integrate into the unit’s planning process.

Communicating Risk to the Commander

By this point, many of the intricacies of the surgeon’s role as an advisor to the commander should be clear (see Figure 22-5). Recall that the commander is responsible for all critical decisions in the unit. However, the commander is only as good as the information he or she is provided. Rarely, if ever, is a decision absolute or a problem unambiguous. Frequently, command decisions are complicated by the variety of adverse outcomes possible based on the nature of the operation and specific branching pathways followed in the decision tree. This is called risk and is defined as the product of the probability of a bad outcome occurring and the severity of the expected consequence.[20]

Risk = Probability × Severity

The commander is responsible for making the difficult decisions inherent in planning for military operations. This responsibility cannot be delegated. However, it is the responsibility of the commander’s staff to identify risk and to communicate it effectively to the commander to enable him to make the best possible decision. Risk management is an art form and a key component of basic staff work. The medical officer should recognize that the vast majority of communications to the commander are based on identifying risk associated with a given situation, quantifying that risk, and presenting potential courses of action to mitigate that risk (ie, risk controls). The commander should never assume risk that may potentially imperil the unit, its members, or its mission without being properly advised by his staff.

Thinking about regular communications with the commander through a risk management framework can help to clarify the correct approach to many problems. Most problems in the conduct of the medical mission within the unit can be thought of as hazards managed by risk controls that are supervised by the commanders, their leaders, or medical personnel. By communicating effectively to the commander, the medical officer shares the burden of difficult decisions not only with commander but also with the entire staff. Collectively this type of collaboration serves to improve the safety and efficiency of all operations within the unit.

DUALITY OF THE MEDICAL OFFICER

After discussing the role and responsibilities of the staff officer, and more specifically of the medical staff officer or command surgeon, it should be evident that there is a unique challenge faced by the medical officer in the unit—that of duality—which can be represented on several different levels.

The Challenge of Maintaining Two Professions

The medical officer must maintain proficiency both as a medical provider and as an officer and leader. This requires continuing education in professional military skills and leadership as well as in medicine. Physicians new to the military know the challenges of keeping up with the medical literature, but now must add the challenge of keeping up with current developments in the political and military arena. Balancing these requirements can be difficult. It is expected within the unit that medical officers will be good physicians and also good staff officers. Often the former comes relatively easily, while the latter requires a fair amount of effort for new medical officers.

New military medical officers often have an inherent belief that the primary function is to provide clinical medical care, which is normal for work in a medical treatment facility. A critical lesson is that in a military unit, only a small fraction of time will be dedicated to clinical medicine, with the remainder of time dedicated to administrative, support, and advisory tasks. New officers must demonstrate constant vigilance toward external agencies attempting to control their time. Command surgeons should not be utilized in other medical activities when full-time application to the unit is necessary to ensure mission accomplishment. These external organizations may benefit from a professionally and cautiously delivered reminder that command surgeons must support their own commander first.

Conflicts Between Loyalty to the Patient and to the Commander

The command surgeon may find himself in a position of conflict between his loyalty to the commander and his inherent loyalty to his patients. Chaplains may also face this dilemma in their normal daily activities. In both the medical and spiritual or mental health encounter with an individual member of the unit, a protected relationship is established that is recognized by common and specific law. Physicians enjoy this confidential patient–doctor relationship with anyone with whom they initiate a medical encounter. This confidentiality serves to create a space in which a patient can trust the physician in a unique way. It may lead to the disclosure of very personal information during the routine course of medical care delivery.

It is important to remember that confidentiality is not a privilege, and that there are occasions where the patient’s privacy comes into conflict with the public good and the physician must report to appropriate authorities. In the context of the military unit, this means that the commander retains a legal authority to access information which may impact the mission or safety within the unit. The medical officer is therefore obligated to disclose what may otherwise be protected information to the commander, despite constraints such as the Health Insurance Portability and Accountability Act (HIPAA) or general patient confidentiality considerations.

One common situation that may cause divided loyalty occurs when a member of the unit develops a new diagnosis that is incompatible with continued service in the military. Regulations require the initiation of a process to evaluate that condition with the goal of either reassigning, retraining, or separating that service member from military service. This evaluation occurs through a Medical Evaluation Board (MEB), Physical Evaluation Board (PEB), or military occupational specialty (MOS)/Medical Retention Board (MMRB). In such a case, the command surgeon will be caught in the middle of competing interests. The surgeon must protect the interests of the command (eg, reassigning the service member in order to obtain a fully mission capable replacement), as well as the interests of the patient (eg, maintaining stability and employment while the service member receives therapy), taking into account the potential for long-term health compromising effects of continued military service.

The command will have substantial interest in the progress of a service member’s treatment and disposition, particularly if their condition disqualifies them from continued service. Such interest will create innumerable situations in which the confidentiality of the patient–doctor relationship is violated, or at the very minimum challenged. It often takes extreme diligence on the part of the command surgeon to navigate this type of situation while maintaining the mutual respect and confidentiality of both command and patient. The command surgeon is encouraged to approach these challenges to communication in a methodical manner to facilitate the service member’s and command’s understanding of the system’s yet to be recognized but mutually beneficial outcomes to both parties. Outcomes from this process may be simultaneously disappointing but correct.

The military physician in the role of command surgeon has legal responsibility to the commander to disclose information regarding the service member patient, and to act on behalf of the commander to expedite case processing. Under command authority, the commander has the privilege to access medical information regarding his or her service members’ medical status even though he or she is not a medical provider involved in the patient’s care. Understanding this critical reality in advance can prevent the creation of unnecessary ethical dilemmas in the process of managing similar scenarios. Fortunately, the personal staff officer role, as defined in the United States Code, protects these communications with the commander. Establishing an effective personal staff officer relationship with the commander will serve the medical officer well in these situations.

Other situations that place the command surgeon into a difficult ethical dilemma may also arise. New medical officers have most likely taken oaths to Hippocrates as a physician (Attachment 8-4), and to the Constitution of the United States as an officer (Attachment 8-5). Managing these situations will require the medical officer to call upon his training as a physician, his understanding of his role as a staff officer, and his best judgment in doing what is right.

Line Versus Staff Functions of the Medical Officer

Yet another aspect of the duality of the medical officer exists within the inherent functions of the command surgeon role that maintains both “line” and “staff” functions. Recall that the commander derives his authority from the president, which is transferred “down the line” to the current level commander and on to the subordinate commanders. Often referred to simply as “the line,” this function is directly involved in the execution of the task for the organization and illustrates the nature of military decision-making authority. Only the commander has the authority to direct actions within the unit. Similarly, clinical medical care is delivered under the authority of the medical officer’s medical license (not the commander’s authority) and can be considered a “line” function. This duality of the medical officer who maintains both “staff” and “line” functions is unique to the medical officer within the command.

The command surgeon has both advisory and directive responsibilities hat are in many ways common to all staff officers. However, the sources of the authority in the command surgeon office are exclusive for each of the two functions. As licensed physicians, command surgeons have the authority to direct medical care within the unit. As staff officers, they advise the commander who retains the sole decision-making and implementation authority.[21] The difficulty for the command surgeon is to discern which hat he or she is wearing during the conduct of daily business, and to balance necessary medical authority against the commander’s command authority. This balance will shift based on the level of command. As medical officers are assigned to higher levels of command in their careers, work will typically shift toward the staff function, with less time and attention being given to primary healthcare. This also implies greater emphasis on leadership as the level of command increases.

The Technical Chain of Command

Because the medical decision-making authority derives separately from the command authority, and due to the technical nature of the myriad Health Service Support functional areas previously discussed, it is necessary within the context of a military unit for there to be a separate technical supervisory process from the chain of command (as is also necessary in other technically oriented staff officers). As discussed earlier, a surgeon is assigned at all levels of command. This implies that the command surgeon will normally have a senior surgeon assigned to the next higher level of command, as well as having several subordinate medical elements at lower levels of command for which he or she maintains a technical supervisory responsibility (Figure 8-5). While the command surgeon reports to and takes orders only from the commander, the senior surgeon is a source for guidance, mentorship, and technical oversight. Similarly, the command surgeon will endeavor to provide mentorship, training programs, and clinical oversight to those junior medical officers and non-commissioned officers in subordinate units. This hierarchy of medical providers is referred to as the “technical chain of command” and mirrors the chain of command. On occasion, the technical chain of command can place the medical officer in a position of split loyalty or responsibility.

In the course of daily routine medical operations, the command surgeon is often required to provide direction to subordinate medical elements to accomplish specific objectives, and to gather certain data through reporting. However, the senior command surgeon does not have decision-making authority over the subordinate medical element. Simply stated, surgeons don’t report to surgeons. The subordinate medical element must take orders only from its own commander. Nevertheless, it is incumbent on the command surgeon to follow the technical guidance and direction of the higher level surgeon as much as is possible, without violating the commander’s intent. Differences in orders through the chain of command and guidance from the technical chain of command may potentially conflict with each other. Awareness of this relationship is critical to resolving these conflicts without compromising the mission. The standing advice is to report directly to the unit commander, but work with the technical chain to the extent possible.

Figure 8-5. The technical medical staff (surgeon cell) also reports to higher level headquarters to ensure communication of relevant medical information. Directives and guidance may be supplied from higher headquarters down to units as well.

Learning to balance the requirements through the technical chain and the command chain can be challenging. However, the technical chain of command ensures that for junior physicians, there is always a medical mentor to assist in times of difficulty. Professional mentorship is a key role within the chain of command and good command surgeons will reach out to their subordinate surgeons in the technical chain of command in order to provide professional guidance and assistance when necessary in accomplishing the medical mission.

THE COMMANDER’S EXPECTATIONS OF THE MEDICAL OFFICER

The best way to gain an understanding of the commander’s expectations of the medical officer joining the unit as command surgeon, is simply to ask. Although this may sound incredibly simple, it may come as a surprise how infrequently a new command surgeon, particularly one that is relatively new to the military, makes the effort to sit down with his command team to simply understand what they expect. When notified of the assignment, incoming command surgeons should reach out to the commander, executive officer (the likely reporting chain), and command sergeant major or command master chief to discuss their expectations. This may afford an opportunity to identify problems or challenges early on that may need to be attended to immediately. It will also provide an opportunity to establish a relationship and gain trust, particularly with the commander, to fulfill the role as a personal staff officer.

At the Uniformed Services University, former line commanders are often invited to speak with the students about their expectations of their medical officers. In an informal dialogue, they are asked to speak about successes and failures of medical officers with whom they have worked, either as fellow staff officers or as their commander. The commonalities among commanders’ opinions are striking. Simply put, a line commander expects his or her medical officer to understand medicine and attend to medicine, but also to understand officership and integrate with his or her team (the command staff). The commander expects the medical officer to be a doctor, and a good one, but also expects the doctor to be a good officer. And while most commanders will recognize that this may take some time, as many of the skills will be new and underdeveloped, he or she also understands that the medical officer, like the rest of the unit’s staff officers, is intelligent, adaptable, and can learn the language quickly. The expectations can be summarized as follows:

- You are my expert on all things medically related.

- You are my link to the medical world.

- You are a leader – physically fit and morally straight.

- You know the military decision-making process and your role in it.

- You are a team player, and always know my soldiers and families come first.

- You are willing to do things outside of your lane.

- You are flexible and anticipate needs.

- You effectively communicate to me – translate the “medical speak” into laymen’s terms and articulate the “so what.”

- You bring solutions to problems.

- You continue to develop yourself professionally.

- You have fun!

Professional Relationship with the Commander

Like the chaplains, medical officers hold a special role regarding their relationship to their commanders. A trusted medical officer provides the commander with both personal services (medical care) and professional services. This includes personal psychological support. Depending on the commander’s style, the medical officer will often become a sounding board and confidant as a means of evaluating and reflecting on new ideas and options. Other inquires and interactions will include the commander seeking opinions on specific or general communication techniques including effectiveness, positive and negative impact, and forecasts about leadership outcomes. The commander will seek guidance and expectations about individual and organizational behaviors and responses. Be prepared to provide this support as it may be the medical officer’s most critical responsibility.

SUMMARY

The command surgeon role is an intricate one. So intricate, that it can in fact be quite overwhelming as the new medical officer attempts in good faith to assimilate the recommendations and model of the good command surgeon. Medical skills, military skills, and leadership are balanced in the effective command surgeon who is truly integrated with his unit as part of the command staff.

Serving as a command staff officer may easily be the highlight of the military medical officer’s career. This role is unique and embodies military service for the physician. It affords the opportunity to positively impact the mission and better the lives of the service members in the unit, while at the same time providing a rich opportunity to develop as a leader and as a physician. By serving as command surgeons, new medical officers join a proud heritage of military medical officers who have preceded them. There will undoubtedly be fond memories of the experiences and relationships acquired in the unit. That history should be honored through personal development as a complete military medical officer, fully prepared to support the commander in accomplishing his/her mission.

REFERENCES

1.   US Department of the Army. Army Health System. Washington DC: DA; 2013. Field Manual 4-02:

2.   Letterman J. Medical recollections of the Army of the Potomac. New York, NY: Appleton; 1866.

3.   US Department of the Army. Commander and Staff Organization and Operations. Washington DC: DA; 2014. Field Manual 6-0, paragraph 2-114.

4.   10 USC §164. Commanders of Combatant Commands: Assignment; Powers and Duties, 1986.

5.   10 USC, Chapter 47. Uniform Code of Military Justice.

6.   US Department of the Army. Army Command Policy. Washington, DC: DA; 2014. Army Regulation 600 – 20.

7.   US Department of Defense. Doctrine for the Armed Forces of the United States. Washington DC: DoD; 2013 Incorporating Change 1, 12 July 2017. Joint Publication 1.

8.   Dunnaback J. Command responsibility: a small unit leader’s perspective. Northwestern Law Review. 2013;108:1385–1422.

9.   10 USC §3583. Requirement of Exemplary Conduct, 1997.

10.   US Department of the Army. Commander and Staff Organization and Operations. Washington, DC: DA; 2014. Field Manual 6-0.

11.   Stratton N. 7 Ways to Fail as a Staff Officer. http://www.themilitaryleader.com/7-ways-to-fail-as-a-staff-officer/. Accessed 26 Mar, 2017.

12.   Jomini A-H. The Art of War. Mendell GH, Craighill WP, trans. Philadelphia, PA: Lippincott; 1862.

13.   Von Clausewitz C. On War. Howard M, Paret P, trans. Princeton, NJ: Princeton University Press; 1989.

14.   Woodson J. Becoming a battalion surgeon. Lecture presented at: Tzameret Program; April 29, 2015; Hebrew University, Jerusalem.

15.   O’Connor F. Military medical practice and leadership program of instruction. Lecture presented at: Uniformed Services University of the Health Sciences Faculty Assembly, 2014; Bethesda, MD.

16.   Nayar V. Three differences between managers and leaders. Harvard Business Review Website. https://hbr.org/2013/08/tests-of-a-leadership-transiti. Published August 2, 2013. Accessed June 19, 2018.

17.   Rush B. Directions for preserving the health of soldiers. Lancaster; 1778.

18.   Brocklesby R. Oeconomical and medical observations in two parts. From the Year 1758 to the Year 1763, Inclusive. London; 1764.

19.   Pringle J. Observations on the Diseases of the Army: In Camp and Garrison; In 3 Parts; With an Appendix. London: Millar; 1753.

20.   Risk Management. Washington DC: Air, Land, and Sea application center; 2001. FM 3-100.12, MCRP 5-12.1C, NTTP 5-03.5, AFTTP(I) 3-2.34

21.   Sepanic J. The Dilemma over Medical Command and Control [master’s thesis]. Fort Leavenworth, Kansas: United States Army Command and General Staff College; 2008.

Attachment 8-1

ON LOYALTY AS A STAFF OFFICER

(Vignette from a young command surgeon)

Problem

As a brand-new battalion surgeon coming out of internship, one of the first challenges I ran into upon assignment to the battalion was a recognition that our unit was NOT medically “ready.” This battalion was designated for rapid deployment and had a continual stream of small-unit downrange deployments. There was a constant command focus on medical readiness, which was a prerequisite for deployment. Despite this focus, I discovered that immunization status was being reported as much higher than it actually was. Medical records review revealed that the reported 98% to 100% compliance rate was in fact as low as 30%!

I had to implement new plans and programs to correct this shortfall, which required a tremendous amount of boots-on-the-ground work by our battalion medical section. My team was constantly bombarded by “hey you” from companies, teams, and individuals who needed support in getting the various immunizations and other preventive medicine items addressed. Though this was at my request (be careful what you ask for!) and was supported by the command, it interfered with my ability to do my basic staff work and meet my general command responsibilities.

Solution

Trying to think outside the box, I determined that the best way to solve this problem was to compartmentalize the time involved in the immunization and medical readiness program so that we could maintain focus and improve efficiency across all required tasks. I had to protect time to do my planning and staff work while still maintaining availability to the 350+ members of the battalion who needed my time to meet their pre-deployment requirements.

My creative solution was to establish “office hours” for immunizations. Without discussing it with my executive officer (my immediate supervisor), I posted on my door a fairly simple and streamlined set of office hours during which I would make my team exclusively available for immunizations and preventive medicine work. Based on the previously encountered routine workflow and traffic, I believed that this would be both reasonable and effective in meeting the needs of the subordinate units.

New Problem

Immediately I felt better about my task accomplishment. I was more prepared for my briefings and I felt my workflow was more balanced and timely for me and my team (the battalion medical section). However, it wasn’t long before I was summoned by a very unhappy executive officer who had just “heard it” from the commander. While I was reasonably well respected by this time in the command as a supportive “Doc,” the company commanders and by proxy the battalion commander were not just upset, but rather were IRATE about my new office hours. The hours did not conform to the unpredictable pre-deployment training schedules that the subordinate units were forced to live by. I was immediately labeled as “self-serving” and “unsupportive.”

I immediately remove my office hours, made an announcement at the next command staff meeting that anybody that needed an immunization or other medical support could come by ANY time during work hours, or after hours with prior coordination. Needless to say my creative solution backfired on me and presented a new challenge of restoring trust with the unit.

Lesson Learned

It is critical to remember that your role is as a supporting character in the cast of the battalion, and that the perception of support is perhaps more important than the reality. Loyalty to the team means, among other things, that you understand your role on the team.

Attachment 8-2

MISSION BRIEFING FORMAT

1. SITUATION

a. Enemy Forces

b. Friendly Forces

c. Attachments and Detachments

2. MISSION

a. Who

b. What

c. When

d. Where

e. Why

3. EXECUTION

a. Concept of the Operation

b. Maneuver

c. Fires

d. Tasks to Maneuver Units

e. Tasks to Combat Support Units

f. Coordinating Instructions

4. SUSTAINMENT

a. General

b. Material and Services

c. Supply

d. Transportation

e. Services

f. Maintenance

g. Medical

h. Personnel

i. Miscellaneous

5. COMMAND AND SIGNAL

Adapted from: US Army. Ranger Handbook. Fort Benning, Georgia: US Army Infantry School; 2017. TC 3-21-76.

Attachment 8-3

DECISION BRIEFING FORMAT

INTRODUCTION

a. Greeting

b. Type and Classification

c. Purpose and Scope

d. Statement of the problem (mission/commander’s intent)

e. The recommendation

MAIN BODY

a. Facts (+ and -)

b. Assumptions

COURSES OF ACTION (COA)

Discussion of the various options

ANALYSIS

a. Evaluation criteria

b. Advantages and disadvantages of each COA

COMPARISON

Show how the courses of action rate against the evaluation criteria

CONCLUSION

a. Describe why the selected solution is preferred

b. Ask for questions

c. Restatement of the recommendation for approval/disapproval

d. Request a decision

Adapted from: US Department of Defense. Joint Planning. Washington DC: DoD; 2017. Joint Publication 5-0.

Attachment 8-4

HIPPOCRATIC OATH, MODERN VERSION[1]:

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of over-treatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.

I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

This modern version of the Hippocratic Oath was written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and is used in many medical schools today.[2]

REFERENCES

1.   Lasagna L. A Modern Hippocratic Oath. Tufts University School of Medicine. 1964.

2.   Miles SH. The Hippocratic Oath and the Ethics of Medicine. 1st ed. New York, NY: Oxford University Press; 2004.

Attachment 8-5

THE OATH OF COMMISSIONED OFFICERS

I, _____ (state your name), having been appointed a (rank) in the Army of the United States, as indicated above in the grade of _____ do solemnly swear (or affirm) that I will support and defend the Constitution of the United States against all enemies, foreign and domestic, that I will bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservations or purpose of evasion; and that I will well and faithfully discharge the duties of the office upon which I am about to enter; So help me God.[1]

REFERENCE

1.   5 USC §3331. Oath of Office. Washington DC, 1966.

Chapter 9

MILITARY MEDICINE IN THE OPERATIONAL AND STRATEGIC CONTEXT

ERIC B. SCHOOMAKER, MD, PHD*

INTRODUCTION

THE FOUR INSTRUMENTS OF NATIONAL POWER

ROLE OF MILITARY MEDICINE IN NATIONAL DEFENSE

DIMENSIONS OF COMPLEXITY IN LEADER ENGAGEMENT AND ORGANIZATION

“THE STRATEGIC CORPORAL”

SUMMARY AND CONCLUSIONS

*Professor and Vice Chair, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; formerly, Surgeon General, US Army, and Commanding General, US Army Medical Command

“You know you never defeated us on the battlefield,” said the American colonel. The North Vietnamese colonel pondered this remark a moment. “That may be so,” he replied, “But it’s also irrelevant.”

—Conversation in Hanoi, April 1975[1]

INTRODUCTION

With this poignant yet profound exchange between two former enemies during the negotiations to end the Vietnam War, the author, Harry Summers Jr, a war-tested professional soldier, summarized a decade-long conflict that took the lives of over 50,000 Americans as well as countless Vietnamese, Laotian, and Cambodian fighters and civilians, and plunged the United States into a generation of soul-searching and political discord.[1] It captures the essence of what one of the seminal writers on the nature of war, the Prussian military theorist Carl Philipp Gottfried von Clausewitz, wrote: “War is merely a continuation of policy [or politics] by other means.”2,3(I-1–I-4) The American and allied military in the Vietnam War were superior in almost every regard to their North Vietnamese regulars and Viet Cong guerilla counterparts. But this proved to be inadequate as they failed to break the will of the North Vietnamese to fight while losing a critical social and political struggle at home, which resulted in the loss of the American people’s will to continue the war. In sum, while the field engagements of the American military were almost uniformly successful, the larger US strategy, needed to win the war of wills, was not.

As a young medical student in the early 1970s struggling to learn the details of human physiology and anatomy, and to apply my nascent diagnostic acumen and newfound respect for therapeutics to human disease, I had a similar “ah-ha” moment late one night in our university hospital. Seeking a place where I could read and reflect, I took a little-used elevator to a top, otherwise vacant floor of the hospital. There I found one of the very large open bay wards with over 50 patient beds that many of the older teaching hospitals featured at the time. Spread across the ward was an entire floor of empty iron lungs parked side-by-side and end-to-end, a battalion of ghostly shiny metal and glass pneumatic tubes large enough to accommodate an adult patient—empty and silent. Having seen these in pictures (Figure 9-1) or in hospitals when I was much younger, I recognized them as life-support devices for patients who suffered from paralysis of the diaphragm and respiratory muscles.

I asked one of my professors the next day on clinical teaching rounds what they were and why they were stored upstairs. He told me that they were in preparation for polio patients for whom respiratory assistance was life-saving. “Why,” I asked, “were they empty and the ward vacant?”

“Because the Salk and Sabin polio vaccines were successful,” he answered.

Figure 9-1. Sergeant Clarence Stewart of the 249th General Hospital demonstrates an iron lung used to treat poliomyelitis to many interested visitors at the Armed Forces Day celebration, Denver, CO, 1960.
Reproduced from: National Library of Medicine (http://resource.nlm.nih.gov/101442594).

Like Colonel Summers on a different kind of battlefield, it was among my first insights into the distinction between tactics and strategy in human medicine. We won the war against polio because we elected to invest in a strategy of prevention and not simply be satisfied with the tactical battle of treating those afflicted with this crippling viral infection. Since this early insight, I have encountered many other medical and military medical decisions that have had a strategic impact on the practice of medicine both in uniform and in civilian life. Among these were Major Jonathan Letterman’s organization of echeloned field medical care during the American Civil War; Army Surgeon General George Miller Sternberg’s decision to send Major Walter Reed to Cuba to identify the vector of yellow fever after the Spanish-American War; and more recently, the decision of Air Force surgeons general P.K. Carlton and Bruce Green to invest in sophisticated intensive care technology in inter-theater air evacuation. These and other important decisions by military medical leaders changed the complexion of care and survival of service members and civilians in war and peace.

Elsewhere in this textbook (Chapter 3, Officership and the Profession of Arms in the 21st Century), Meese and Wilson discuss the dual world in which military and uniformed medical officers exist: the world of medicine and the professional world of the military or uniformed officer. Additionally, professional uniformed officers must function in a technical world of scientific advances and applications of medical practice while serving in a parallel context of analysis and decision-making related to the impacts of these practices on a hierarchy of social and organizational complexity. Several examples above describe how protecting the fighting force from health threats, building the physical and emotional dimensions of resilience and restoration of health, and maintaining wellness and physical fitness are vital elements of ensuring a military force capable of defending the nation and fighting and winning its wars. The medical officer operates simultaneously in three spheres or contexts: a tactical context, in which the health of small units is protected and medical care is delivered to warriors; an operational context, in which battle and theater-level health and healthcare issues must be fine-tuned to achieve advantages for mission success; and a strategic sphere, in which sustainment and restoration of the joint fighting force, care of the larger military family, and nation-building from the standpoint of public health and medical care delivery may impact the national security strategy (NSS) and even national and global health.3(I-7) The medical officer must understand his or her role and impact in each of these dimensions. Most of this book deals with tactical issues, but in this chapter, the concepts of the operational and strategic art as they apply to military medicine are introduced.

As a military and uniformed medical officer, your career will be filled with moments similar to mine, when you encounter the interfaces among the different domains of planning and execution of your duties. While a medical officer’s roles may be consumed with the day-to-day myriad events that characterize the prevention, mitigation, and management of diseases, injuries, and combat wounds, they must understand how their work and the activities of their team and organization—clinic, operational medical unit, hospital, research laboratory, or other—are ideally derivative of and support a larger operational and strategic scheme. To best gain this understanding, it is necessary to step back and consider the role the US military plays in national security and defense, and how this role is articulated by the national command authority.

THE FOUR INSTRUMENTS OF NATIONAL POWER

Many members of the uniformed services, especially those in the armed forces, are surprised to learn that the employment of the nation’s military is but one of four different strategic tools by which the United States attends to its national security on the world stage. Often, the exercise of military power is the least desirable and least effective of them. The four instruments of national power form an easily remembered mnemonic, “D-I-M-E”3(I-11): diplomatic, informational, military, and economic.

The nation’s diplomatic efforts are officially exercised through the authority of Congress to regulate diplomatic relations between and among nations and largely carried out through the Department of State or special emissaries of the legislative and executive branches of government. Diplomatic exchanges constitute a continuous form of communications that ensure the clarification of national intent behind specific actions, the creation of mutual understanding for bilateral or multilateral benefit, and expressions of displeasure or concern about events or actions taken by others. Diplomatic exchanges often take place even when the United States or other parties do not have formal diplomatic relations; these occur through intermediaries in the diplomatic world or other ad hoc devices.

Information has always represented an essential method of influencing international relations and events. With the rise of the Internet, social media, sophisticated technological advances in intelligence collection, and nearly universal access to electronic media, the informational instrument of national power has taken on added importance and complexity. Virtually no major development of importance in the security of the United States occurs without an effort to influence the domestic and international public’s perception of these events, as well as to sway the opinions of world leaders and powerful influencers. These occur through acts of commission—such as releasing heretofore privileged or classified information more widely—or omission—such as restricting this information. The emergence of deliberate and coordinated assailants or simply mischievous parties bent on disrupting activities, divulging information, or creating “alternate realities” to deceive or create instability and confusion have raised the stakes for protecting sources of information and the critical databases and tools for free and easy information exchange.

The War Powers Act of 1973[4] permits the president to exercise certain military actions to protect and defend the nation against foreign enemies. But the exercise of the military instrument of national power has constitutionally resided principally in Congress, which, in any event, can leverage the power of the purse to limit even presidential directives to employ the nation’s military. The most favorable interpretation of this interplay between the legislative and executive branches is an exercise of checks and balances. That is, it is a “dialogue” among the branches of the federal government intended to promote US military intervention as truly reflecting “the will of the people”—as is so pointedly demonstrated in the opening vignette. It also encourages the greatest degree of coordination of resources, expertise, and experience among different federal executive departments and agencies (the “interagency”) in conducting the four instruments of national power represented by D-I-M-E.

Many of the most effective tools for promoting US national interests are economic in nature. Tariffs on trading with those the United States intends to influence or punish—trade embargoes, confiscation of the properties of these nations or their citizens, limitations on how US citizens can invest in these nations, withholding foreign aid, and other financial instruments—are among the oldest and most often employed approaches used in international affairs. Conversely, favorable relations can be encouraged between and among nations that favor one party in an international dispute at the expense of the other by exercising the opposite of these measures. Both approaches—punishing and rewarding—have been undertaken throughout American history with great success. The emergence of security threats arising from non-state actors such as transnational criminal elements and terrorist organizations have made diplomatic and informational efforts more difficult. One of the more recently applied tools in the struggle against these enemies is to find and choke off funding for their activities.

It should be evident from this discussion with these and other examples that the NSS of the United States extends beyond the isolated use of its military. In fact, the NSS drives the cascading of a strategic discussion and the articulation of goals and objectives from all elements of the government—departments and agencies alike—including but not limited to the Departments of State, Treasury, Commerce, Homeland Security, Defense, Justice, Health and Human Services, Veterans Affairs, and Energy; the multifaceted 17-member US intelligence community; and all other offices that can make important contributions within the D-I-M-E framework. The role of the US military is subordinate to a larger scale effort to employ a “whole of government approach” for a unified strategy in advancing the national interests of the nation. Within the Department of Defense (DoD), this is outlined in the National Defense Strategy (NDS) and National Military Strategy (NMS), from which all subordinate DoD agencies, departments, and commands derive their guidance in support of the NSS (see also Chapter 7, The National Security Structure).

ROLE OF MILITARY MEDICINE IN NATIONAL DEFENSE

The same relationship exists with respect to the role of military medicine in supporting the overarching military strategy found in the NMS and reflected in derivative guidance provided by the military services, the Defense Health Agency, the assistant secretary of defense for health affairs, and the secretary of health and human services (for members of the US Public Health Service). Advancing health within the military services, and the wider American public through the Public Health Service, and caring for illnesses, injuries, and combat wounds suffered by beneficiaries of military healthcare are not ends in themselves. To be clear, these are the principal focuses of the uniformed services health and healthcare community. But these efforts serve a greater good in maintaining the readiness of members of the armed services, and even the wider American public, to serve in defense of the nation and to keep the nation strong. The health and well-being of the uniformed service member (and by extension, the US population) is the center of gravity of national strength and the readiness of the force to defend the nation.

Some within the uniformed health professions find this “dual agency” an ethical and moral challenge. This chapter is not intended to fully explore this challenge (see Chapter 3, Officership and the Profession of Arms in the 21st Century, and Chapter 5, Military Law and Ethics, for a more complete discussion). Suffice it to say that a potential for tension may arise between the obligation to care for the individual military patient and the duty to ensure the mission of the armed services to fight and defend the country. (This tension is not unique to the military physician. Consider, for example, the conflict between patient privacy and the legal obligation to report sexually transmitted diseases to the public health authorities or a battered spouse to the legal authorities.) But in the main, these two roles and codes of professional ethics—that of the caregiver physician and that of the military medical officer—are in alignment and without conflict. Optimally caring for the service member is, in fact, ensuring the capability of the military unit to succeed in its mission, whether it is in preventing disease, injury, and combat wounds; restoring health; or ensuring full recovery and rehabilitation. Ensuring the optimal restoration of health and function in the most seriously ill, injured, or combat wounded warrior is critical to retaining the full trust and confidence of combatants that the nation and its military respect their sacrifices and will not abandon them in times of need.

DIMENSIONS OF COMPLEXITY IN LEADER ENGAGEMENT AND ORGANIZATION

Up to this point, this chapter has discussed the notion of “strategy” in depth and has used this term liberally. But many do not recognize the distinction between and among the tiers or dimensions of complexity and focus within organizations that engage leaders and unit members: strategic, operational, and tactical. Although “strategy” was often inferred from the classical texts of such conflicts as Caesar’s Gallic Wars and the Second Punic War, and it has certainly inspired and informed more recent military strategists, its separation into political and military elements and the exposition of an overarching intent for these conflicts, as distinct from more practical activities involved in the waging of individual campaigns and battles (operational and tactical), is not clear. More explicit discussions of strategy emerged in the 19th century among philosophers, political scientists, and military thinkers, such as the previously mentioned Prussian theorist, von Clausewitz. The evolution and overlap among these dimensions have been changing with the advent of late 20th and early 21st century technology, including weapons and communications.[5] (The Soviets introduced operational art in the 1920s, although the Western European and NATO allies used grand tactics until 1982; both communities were working with the same issues raised by span of control and communications.) In the simplest scheme, these can be considered as vertically arrayed one above the other, from the highest and most complex dimension that addresses key national goals to the lowest and smallest events and issues:

- Strategic. Fundamental, overarching themes at the heart of the military medical mission, the DoD mission, and by extension, the national defense. Examples:

- Force health protection via vaccines, preventive mental health protocols, and food and water policies.

- Service member accession and retention health standards.

- Policies governing the standardization of the continuum of battlefield casualty care (Tactical Combat Casualty Care) and recovery from the point of injury to rehabilitation in DoD and Veterans Affairs medical facilities (these set the stage for clinical, administrative, and business practice guidelines at the operational and tactical levels.)

- The impact of military and uniformed health policies and healthcare practices on national and global health and healthcare organization, practice, and metrics.

- Operational. Issues that require planning and coordinated execution at the larger corporate (ie, DoD, service) or major command level. Examples:

- Harmonizing and aligning theater-level immunization and prophylactic medication policies among the services.

- Adoption of standardized blood products protocols across in-theater medical treatment facilities.

- Coordinated clinical, administrative, and business practice guidelines across service camps, posts, stations, and bases.

- Theater patient holding and evacuation policies.

- Tactical. Practical, local issues or processes that address the needs of individual service members and build the basis for operational and strategic success. Examples:

- Details of the administration of individual vaccines and patient care at the aid station, clinic, hospital, or deployable medical facility level.

- Local adjustments of clinical practice guidelines to accommodate variations in resources, patient flow, provider availability, evacuation policies, etc.

- Execution of field sanitation and food and water safety standards at the small unit level (eg, hand washing, latrine placement, water purification steps).

While the appropriate focus of the individual student and trainee is on the many details of basic science and applied clinical science that will lead to their service as well-qualified, safe, and knowledgeable practitioners, it should be recognized that these concerns are principally at the tactical level. The ideal goal of healthcare provider education is to provide every physician, nurse, and allied healthcare practitioner and specialist with the skills needed to conduct optimal health promotion, disease and injury prevention, and healthcare at the practitioner-patient interface (the tactical level). No degree of higher order understanding of their organizational role can replace the achievement of success patient by patient.

However, in a larger context, the relevance of the uniformed medical and public health officer ultimately lies in their support of an operational plan that is inextricably linked to the strategic goals of the combined military and coalition force. These military goals, as discussed above, in turn support an even grander scheme of support of the NSS through D-I-M-E. Just as every soldier engaged in direct combat, every airman in support of air operations, every sailor ensuring the continuous operation of a naval vessel, and every Marine trained to conduct amphibious landings cannot succeed alone in achieving the larger mission to fight and win the nation’s wars, no one practitioner alone can ensure the overarching goals of force health protection, or maintaining the fighting strength. These require the coordinated and synchronized operational actions of a wide array of tactical events and people whose combined behaviors support the strategic goals of military and federal medicine.

“THE STRATEGIC CORPORAL”

Having said this, and having aligned the strategic, operational, and tactical levels one above the other with each supporting the higher level and guided—ideally—by the strategic goals at the top level, it is increasingly clear that crisp separations of one level from the other are not always possible. As forecast by Jablonsky’s “revolution in military affairs”[5] and dramatically depicted by former commandant of the Marine Corps, General Charles C. Krulak,[6] the complexity of modern armed conflict, the impact of technology, and the omnipresence of communications with the outside world through cell phones and the media has led to the “strategic corporal.” That is to say, the tactical has begun to bleed or overlap in increasingly more important ways into the higher operational and strategic levels, sometimes profoundly enhancing or preventing the achievement of strategic goals.

Figure 9-2. Army combat medic Specialist Billie Grimes, chairman of the Joint Chiefs of Staff General Richard Myers (US Air Force), and Army surgeon general Lieutenant General Kevin Kiley proudly display the cover of a national news magazine featuring Specialist Grimes and her comrades during Operation Iraqi Freedom in 2003. This is an example of the “strategic corporal” phenomenon in which the actions of medical personnel and events at the tactical level have strategic impact and implications. (Cover image and full story available at: http://archive.defense.gov/news/newsarticle.aspx?id=27583.)

Figure 9-3. Sergeant Major Brent Jurgersen, US Army, senior enlisted advisory to the US Army Wounded Warrior (AW2) program, 2007–2009, leading by example as a twice-wounded recovering soldier.
Reproduced from: Fort Cason Mountaineer, January 29, 2009.

The improvement or maintenance of health and the provision of healthcare play a critical role in this phenomenon. Human health and well-being resonates strongly with the American public and global audiences. Measures to secure these aims or to demonstrate military medicine’s resolve to act ethically, professionally, and with the highest standards of quality have great influence on the perception of the public about who we are as a US military and federal health force. These public audiences are major stakeholders in determining both national security interests and the degree to which these interests can be advanced. As a consequence, the actions—or inactions—of uniformed healthcare providers in performing their duties can have a dramatic impact on the success of the larger military mission and even interagency effort. Figures 9-2 through 9-4 illustrate some examples of “strategic corporals” in recent military medical operations. Each represents a strategic message about the contribution of the military medical community through the execution of their tactical duties.

Figure 9-4. A combat medic in Afghanistan examining a child in a humanitarian operation to improve host nation public health. US Army Specialist Joe Kunsch performs medical checks on village children during a combat patrol in Khowst province, Afghanistan, January 25, 2012. Kunsch is a medic assigned to 2nd Battalion, 377th Parachute Field Artillery Regiment.
Reproduced from: https://www.defense.gov/Photos/Essay-View/CollectionID/9224/.

SUMMARY AND CONCLUSIONS

On September 17, 1862, an event occurred that changed the course of American history and was pivotal to the development of modern military and uniformed medicine and US public health (this conclusion is inspired by the comments of Dale Smith, PhD, leading the Uniformed Services University of the Health Sciences annual terrain walk at Antietam National Battlefield, 2012–2017). At the small western Maryland town of Sharpsburg near Antietam Creek, Union and Confederate forces clashed in a battle with the ignominious distinction of creating the largest number of casualties in a single day of armed conflict in American history—over 23,000 wounded or dead federal and Southern soldiers. The military surgeon serving as the medical director of the Army of the Potomac in that battle (Figure 9-5), Major Jonathan Letterman, was a battle-tested, experienced military medical officer with over a decade of practice in the Indian Wars, as well as on earlier Civil War battlefields.[7] In the few months following his appointment as the senior medical officer for his command, he had worked diligently to devise a system of evacuation teams far forward on the battlefield with evacuation by horse-drawn ambulances to larger makeshift facilities in the rear. Antietam was his first opportunity to test his system; the battles of Fredericksburg and Gettysburg that followed in 1863 permitted him to apply his system more comprehensively and convincingly.

Figure 9-5. Major (Doctor) Jonathan Letterman (seated, first on the left) and his medical staff of the Army of the Potomac. Originally printed in Miller’s photo history of the Civil War, v. 7, p. 219.
Reproduced from: https://collections.nlm.nih.gov/catalog/nlm:nlmuid-101436488-img.

The Battle of Antietam was an encounter noteworthy as one of the earliest “victories” for the Union Army, enabling President Abraham Lincoln to publish the Emancipation Proclamation, which freed all slaves in the secessionist Confederate States. Lincoln had completed the edict earlier but did not issue it, fearing that in the absence of any clear Union victory it would appear to be an act of desperation. Upon the completion of the battle, Letterman faced a major decision of his own. Traditionally educated in the medical care principles and practices of the day, as are the healthcare professionals reading this textbook, Letterman was fully focused on providing optimal care to his individual patients. But Antietam created for him a crisis of conscience in which he came to see that he bore the responsibility to care for the entire Army—that care of the individual soldier rested upon his understanding of how to organize, man, equip, control, and provide proximate, continuous, and flexible care that conformed to both the ongoing battle and to a uniform standard of excellent care for the entire fighting force.

Letterman’s subsequent creation of the “Letterman plan,” completed in October 1862, revolutionized battlefield medicine as well as emergency care for many civilian cities following the war. US Navy observers of the battle also learned these lessons and applied them to maritime and riverine care. Letterman’s insights remain some of the most significant in the history of healthcare in armed conflict as well as in natural and manmade disasters.

Major Letterman underwent a transformation in his thinking that every civilian and uniformed medical officer must undergo if they are to both provide the greatest impact for those they serve, and achieve the highest level of professional practice. This chapter has fully explored and deconstructed the elements of that transformation. While medical practice rests upon tactical events involved in the promotion of health and delivery of care to individual patients, the uniformed medical officer is incomplete without an understanding of and facility with operational level engagements, such as occur on an entire battlefield, a major medical treatment facility, or an epidemic or natural disaster. Survivors of the battles that followed Antietam and Gettysburg took their observations and experiences home to cities throughout the country. They demanded that their civic leaders emulate the Letterman Plan or began their own efforts in urban emergency care to duplicate the efficient and effective methods of care delivery they had seen in the Civil War. Letterman’s efforts were truly strategic in their impact on American and global health and healthcare.

Ultimately, the role of military and uniformed medical care in the larger strategic context of defending the nation and preserving the health of the public must be learned to become a successful and complete medical officer. The demands of developing an understanding of human disease and injury and of maintaining proficiency in their treatment are often more engaging and personally rewarding—at least in the short run. But they cannot define the extent of a uniformed and military medical officer’s skills. Like Jonathan Letterman, today’s medical officers are challenged to ascend to a higher level of understanding and leadership if they are to fulfill their aspirations to serve honorably and the obligation to reach their full potential.

REFERENCES

1.   Summers HG Jr. On Strategy: A Critical Analysis of the Vietnam War. New York, NY: Random House; 1982: 1.

2.   von Clausewitz C. On War. Howard M, Paret P, trans-eds. Princeton, NJ: Princeton University Press; 1976: 87.

3.   US Department of Defense. Doctrine for the Armed Forces of the United States. Washington, DC: DoD; 2013. Joint Publication 1.

4.   50 USC Ch 33: War Powers Resolution. http://uscode.house.gov/view.xhtml?path=/prelim@title50/chapter33&edition=prelim. Accessed January 3, 2018.

5.   Jablonsky D. US military doctrine and the revolution in military affairs. Parameters. 1994;autumn:18–36.

6.   Krulak CC. The strategic corporal: leadership in the three block war. Marines Magazine. 1999;83(1). http://www.au.af.mil/au/awc/awcgate/usmc/strategic_corporal.htm. Accessed November 13, 2017.

7.   McGaugh S. Surgeon in Blue: Jonathan Letterman, the Civil War Doctor Who Pioneered Battlefield Care. New York, NY: Arcade; 2013.

Chapter 10

TACTICAL FIELD SKILLS FOR THE MILITARY PHYSICIAN

SEAN MULVANEY, MD,* AND TONY S. KIM, MD†

INTRODUCTION

THE PROBLEM AND NEED FOR TRAINING

SHOOT

Weapons Training

Combatives

MOVE

Principles of Navigation

Driving Military Vehicles

Convoy Operations

Personal Equipment and Moving

COMMUNICATE

ADDITIONAL OPERATIONAL MEDICAL TRAINING

Flight Medicine

Dive Medicine

Airborne

Survival, Evasion, Resistance, Escape

OTHER CONSIDERATIONS

Military Bearing

Medical Evacuation and Mass Casualty Planning and Training

Preventive Medicine

Operational and Intelligence Briefings

Time Management

SUMMARY

*Colonel (Retired), Medical Corps, US Army; Associate Professor, Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Colonel, Medical Corps, US Air Force; Assistant Professor, Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

There are two compelling reasons for military physicians to learn and hone the basics of military combat skills. The first is that the physician must never be a liability for the supported unit. The second is that by fundamentally understanding the demands of the unit’s mission-essential tasks, the physician is better able to interpret injury patterns and set reasonable return-to-duty requirements and limitations. In addition, learning these skills establishes a set of shared experiences that facilitate effective communication between physician and patient.

At its core, soldiering skills consist of being able to safely and effectively shoot, move, and communicate. Each of these basic tasks has a series of implied tasks. For example, to shoot, one must first know how to safely handle and sight-in (or “zero”) the weapon. To move, one must know how to establish his or her position and navigate. According to the tenets of the Geneva Conventions, medical personnel are not combatants and are entitled to certain protections (so long as they are working exclusively in a medical role and not participating in acts harmful to the enemy).1–3 However, the vast majority of armed conflicts the United States has engaged in since World War II include combatants that do not adhere to the Geneva Conventions. Thus, the physician cannot assume the protections of Geneva Conventions status and must be prepared to be treated as a combatant.

As a rule, units are willing to facilitate teaching their assigned physician combat skills if he or she shows an interest. It is beneficial to the unit to have a physician who is independent and competent in a combat zone; a physician cannot execute the critical medical role if he or she is lost or dead. Deployable medical units have a cadre with the responsibility to teach basic combat skills to their medical providers. In other units, a physician with initiative and persistence will find trained personnel and resources to help. Learning combat skills is experiential; reading it in a book, seeing it on a video, or being told what to do will not suffice. The skills must be performed, and becoming proficient in them takes time, in some cases years. Although these skills may never be used in combat, they are worth learning and will increase the physician’s ability to both care for and relate to patients. Although the easiest time to learn these skills is early in one’s career, it is never too late to begin and it is always appropriate to review and refresh these skills on a regular basis.

Vice Admiral Joel Boone is arguably among the best examples of a combat physician. This is his Medal of Honor Citation from World War I:

For extraordinary heroism, conspicuous gallantry, and intrepidity while serving with the 6th Regiment, U.S. Marines, in actual conflict with the enemy. With absolute disregard for personal safety, ever conscious and mindful of the suffering fallen, Surg. Boone, leaving the shelter of a ravine, went forward onto the open field where there was no protection and despite the extreme enemy fire of all calibers, through a heavy mist of gas, applied dressings and first aid to wounded marines. This occurred southeast of Vierzy, near the cemetery, and on the road south from that town. When the dressings and supplies had been exhausted, he went through a heavy barrage of large-caliber shells, both high explosive and gas, to replenish these supplies, returning quickly with a sidecar load, and administered them in saving the lives of the wounded. A second trip, under the same conditions and for the same purpose, was made by Surg. Boone later that day.[4]

In addition to earning the Medal of Honor, Boone was awarded the Army’s Distinguished Service Cross, multiple Silver Stars, and many other awards, making him among the most decorated military physicians in history.[5] With one of the most remarkable and distinguished careers in the history of the US military, Vice Admiral Boone demonstrated preparedness and readiness that led to courage and success when it really counted. He is an excellent example for all military physicians.

THE PROBLEM AND NEED FOR TRAINING

With the exception of Special Operations units, no service officially requires physicians to become proficient or familiar with any combat skills, and military units often do not place any demands on the physician outside of medical tasks beyond the minimum military requirements. Special Operations units expect their physicians to have (from prior service) or to develop the ability to handle themselves in rapidly changing situations, including combat. Thus, the opportunity for these physicians to regularly train in combat skills with their unit members is expected. In all other units, pursuing training in these skills is the physician’s responsibility; it is often not provided by the unit.

As a result, physicians may receive only a half-day of familiarization with a pistol, while the remainder of readiness preparation involves updating medical/dental/immunizations requirements; ensuring their security clearance and ISOPREP (isolated personnel report, a secure individual profile on file in case a person must be rescued and their identity verified) is up to date; and making sure various computer-based training is current. These kinds of activities, although important for deployment readiness, do not constitute tactical field skills preparation or adequately prepare the physician for working in a combat environment. The unit may facilitate scheduling combat arms training but not offer extra training such as combatives, land navigation, or small team tactics.

Likewise, training as a physician does not include preparation for combat field medicine. Experienced combat-proven medics often know more about saving lives of wounded warfighters in the field than physicians. Medics are experts in Tactical Combat Casualty Care (TCCC),[6] and it behooves the military physician to learn and be able to execute these standards as well as Advanced Trauma Life Support or Advanced Cardiac Life Support standards. However, medics will look to the unit physician for medical training, validation, and mentorship. The physician must have an in-depth understanding of TCCC principles and techniques to be able to communicate in a common language and utilize the same treatment algorithms when it is necessary to provide care under fire. Physicians need to train medics in TCCC-recommended medications for pain control and wound prophylaxis; medics have the know-how to administer medications but may not fully understand how they work or when certain medications may be better than another. It is important to practice how to care for casualties out of an aid bag, including in the dark. Practice improves performance not just individually, but also collectively between the tactical physician and medic.

SHOOT

Weapons Training

In a combat zone, the physician is usually assigned a weapon, most often a pistol (M9) or possibly a rifle (M4). Even under almost all theater-established rules of engagement, medical personnel never lose the right to self-defense according to the Geneva Conventions. Rules of engagement vary with the threat level and phase of combat operations. For example, in the initial assault phase of a combat operation, a soldier may legally shoot any enemy holding a weapon, whereas in the stabilization phase of combat operations, the soldier may have to wait until that same enemy makes a threatening gesture before shots can be fired. By the Geneva Conventions, however, as medical personnel, physicians can shoot only if threatened and there is a need to protect their own life or the life of patients.[7] In such cases, deadly force may be used. It is vitally important to understand such rules of engagement within the confines of the Geneva Conventions, and medical personnel must be ready to utilize deadly force when appropriate in order to be a force multiplier for the unit. Physicians should not be the cause of further casualties because of a lack of resolve or understanding of their role in combat.

There are reasons to be familiar with weapons and shooting other than self-defense and protecting patients. Chances are, firing a weapon is an activity at least some members of the unit do regularly as part of their job, and understanding the forces imparted to the body, both from recoil and from shooting positions, will help the physician more appropriately profile (impose medical duty limitations) to protect these patients while recovering from injury. Shooting also provides first-hand experience with the occupational noise exposure warfighters face, which emphasizes the importance of advocating for the funding and enforcement of appropriate hearing protection. In addition, shooting can be a significant source of occupational lead exposure, especially for personnel who routinely shoot in indoor ranges. The unit physician should track shooting-associated occupational concerns such as proper ventilation in firing ranges, hand-washing immediately after firing range operations, and blood lead level monitoring in populations that routinely fire assigned weapons. In addition, going to the range and firing weapons once or twice a year provides physicians an opportunity to get to know their patients in a nonclinical setting.

The ideal time to learn how to safely handle and employ firearms is before deployment; during deployment is too late to become comfortable with a weapon. Weapons may be assigned because of an increased threat level, and there is no time to become proficient with a weapon once an assault starts. Hospitals and aid stations are notoriously soft targets that enemies will exploit if given a chance.

Physicians should seek weapons training and work through the chain of command to get more time on the firing range. Depending on the military service (Army, Navy, Marines, or Air Force) and the particular type of unit the physician is assigned to (conventional forces vs special operations), the method and ease of obtaining time on the shooting range will differ. However, all physicians should respect and be friendly with unit noncommissioned officers, who can be immensely helpful and have established lines of communication and trust with other units and agencies involved with scheduling training (see Chapter 12, Enlisted Service Members, for a more detailed explanation of the role of the enlisted corps). If the extra training cannot get scheduled or authorized through regular channels, physicians should take the initiative to go to a local shooting range, many of which are within driving distance from most military bases and can provide weapons and training in the fundamentals. Civilian 9-mm pistols are similar to those most likely issued to officers during deployments.

This chapter is not a resource on weapons safety. However, a few foundational concepts that should be understood by anyone who works around firearms are provided here. Regardless of whether one is a novice or expert with firearms, the following rules must never be modified or broken:

1. Always treat the weapon as if it was loaded, and do not rely on a mechanical safety to keep the weapon safe.

2. Never point a weapon at anything other than the intended target.

3. Keep fingers off the trigger until ready to shoot.

4. Be sure of the target, what is around it, in front of it, and behind it.

Additionally, every time a firearm is held, the weapon must be inspected: is there a loaded magazine or a round of ammunition in the chamber (the chamber is where the round of ammunition lines up with the barrel for firing)? Physicians must be familiar with this procedure before accepting a weapon. There must be absolute certainty about the status of any weapon being held; a round of ammunition negligently fired can never be taken back, and the consequences can be permanent and tragic. There is never an acceptable excuse for a negligent discharge of a weapon.

Although much can be learned about weapons handling and shooting from books and videos, it is a physical skill that must be executed to truly learn it. Dry firing, the act of going through the motions of shooting with a confirmed (and reconfirmed) empty weapon, does not hurt the weapon and is an excellent way to practice employing a firearm (the shot must still be performed in a safe direction). Specifically, dry firing can provide practice grasping the handle, using the weapons sights, establishing a smooth trigger squeeze (trigger “press”), and aiming in different firing positions (prone, sitting, kneeling, firing around barricades). In addition, magazine changes with empty magazines can be practiced.

Sighting in or “zeroing” a weapon is the critical process of adjusting the weapon sights (iron sights or optics) so that the fired round impacts the intended target. The initial sight in or “zero” should be at close range (15 m or less for a pistol, 25 m for a rifle). Once the sights are grossly adjusted and there is a consistent shot grouping at close range, the process should be repeated at actual engagement ranges to further fine-tune the sighting (25 m for pistol, 200+ m for rifle).

Additionally, shooting should be practiced while wearing assigned protective equipment. Firing a weapon while wearing a helmet and body armor is much different than without: sling length, holster position, and shooting positions will change. Ear and eye protection must also be worn, and eye protection may slightly alter the sight picture and negatively affect accuracy if the user is not looking through the center of the lenses.

Physicians should clean their own weapon no matter what their rank or how busy their schedule is; this responsibility should never be delegated. There is much to be learned about a firearm from the cleaning process, and doing so will earn respect from soldiers who see this as a duty that should never be shirked.

Combatives

Combatives (or hand-to-hand fighting) training is widely available on most military bases. Understanding the forces and stress on personnel undergoing combatives training is important for the military physician assigned to a combat unit. The best way to understand the forces involved in combatives training is by firsthand experience. During sparring, a “preposterone effect” can occur, in which the intensity increases to the point where sparring partners end up hurting each other. A military physician who works with combatives instructors is able to effectively collaborate and better protect unit members from unnecessary injury while undergoing this training. A physician does not need to become an expert fighter, but learning the basic skills helps the physician understand possible injuries from combatives, provides a modicum of physical confidence, and can be fun.

MOVE

Principles of Navigation

It is critical to learn navigation by map and compass even in the global positioning system (GPS) era. This skill is still taught for several reasons, including the possibility of losing GPS access when fighting an enemy with advanced capabilities. For a decade, the Navy had stopped teaching midshipmen celestial navigation, but as of 2016 it is back in the curriculum because of a reasonable assessment of the threat and potential vulnerability of US satellites.[8] Navigating with a map and compass is a basic soldiering skill, is reasonably easy to learn, and provides confidence when moving through rural areas for training or combat. It is a key step for many military schools, such as Ranger training, and in all combat arms training.

There are many good books on navigation, both military and civilian. Navigation training does not require any special equipment, and is available at local orienteering or outdoor clubs if efforts to find military training come up short. Physicians should make every effort to participate when their unit conducts this training, including land navigation at night, which can be much more difficult and requires practice. Knowing how to read a contour map is also important; however, it is not as critical as being able to accurately locate oneself on a standard map.

Nautical charts and maps use the universal system of latitude and longitude to describe a location on the globe. All maps are based on a model of the earth’s sphere called a “datum,” which incorporates a grid system, called a “projection,” which mathematically transforms the 3-dimensional sphere to a 2-dimensional map. Worldwide, there are many datum choices. Examples of common datums for US maps and charts are WGS-84 or NAD–83. When using coordinate systems such as latitude and longitude, or grid coordinates, it is necessary to know which datum the coordinates are based on. The error of the same coordinates in two different datums can be substantial, on the order of kilometers.

A geocoding system founded in 2013, called “What-3words,” has assigned three dictionary words to every 3 × 3 m^2 of the globe.[9] It is a simple way to locate any place on the planet; for example, a square at the foot of the Statue of Liberty is exactly described by the words “planet.inches.most.” Three words are much easier to remember than a 10-character alphanumeric, and much less likely to result in a transcription error. The three words can be translated into a GPS location (and vice versa), as well as driving instructions, with simple, free phone applications. The system is already being used in over 170 countries and its use is growing, especially in the developing world where many existing roads are not named or posted. While not currently used by the US military, it could be especially useful in large refugee camps without street addresses, or in humanitarian aid and disaster response missions.

Driving Military Vehicles

Driver training and getting licensed for driving military vehicles is fairly easy, although physicians are not usually required to get these licenses. However, if the base is located in a cold climate, there may be mandatory cold weather driving and vehicle maintenance training; if overseas, there may be specific driving license testing requirements. Operational units and any military facility with a motor pool (a location where military vehicles are stored and maintained) have procedures for qualifying and licensing military personnel to drive military vehicles. Although guidelines establish priority to receive training, there are always opportunities to receive training by request (a recurring theme for most of the skills described in this chapter, which allow physicians to broaden skill sets and function in multiple capacities to be a force multiplier in combat settings).

Convoy Operations

Medical personnel do not usually run convoy operations but may need to travel with a convoy to other locations within a combat zone. Convoys should not be joined without preparation. All participants must be prepared to respond to an attack, which requires practice. The convoy leader (who may not be the senior person in the convoy) should explain and rehearse the proper immediate response to an improvised explosive device (IED) and other types of ambush. Unit medics and physicians must know exactly where medical gear (litter, burn blanket, other blankets, additional aid bags, etc) is located within the convoy and inspect it prior to moving.

Convoy participants should also study the route to be taken; note significant terrain features (eg, which side of the big bend in the Tigris River the embassy is on); keep in mind the safest direction to travel in case of separation; and memorize any rendezvous points along the route. Many convoys carry a tracking device that sends a GPS signal to a secure satellite, which can be tracked by secure ground stations. Some of these tracking devices have an emergency switch; all participants should learn how this device works and how to activate any emergency beacon functions. The physician should know the MEDEVAC (medical evacuation) radio frequency, the frequency to the tactical operations center, and how to work the radio in the vehicle (see Communicate, below). Participants should know about any other countermeasures.

Passengers should sit in the back seat on the driver’s side in countries that drive on the right side of the road (away from the side of the road where bombs might be buried), and wear proper protective equipment (helmet, body armor, eye protection). Electronic noise-cancelling hearing protection, if available, is also beneficial because even a single unprotected exposure to a very loud sound, such as a roadside IED detonation, can permanently damage hearing. This equipment blocks loud and harmful sounds, such as gunfire or explosions, while allowing the wearer to hear faint sounds to maintain situational awareness.

Passengers, even if qualified on the weapon, should stay out of the gun turret. Despite how nice it may feel to get fresh air and how exciting it may be to fire such a weapon, this is an unnecessary risk that puts the entire unit in jeopardy. In addition, filling such a combat role when not absolutely necessary jeopardizes one’s Geneva Convention status and may do irreparable harm to the mission due to unfavorable press coverage.

When moving around a semi-permissive environment (one in which the host nation has only partial effective control of the territory) in civilian-style vehicles, soldiers should try to blend in as much as possible (eg, if the locals do not wear sunglasses, anyone wearing them would be marked as a foreigner).

Personal Equipment and Moving

The concept of “layering” personal combat equipment must be understood. There are three basic layers of personal equipment:

1. The base layer is always worn and consists of the uniform itself; protective equipment (body armor, helmet, eye protection, ear protection, gloves, etc); the Individual First Aid Kit (IFAK), which includes bandaging, tourniquets, analgesics, and antibiotics; critical survival items kept in pockets (map, compass, knife, red-lens LED headlamp, fire starter, etc); and assigned weapon.

2. The second layer is the “combat load,” consisting of items critical to the performance of the mission. It usually consists of ammunition, water, personal radio (if assigned), night optic device (if assigned), and in the case of the unit physician, the aid bag.

3. The final layer is the sustainment load, carried in a rucksack and consisting of items needed for the length of the mission. For a multiday mission, these items include additional water, food, additional ammunition, batteries, climate-appropriate clothing and foul-weather gear, sleeping bag with ground pad, hygiene items, and other items as the mission dictates.

The IFAK should be carried at all times in the location specified by the unit’s standard operating procedure. This allows everyone on the convoy to know where to rapidly find the critical first aid supplies if a soldier is wounded. Common practice is to use supplies from the wounded soldier’s IFAK first, and then use supplies from other IFAKs only if needed.

If movement occurs in the dark of night, helmet-mountable night optic devices (NODs) should be used if available (the term “night vision goggles” should not be used because many common NODs, such as the PVS-14, are monocular and not a goggle). If a NOD is available, the correct mount and bracket to attach the NOD to the assigned helmet must be confirmed and the physician will need to practice with it. In case the physician is the only one uninjured to drive the vehicle, he or she should also practice driving with NODs.

COMMUNICATE

Understanding the basics of military communications is a foundational skill that all military members should grasp, including physicians. This skill is needed to call for a MEDEVAC, to call for help, and to talk with the search and rescue aircraft when forced to escape and evade. Communications equipment is often encrypted, so it is important to have a basic understanding of handling cryptologic material. All communications methods can fail, sometimes at critical times, so familiarity with the communications plan that outlines the multiple redundant communications systems is useful.

The “PACE” (Primary, Alternate, Contingency, Emergency) mnemonic is often used in military communications plans; for example:

- Primary–VHF (very high frequency) military radio

- Alternate–satellite phone

- Contingency–cell phones

- Emergency–send a runner

It is vitally important that all members of a unit, including the physician, be familiar with the plan and know the proper frequencies and numbers necessary to use the equipment. The unit cannot rely on just a few members who are considered responsible for the radio. The unit physician may have to use the radio because the warfighters who are supposed to use it are either incapacitated or actively engaging the enemy.

Military radios are called transceivers, which is a combination of a transmitter (which sends signals) and a receiver (which reads incoming signals). Transceivers use different frequencies of electromagnetic waves, and these frequencies are artificially grouped into named bandwidths. The details on the various bandwidths are listed in Exhibit 10-1.

EXHIBIT 10-1

RADIO FREQUENCY TYPES

- UHF (ultra high frequency), 300–3,000 MHz. Used for line-of-sight communication with aircraft and for satellite communications. Because of its relatively dense frequency, UHF can carry a relatively large amount of data for a given bandwidth. UHF has good short-range penetration and is good for communications inside buildings and structures; however, it has limited range for most ground-to-ground communications and is rarely used for this purpose. Obstacles on the ground more rapidly attenuate UHF than lower frequencies.

- VHF (very high frequency), 30–300 MHz. In the military, VHF is used primarily in ground-to-ground communications, but may be used in military aircraft to communicate with ground-based troops. VHF is the same range used by commercial radio stations. The voice (or data) information is embedded in a carrier frequency by a technique called “frequency modulation,” or FM. As a result, VHF communications are often referred to by the alphanumeric term “Fox Mike” (for FM). Military radios may use a frequency-hopping capability to attempt to foil an enemy from either listening in or using direction-finding equipment to locate the unit. Frequency-hopping radios in communication with each other must be synchronized on the same algorithm (otherwise, communications are impossible); in an emergency, synchronization can be complicated if the user is not familiar with the radio’s operation. Operators should know how to take the radio out of frequency hopping mode and establish communications (“get up”) on the MEDEVAC frequency. VHF is generally useful for line-of-sight communications with a maximum range roughly determined by the height of the antenna, curvature of the earth, and power output, with a common maximum range of 30 miles in clear terrain, and a minimum range of 1 mile or less in dense jungle.

- HF (high frequency), 3–30 MHz. Also known as “shortwave radio,” HF used to be a staple of military long-range communications because it has a potential global reach, but it has largely been replaced by satellite communications. When higher-frequency transmissions reach the ionosphere, they keep going (which is why UHF is useful to communicate with satellites). Under the right circumstances, HF waves could be refracted (bent) by the ionosphere back to earth, potentially sending the signal around the world. HF communications are heavily dependent on time of day, frequency, atmospheric and sun spot activity, antenna configuration, and power output of the transmitter. These factors make HF communications less reliable for military communications. However, the vulnerability of satellites to electro-magnetic pulse radiation may bring HF communications back into more common use in the military. Like all communications, HF signals can be encrypted, and they can be sent in dense brief bursts of data. “Burst” transmissions (versus “voice transmissions”) dramatically reduce the time a potential enemy has to use direction-finding equipment.

“Radio discipline” is exemplified by clear and succinct transmissions, sent only when appropriate. Radio discipline implies using the assigned radio channel (or “net”) only when there is something important to say, and interfering with an ongoing transmission only in an emergency. If a unit is under attack, communication often starts with a phrase such as, “emergency, troops in contact.” This tells everyone on the radio network cease nonemergency communication and prepare to provide assistance. If those listening are unable to help, they remain quiet and off the network while others who are able to assist (eg, a reaction force, close air support, or MEDEVAC personnel) can communicate.

Radio discipline also means knowing when to use standardized formats, such as calling in MEDEVAC or close air support. Exhibit 10-2 is an example of a standard 9-line MEDEVAC format. A 9-line request card should be carried by all service members in a combat zone to use as reference. Executing the request properly will prevent unnecessary delays that could lead to worsened patient outcomes. Utilizing the “9-line” in checklist fashion helps ensure all necessary items, such as hoists, other extraction equipment, or specific medical equipment are requested (memorizing the 9-line MEDEVAC request should not be relied on).

Cryptologic material encodes and decodes communications. Because radios are designed to talk to each other, they all run the same codes (or “fill”) on any given day. This means the loss or misplacement of cryptologic material renders the entire global US military communications system vulnerable. Mishandling cryptologic materials is a significant mistake with serious and lasting consequences. It is absolutely imperative that lost or suspected loss of cryptologic material is immediately reported to the chain of command. Proper handling of cryptologic material is similar to handling narcotics: they must be kept in an approved safe and exactly accounted for on a permanent record. Most military radios have encryption capability. How to “zero-out” or “dump” (permanently delete) the cryptologic material on the radio to prevent it from falling into enemy hands is another skill the physician should learn.

EXHIBIT 10-2

9-LINE MEDEVAC REQUEST

Line 1. Location of the pick-up site.

Line 2. Radio frequency, call sign, and suffix.

Line 3. Number of patients by precedence.

A: Urgent

B: Urgent surgical

C: Priority

D: Routine

E: Convenience

Line 4. Special equipment required.

A: None

B: Hoist

C: Extraction equipment

D: Ventilator

Line 5. Number of patients.

A: Litter

B: Ambulatory

Line 6. Security at pick-up site.*

N: No enemy troops in area

P: Possible enemy troops in area (approach with caution)

E: Enemy troops in area (approach with caution)

X: Enemy troops in area (armed escort required)

*In peacetime, list instead number and types of wounds, injuries, and illnesses.

Line 7. Method of marking pick-up site.

A: Panels

B: Pyrotechnic signal

C: Smoke signal

D: None

E: Other

Line 8. Patient nationality and status.

A: US Military

B: US Civilian

C: Non-US Military

D: Non-US Civilian

E: Enemy Prisoner of War

Line 9. NBC contamination.*

N: Nuclear

B: Biological

C: Chemical

*In peacetime, instead provide terrain description of pick-up site.

Portable satellite communications may be conducted with an encrypted UHF (ultra-high frequency) radio transceiver and a small directional antenna. The antenna must be pointed roughly at the satellite’s location in space, meaning the antenna is pointed on the correct compass bearing and azimuth (angle above the ground, with 90° pointing straight up and 0° pointing at the horizon). Most communications satellites used by the military are in geosynchronous orbits, meaning they stay in the same part of the sky relative to the earth as it spins. These satellites may only be available during certain time windows. The radio must be on the correctly assigned frequencies for sending and receiving, with the correct cryptologic material fill. With the right frequency, fill, and time period, satellite communications are usually the most reliable form of long-distance communication. “Long-distance” is defined as any distance longer than ground-based VHF radios can reliably communicate. One potential disadvantage of satellite communications is that unless the unit also has a specialized antenna for use on a moving vehicle, the vehicle must stop so that the antenna can be pointed in the correct direction and elevation to communicate.

Relying on mobile phones as the primary or only means of communication is a poor plan. Even if it works well in one location on a particular day, it may not work when and where it is needed. When a mobile phone must be used, do not use a personal phone unless it is a true emergency (and part of the PACE plan as described above). A mobile phone may work in one country but fail when the border is crossed into a neighboring country. Country code dialing prefixes for all surrounding countries in the area of operation should be known. Other practical tips that are easy to forget include having the correct plug adapters for charging cables and carrying extra batteries or power supplies to recharge batteries. In many developing countries, mobile phone networks are unreliable during high-use time periods, and dead zones are common and large. If a voice phone call does not go through, sometimes text messages will go through.

Satellite phones, however, do not rely on local cellular networks. They directly communicate with a constellation of satellites that provide global coverage. They are a reasonable alternative plan for communications, but must be routinely tested in locations where they may be needed. Satellite phones that have not been tested cannot be relied on; they may work intermittently; and batteries may die at inopportune times. Units should also ensure there is time on the service contract to cover the period of anticipated use plus at least 2 months. No matter the type of communications device being used, if it is not encrypted, users must not talk about, or around, classified topics.

ADDITIONAL OPERATIONAL MEDICAL TRAINING

In addition to being a physician assigned to a combat unit or special operations unit, there are unique operational medical billets that include training as a flight surgeon (FS) or a dive medical officer (DMO) in the Army or as an undersea medical officer (UMO) in the Navy.

Flight Medicine

Becoming an FS takes between 6 weeks (Army and Air Force) and 6 months (Navy). The reason the Navy’s program is so much longer is because the Navy FS training program includes actual flight training up to the point of solo flight, while the Army and Air Force programs provide only orientation and familiarization flights, not individual flight training. The term “surgeon” is a holdover from the days when all military physicians were considered “field surgeons.” FSs learn the physiological effects of flight and atmosphere as well as the medical administrative requirements for safely providing medical care to aviation personnel. FSs are required to fly as a crew member a minimum of 4 hours a month while in flight status in order to better understand the patient population and their occupational hazards. Similar to a unit physician assigned to an airborne unit who is expected to have parachuting experience, an FS is expected to understand the nuances of the world of military aviation. FSs also perform medical services for military freefall parachute jumpers and drone pilots.

A major challenge faced by the FS is balancing the needs and requests of individual aviators with the needs of the team and mission. An FS must maintain confidentiality with individual aviators, but must also have the authority to ground any aviators when their medical condition may compromise flight safety or mission success. This may involve being available to the flying unit at all times for consultation, as well as coordinating medical care with specialists in a timely manner to get the grounded aviator back to flying status as soon as possible. Being part of the team, while maintaining a proper professionalism to make tough calls, can be difficult. These situations can be managed most effectively when the unit’s aviation personnel know and trust their FS as a person and as a physician. This rapport comes most easily if the FS regularly flies with the crew and spends time with the unit, even in non-work situations. The more time an FS spends with the unit, the more trust and respect he or she will earn, and the FS’s ability to effectively care for the unit and enhance mission-readiness will be multiplied.

Dive Medicine

Army DMOs and Navy UMOs are also specialized operational medical billets. Both are trained as military divers, which is academically and physically very rigorous. A DMO is limited to the care of military undersea divers, while the UMO is also responsible for the medical requirements and medical hazards unique to submariners. Training to become a DMO takes 9 weeks and is conducted by the Navy. Training to become a UMO takes a total of 22 weeks in three phases.[10] Both DMOs and UMOs are experts in the recognition and treatment of diving casualties, including the use of recompression protocols in hyperbaric chambers.

Airborne

Some assignments include an opportunity to attend airborne training. Physicians assigned to an airborne unit are expected to have parachute wings. If they are not already earned, the unit will send the physician to airborne training. Again, this training is a fairly intense shared experience and an opportunity to build rapport, which is critical to earning the unit’s trust and respect, and being an effective unit physician. Experience with parachuting helps a physician understand the unit’s various medical issues and assess its overall health and readiness.

Survival, Evasion, Resistance, Escape

Training in survival, evasion, resistance, and escape (SERE) is vital for military physicians. SERE training teaches vital strategies for staying alive if captured by the enemy. When groups of service members are captured, the captors will exploit the weakest link, and those who have not had SERE training are more likely to succumb. The training is unpleasant at times, but the payoff is more than worth the temporary discomfort. If at all possible, enrollment in SERE training should be pursued by military medical providers.

OTHER CONSIDERATIONS

Military Bearing

In operational units, active duty service members judge the physician by his or her military bearing and appearance. Despite other qualifications, physicians who do not meet weight standards or wear the uniform properly lose credibility. Simple keys to success include staying physically fit, wearing the uniform correctly, keeping hair in regulation, and learning how to give a crisp salute. These simple actions will pay dividends in training opportunities and building respect.

Medical Evacuation and Mass Casualty Planning and Training

Regardless of whether the physician arrives at a new or established deployment location, there are several critical tasks he or she must accomplish. MEDEVAC plans must be confirmed, clinic supplies must be checked, a mass casualty (MASCAL) plan must be ready, and the casualty collection points must be stocked and ready for use. The physician must never fully rely on anyone else to do these tasks, and should not rest until they are done.

Within a week or so of arrival, the physician should insist on a full live rehearsal of the MEDEVAC plan. MASCAL lockers at the casualty collection points should be well stocked with TCCC-approved medical supplies. Well-organized plans to triage, mark, and track casualties, as well as treat multiple casualties at night in foul (or hot) weather is critical. In addition, expansion plans utilizing buildings of opportunity or putting up additional tents must be considered if tactically appropriate.

Reliably receiving medical supplies in a timely manner can be notoriously difficult in a combat setting, so the physician must understand how medical supplies (Class VIII) are ordered and how long it takes to receive them. A good starting plan is to arrive with enough supplies to last at least twice as long as the typical logistics chain timeframe without resupply.

Preventive Medicine

Field sanitation and preventive medicine are vital to the health and readiness of the unit. The unit physician oversees unit preventive medicine assets and must ensure that adequate preventive medicine measures are in place. He or she is responsible for maintaining acceptable, approved methods of procuring clean water, adequate hand-washing stations, vector control measures, and latrine and shower facilities, both for enhancing unit morale and, more importantly, for controlling disease rates. Throughout history, unit effectiveness has been harmed more by disease and nonbattle injuries than from conflict-inflicted injuries. It is vital for the unit physician perform this role effectively (see Chapters 16 and 40).

Operational and Intelligence Briefings

The physician must understand what the unit’s objective and mission are and where they will take place. To be effective in a combat environment and thus a force multiplier, the physician must understand the mission to anticipate the medical threats to the unit. Thus, the physician should request operational briefings from the operations section of the unit to develop a proper situational awareness. If possible, the physician should see where the troops are living, especially if they are remotely located. Food safety must be assessed (actually a military public health officer responsibility, but the physician has overlapping responsibilities), as well as water safety, sanitation, and force protection measures such as ensuring warfighters are taking proper precautions to protect themselves from vector-borne illnesses (eg, antimalarials). The physician is responsible for performing these tasks without direction from command. The physician is the subject matter expert and must bring any concerns found during these inspections to the unit commander.

In addition to receiving briefings from operations, the physician should seek a briefing from the intelligence section for information about the enemy situation. Similar to the operational environment, the intelligence environment and threats must be understood by the physician, at least in broad strokes. For example, understanding how realistic it is for chemical, biological, radiological, nuclear, or explosive (CBRNE) weapons to be used by the enemy will greatly enhance the physician’s preparations for what kind of casualties may be expected. The CBRNE threat is real, and it is better to be prepared for the worst scenario. Intelligence personnel will help the physician increase situational awareness within the confines of security clearances.

Time Management

Although physicians should seek combat training as described in this chapter, their primary duty is to be an outstanding physician. The unit physician must be mindful of impressions (eg, if the physician is out of the clinic too often going to the shooting on the range, it may cause resentment from colleagues who may have to cover clinic duties). The unit physician must learn how to balance personal injury risk from combat training activities, time outside the clinic, and maintaining clinical proficiency to perform the primary task as the unit’s medical expert. During training as well as at deployed locations, the physician should be willing to help load pallets, put blast blankets over windows, help fill sand bags, and perform other unit tasks. In this way other unit members will accept the physician as a team member, working toward the same mission goals. This earned respect will pay dividends by the warfighters who will look out for their physician in ways that cannot be easily articulated.

SUMMARY

To be an effective military physician and a force multiplier by supporting the warfighters in the combat unit, medical officers must take the initiative to learn tactical field skills. It is not enough to be a good physician. Military physicians must know the warfighters and their mission, and they must learn to shoot, move, and communicate effectively. Physicians must balance this training with their primary role as the unit medical officer. During deployment, the physician is ultimately responsible for casualties, and even experienced medics will look to them for guidance and leadership, whether or not the physician has tactical experience. At all times, physicians must prepare for and respond to threats to the unit’s health and readiness. To be most effective, they must employ both medical and tactical training.

REFERENCES

1.   Geneva Convention I, articles 24–26.

2.   Geneva Convention II, article 36.

3.   Geneva Convention IV, article 20.

4.   Congressional Medal of Honor Society. Boone, Joel Thompson. http://www.cmohs.org/recipient-detail/2506/boone-joel-thompson.php#. Accessed May 30, 2017.

5.   The US Navy Memorial. Joel Thompson Boone. http://navylog.navymemorial.org/boone-joel. Accessed May 30, 2017.

6.   Committee on Tactical Combat Casualty Care. PHTLS (Prehospital Trauma Life Support), Military. 8th ed. Burlington, MA: Jones & Bartlett Learning; 2016: 655–850.

7.   Geneva Convention I, article 22.

8.   Peterson A. Why Naval Academy students are learning to sail by the stars in the first time in a decade. Washington Post. https://www.washingtonpost.com/news/the-switch/wp/2016/02/17/why-naval-academy-students-are-learning-to-sail-by-the-stars-for-the-first-time-in-a-decade/?utm_term=.ebee5a6caea0. Published February 17, 2016. Accessed August 28, 2018.

9.   what3words website. https://what3words.com. Accessed August 28, 2018.

10.   Navy Medicine Operational Training Center website. http://www.med.navy.mil/sites/nmotc/numi/Pages/default.aspx. Accessed August 28, 2018.

Chapter 11

MILITARY COMMUNICATION

ANGELA M. YARNELL, PHD*; CINDY DULLEA, RN, MBA†; AND NEIL E. GRUNBERG, PHD‡

INTRODUCTION

DEFINITION

RELEVANCE OF MILITARY AND MEDICAL COMMUNICATION

COMMUNICATION AS IT RELATES TO LEADERSHIP

PRINCIPLES OF EFFECTIVE COMMUNICATION

FORMS OF COMMUNICATION

MILITARY-SPECIFIC COMMUNICATION REQUIREMENTS

Written Communication

Formal Oral Communication

Counseling and Feedback

OTHER COMMUNICATION CONSIDERATIONS

Addressing Difficult Topics

Importance of Communication to the Military Family

RESOURCES

SUMMARY

ATTACHMENT: KEY COMPONENTS OF MILITARY COMMUNICATION FOR MEDICAL OFFICERS

*Major, Medical Service Corps, US Army; Research Psychologist, Behavioral Biology Branch, Center for Military Psychiatry Neuroscience Research, Walter Reed Army Institute of Research, Silver Spring, Maryland

†Rear Admiral (Retired), Nurse Corps, US Navy Reserve; Chief Marketing Officer, Experian Health Inc, Franklin, Tennessee

‡Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

Good communication is a cornerstone of effective leadership. To optimize influence, the medical leader must provide purpose, direction, and motivation. To this end, the medical leader’s primary tools are written, spoken, and nonverbal communication skills. Military briefings, military correspondence, checklists, and appropriate communication style are all critical leadership skills needed in all military settings and mission profiles.

Communication is an important component to success in the military and in medicine. More than the process of exchanging or transferring information in an understandable way, effective communication is a key competency of military and medical leaders.[1] To accomplish this goal, military medical leaders need to develop social and interpersonal communication skills. Though they occur from the beginning of life, most people are unaware of their strengths and weaknesses when it comes to communication. The purpose of this chapter is to define communication, describe the relevance of military and medical communication, emphasize the importance of communication to leadership, and provide specific examples of effective communication. The chapter concludes with specifics about military communication forms and formats.

DEFINITION

Communication in its simplest form is defined as the exchange of information; it includes sending and receiving information verbally and nonverbally. It is inherently an interactive social process[2] that facilitates understanding between individuals. However, the purpose of communication among military leaders is not simply to exchange information; it is also to change or influence others so that they perform a desired action. Communication can be used to increase awareness of issues and provide possible solutions; it can help bridge cultural sensitivities and lead to consensus. Ineffective communication can have the opposite impact.

RELEVANCE OF MILITARY AND MEDICAL COMMUNICATION

Conveyance of information by the armed forces is vital to military success, and it is especially critical for the coordination of action.[3] Passing information among troops has been necessary since the first military engagements, and forms of military communication have been transformed along with military forces as technology has improved. The earliest communication was delivered on foot by runners carrying messages, followed by the use of visual and audible signals. Signals were transferred over long distances using drums, horns, flags, and riders on horseback. While the US Army was the first in the world to have a separate communication branch (the Signal Corps, formed in 1863, based on the adoption of signal flags developed by Army doctor Albert Myer), effective use of communications technology (signal flags) was a testable skill for certain naval ratings more than a century earlier.

Despite this long history, communication in the military and in medicine is subject to limitations. Information can be lost or distorted as it is passed among individuals. In business, it is estimated that 80% of information is lost as it is translated from top management to the lowest level of employees.[4] This distortion can occur if information is intentionally changed, or when there is a subtle change in each transmission, like the children’s game of telephone. Changes occur based on assumptions as well as cognitive, physical, or social limitations[5] of the sender or receiver. In the military and in medicine, loss or distortion of information can have catastrophic consequences.

In the military, giving clear and precise instructions in the form of orders is important for success. For this reason specified formats have been developed to issue orders and for most forms of military communication (specifics appear later in this chapter). When performance is expected to occur under stressful conditions, training and rehearsal become particularly important, and communication cannot be forgotten in this process. A mark of a highly trained unit is rapid and accurate communication that results in automatic responses.[3]

Not only is effective communication vital to military success, but it is also key to providing quality medicine. Interpersonal and communication skills are one of six competencies expected of residents by the Accreditation Council for Graduate Medical Education[6] and may be as crucial as other technical proficiencies in patient care. According to a report by the US Department of Health and Human Services,[7] these skills commonly include data-gathering skills (eg, use of open-ended questions, particularly in the psychosocial domain); relationship skills (eg, use of empathy, reassurance, support, and emotional responsiveness); partnering skills (eg, paraphrasing, asking for patient opinions, negotiation, and joint problem solving); and counseling skills (eg, informativeness, persuasion).8,9

These necessary patient communication skills are collectively referred to as “patient-centeredness”8,10,11 and are demonstrated via responsiveness to patients’ values, needs, and preferences. Effective communication allows healthcare providers to build trust with their patients and enhance clinical care.12–14 Further, patient-centered physician behaviors have been associated with positive patient relationships and health outcomes.15,16 Specifically, communication skills have been linked to a number of valued patient outcomes, including satisfaction, adherence to treatment regimen, and positive health indicators.[8] With regard to these skills, it is important to consider how characteristics of the physician, either innate or shaped by experiences, contribute to the patient-provider interaction. Several specific components of physician-patient communication valued by American adults have been identified, including the values of any effective communication: respect, attentiveness, and assuring the communication is a dialogue. Beyond verbal communication skills, the physician must be able to interpret a patient’s nonverbal cues and adapt communication to individual patients. Dyche[17] highlights valuable interpersonal skills for medicine, including understanding, empathy, and relational versatility. Communicating with patients to ensure that they understand the medical care they are receiving, often referred to as “informed consent,” is also an important skill (Exhibit 11-1) and is especially nuanced in the military provider-patient relationship.

EXHIBIT 11-1

INFORMED CONSENT

Medical providers are often required to ensure the patient understands what will happen as it relates to medical care and procedures. This process is often done orally, and the provider explains potential risks and benefits of medical care or procedures and asks the patient if he or she understands and is ready to receive the care, such as in the case of inserting an intravenous line. The process entails transmitting information and receiving consent to ensure that the message is received. During treatment of active duty service members, the service members have some rights, but their right to refuse care is limited. Knowing these boundaries is important for the military medical officer (MMO). The context of the provider-patient information exchange is also important: on the battlefield, there are not a lot of alternative options for receiving care, but in the clinic there may be. Because of these circumstances, establishing a patient-provider relationship beyond the one that comes with the uniform or based on rank is important. To establish trust, the MMO should leverage commonalities between the patient and the provider (eg, both wear the uniform, speak a common language). Providers must know when to use or not use vernacular and be mindful of the context. Some tips for developing this kind of interaction include:

- engaging patients and patient populations at every opportunity

- ask about common acronyms

- ask about their jobs

- do not be afraid to ask

- understand patient identity

- practice military bearing

- seek out opportunities for improvement (eg, a committee that provides other people’s perspectives, such as a risk management committee or patient complaint committee)

- break through rank structure when possible (eg, not wearing the uniform)

- be a lifelong learner, seeking answers and sharing information with colleagues

- know what must be disclosed to patients’ leadership, which may differ by unit or service (eg, pregnancy, other potential limitations related to a diagnosis, substance abuse, suicidal ideation)

- try to develop a therapeutic alliance prior to making necessary disclosures that may facilitate the patient to self-disclose, eg, ask “who would you like me to talk to in your command?”

- support patients through the process

Not only is provider-patient interaction important, but also the interaction within medical teams can impact medical care.[18] Poor communication among medical team members (physicians, nurses, other caregivers) is related to greater conflict among these groups, disruption in service to patients, medical errors, and reduced quality of care.19–24 Subtle factors involved in communication, such as status or power, values, and attitudes,[25] can affect the information exchanged among team members. Given these factors, optimal communication is key to the development and operation of teams. Specifically, the sharing of mutual knowledge is accomplished by team members frequently listening to each other, participating in joint decision-making, and engaging in informal as well as formal interactions.[26] Enhancing the interaction of teams is ultimately about leadership, and leadership is an obvious intersection between being a medical provider and being a military officer. The following section addresses communication and its important implications for leading military medical teams.

COMMUNICATION AS IT RELATES TO LEADERSHIP

There is a strong positive correlation between communication and leadership effectiveness.[27] Leaders who demonstrate communication skills are considered more effective than leaders who do not communicate well. Each of the services incorporates communication into leadership principles in similar ways (Exhibit 11-2).

Leaders communicate more than do other group members, but it is not always about how much is communicated; rather, the quality of what is communicated and the way in which the communication occurs may be more important than the quantity.[28] Effective communication occurs when leaders are skilled in self-presentation and impression management29,30; when they listen and care about their followers’ perspective; and when they motivate followers by framing their communication according to that perspective. These behaviors are all evidence of highly developed communication skills.[28] These skills go beyond the traditional personality traits often associated with “good” communicators (eg, sociability, extraversion, assertiveness); other necessary skills include the ability to decode information or cues from others and to adapt communication to changing situations.[28]

EXHIBIT 11-2

COMMUNICATION AS IT RELATES TO LEADERSHIP BY SERVICE

Army

According to Army Regulation 600-100,[1] “Leaders communicate by expressing ideas and actively listening to others. Effective leaders understand the nature and power of communication and practice effective communication techniques so they can better relate to others and translate goals into actions. Communication is essential to all other leadership competencies.” Additionally, according to Army Field Manual 6-22,[2] “Communication needs to achieve a new understanding …. Leaders cannot lead, supervise, build teams, counsel, coach, or mentor without the ability to communicate clearly.”

Air Force

Air Force leadership doctrine (AFDD 1-1[3]) highlights communication as a tool for Air Force leaders, who must facilitate communication to “ensure a free flow of information and communication up, down, across, and within an organization by actively listening and encouraging the open expression of ideas and opinions.”

Navy

The Naval Leadership Competency Model, proposed to improve the definition of leadership by defining the expected behaviors and knowledge of Navy leaders, includes “working with people” as one of its five core competencies, with subcompetencies of written and oral communication.[4]

Marines

One of the primary leadership resources for the US Marine Corps is Marine Corps Warfighting Publication 6-11, Leading Marines,[5] which emphasizes qualities of the individual leader and leadership principles. Critical communication components can be surmised from traits (eg, tact, bearing) and principles, which are trained starting in boot camp and professional training for officers.

____________

1. Department of the Army. Army Profession and Leadership Policy. Washington, DC: HQDA; 5 April 2017. AR 600-100.

2. Department of the Army. Army Leadership. Washington, DC: HQDA; October 2006. FM 6-22.

3. Department of the Air Force. Leadership and Force Development. Washington, DC: USAF; 8 November 2011. Air Force Doctrine Document 1.1.

4. Air University website. Navy Leadership Competency Model. http://www.au.af.mil/au/awc/awcgate/navy/navy-ldr-comp.htm. Accessed August 26, 2018.

5. Department of the Navy. Leading Marines. Washington, DC: US Marine Corps; 27 November 2002. Marine Corps Warfighting Publication 6-11.

Leaders must develop social and interpersonal skills to be effective communicators, specifically, social skills such as self-monitoring,[31] behavioral flexibility,[32] and social intelligence, and interpersonal skills including interpersonal acumen[33] and emotional intelligence. An important aspect of social skill is self-monitoring. Self-monitoring can be described as the ability to adapt one’s behavior to perform appropriately in social situations by assessing those situations.34,35 High self-monitors adapt to situations around them better than low-self monitors and are more likely to emerge as leaders. Skillful communication requires this kind of adaptation.[28] Socially skilled communicators adapt based on audience reaction; critical feedback; changes in the environment or situation in which the communication is taking place; and updated facts or new developments relevant to communication. Socially skilled leaders perform better under stressful situations.[36]

In medicine, better social skills used in communication facilitate agreement from patients on difficult treatment decisions and long-term compliance with treatment plans.37–40 Social skill in communicating includes expressivity (sending), sensitivity (decoding), and control (regulating communication), which occur in the verbal/social domain as well as the nonverbal/emotional domain. A skilled communicator demonstrates expertise by balancing each of these three competencies across both domains.[41] These skills are trainable and evolve with experience. Specifically, social expressivity and social control improve through clinical experience, receiving feedback from attending physicians, and interactions with patients and peers.[42]

Social expressivity and social control may contribute to a greater amount of social intelligence. As described by Zaccaro,[31] a person with social intelligence is able to perceive and interpret social situations and is also flexible and adaptable in his or her behaviors. Social intelligence is particularly important for effective leadership, especially the higher an individual moves up in an organization, where he or she is likely to experience more complex social situations.[31]

In addition to social skills, effective communicators possess necessary interpersonal skills or interpersonal sensitivity. These skills include listening and decoding abilities, which develop good relationships that lead to increased subordinate satisfaction.43,44 Emotional intelligence is important for interpersonal interactions. Emotional intelligence represents the ability to:

- monitor the emotions of self and others,

- differentiate distinct emotions,

- label emotions correctly, and

- use this information to guide behavior.[45]

Leader-follower relationships are highly dependent on emotional intelligence. A leader needs to be able to perceive the emotions of others as well as generate and regulate his or her own emotions.[46] Emotional intelligence can be a leadership attribute (ie, it comes naturally to some leaders) or it may require training and practice to accomplish it fully and genuinely.

In practice, understanding and being receptive to the emotions of others enhances communication. To influence an audience of followers or subordinates, a leader must first appreciate how that audience feels and thinks, and what they care about, as well as genuinely respond to these thoughts and feelings.[2] To motivate followers into action through communication, the leader must first understand what motivates them, or “meet them where they are.” Followers and patients have their own ideas, feelings, concerns, and perspectives, and effective communicators start by taking these aspects seriously. Leaders who arouse, inspire, and motivate followers via effective communication are typically demonstrating transformational leadership.[28] This form of leadership is associated with more satisfied and higher performing groups.

Active listening is another interpersonal skill that can be used to understand what motivates followers. An active listener avoids interruption, indicates to the speaker that he or she is attentive, keeps mental or written notes to follow up on once the speaker is finished, does not form a response instead of listening to the entire message being conveyed, and is not distracted or otherwise impeded from listening. An active listener is absorbing not only what is said, but also how it is said, and attempts to appreciate the emotion in the message in addition to the content.

It is clear why effective communication skills are important to military medical leadership, but exactly how to achieve skill with communication requires additional information. The next section provides specific examples about how to communicate effectively.

PRINCIPLES OF EFFECTIVE COMMUNICATION

Principles of effective communication stem from social psychological research, which originated with the concept of informal social communication. In a ground-breaking study, Festinger, Back, and Schachter found that functional space as opposed to the physical environment had a greater influence on the amount and quality of communication among neighbors in a housing complex.[47] Schachter’s role in this research was influenced by his time serving in the Army Signal Corps. Functional space is a simple concept that can be applied on the battlefield as well as in the clinic. For example, the set-up of a triage area or treatment tent in the field can make or break effective communication. If the surgeon is able to treat two patients simultaneously with the assistance of medics or corpsmen, then he or she will be more efficient, and this added efficiency can be facilitated by orchestrating the functional space. The communicator should always consider manipulating the environment to facilitate communication. Some specific examples for military medicine include horseshoe formations, noise reduction, face-to-face versus email communication, and use of social media.

Additional concepts for enhancing effective communication can be gleaned from psychological research. The timing or order of information presentation is important. For example, items or arguments offered at the beginning of the communication are best remembered, which is referred to as primacy.[48] In the military, the concept of giving the “BLUF,” or “bottom line up front,” is used to convey the most important information, or a summary, before providing all the details. This practice allows for efficient communication and is favored by many in military culture, especially senior leadership. Like primacy, research also supports the notion of recency, where arguments made at the end of a communication are well remembered.[48] Effective communication also includes repetition of key concepts to increase their salience for the audience.

The credibility of the communicator has a great effect on how and how well the information is received. Military medical officers (MMOs) are often challenged to prove their credibility in situations where they interact with line-level commanders and patients. For example, the unit surgeon is the medical advisor to the commander and therefore should establish credibility for providing necessary medical information about the unit and its mission. The credibility of a physician also may be key in patient interactions. Patients must find their doctor credible to take advice about their health. There are ways to increase the perceived credibility of the communicator. The first is to defend against or minimize perceived self-interest.[49] When it is perceived that the communicator stands to gain more from the communication than those who are receiving it, the information is often not effective. If the communicator is at least able to demonstrate a shared interest, he or she is more likely to be viewed as credible and the communicated information will be better received.

The MMO must know when to highlight medical credentials versus military credentials. For example, when building rapport, sometimes it may be important for the patient to be understood as a service member, and related to in that way; whereas, in other situations, patients may want to be more confident in their provider’s medical knowledge and ability to address their concerns. Reading the patient’s body language and developing a rapport that facilitates communication is important to establish credibility. In interactions in which trust seems lacking (eg, noncompliance by patient), the MMO must take steps to build credibility or trust. Asking, “What do you need to know about me as a physician?” may be a good place to start when it seems that the patient is questioning the MMO’s medical knowledge. Then providing information about credentials such as, “I have these qualifications” or “I have this number of years of training” or “I have the same qualifications as doctors at X civilian hospital” may be good information to share.

Another way to establish credibility is to demonstrate it over time. The “sleeper effect” is a phenomenon in which over time the source of the information is forgotten and only the content is remembered.50,51 An MMO may accomplish this form of credibility by slowly but consistently performing at or above the expectations of those around him or her. This consistent build, often in small ways (eg, respectful interactions with subordinates, always being early or on time for obligations), will over time lead to a positive regard for the leader or communicator. Ultimately, the best way to establish and maintain credibility is to ensure words are matched by actions; otherwise, the communicator is viewed as not credible.[2]

FORMS OF COMMUNICATION

There are two main forms of communication: verbal and nonverbal. Important aspects of verbal or spoken communication to keep in mind include volume, verbal tics, silence, tone, phrasing, pitch, tempo, rhythm, accents, dialect, and use of colorful language. Characteristics of nonverbal communication include attire, position and proximity, movement, facial expressions, body language, eye contact, gestures, interactions with media, and interactions with audience or listeners.

Military bearing is a key component of both verbal and nonverbal communication. Military bearing is described as projecting a commanding presence, an image of authority and discipline. This attribute carries great importance for communication and leadership for military officers. Leaders and communicators are judged based on three observable attributes: bearing, how the communicator engages with others, and words used for the interaction. Judgments based on bearing are made in the first 15 seconds. Before a word is even spoken, the audience is judging the speaker and deciding if they should pay attention, if they can rely on what he or she is saying, and whether or not he or she is credible; these decisions can define the audience’s reaction regardless of what the speaker has to say.[2] A communicator who displays nervousness or discomfort will cause the audience to look away and disengage, while one who displays comfort and confidence will capture the audience’s attention. A communicator can establish a physical presence of confidence by planting his or her feet further apart than natural, or taking on a position of power.52,53 Even if the speaker does not inwardly feel confident, taking on this position will convey confidence and command the audience’s attention. Formal appearance, from the cleanliness of one’s uniform, to adherence to height and weight standards, to style and amount of makeup, will also be judged as part of the communicator’s bearing.

The communicator’s subsequent behaviors are also important to connecting with the audience. Looking down, random hand movements, shuffling of feet, licking lips, looking at objects versus people, and speaking in a monotone voice all cause an audience to disengage. These behaviors can have compounding effects and diminish the speaker’s effectiveness. However, the use of gestures should not be completely discouraged. In fact, when a speaker uses gestures the audience retains more of the information being transmitted, especially when the voice, gestures, and content of the speech are well aligned and gestures allow the speaker to use different voice effects (eg, varying volume, pitch, speed, pauses). The speaker should also move around in concert with what is being said, not randomly.

MILITARY-SPECIFIC COMMUNICATION REQUIREMENTS

There are requirements and nuances of communicating in the military, which include specifications for written communications, formal oral communications (military briefings), and counseling or feedback. This section outlines some of the resources available for written communication, military briefings, and providing counseling and feedback.

Written Communication

Specific regulations are associated with written correspondence and communication in the military. Memorandums and executive summaries (EXSUMs) are examples of specific written correspondence. An EXSUM is a short document or section of a document in which a summary of the longer report is provided to allow for rapid acquaintance with a large body of material without having to read it all. This summary is typically provided to higher leadership to inform them of a body of work or other important information. Table 11-1 provides a list of resources with guidance to prepare an EXSUM (however, organizations often develop their own guidance for writing an EXSUM based on the leadership preferences). Table 11-1 also lists specific service manuals for written communication.

EXHIBIT 11-3

CHECKLIST EXAMPLES

SOAP Note

The “SOAP note” is a way to document medical information and increase communication among members of a medical team.

S: Subjective, or what the patient tells you.

O: Objective, or the physical findings of the exam.

A: Assessment, or your interpretation of the patient’s condition.

P: Plan, which may include medical treatment, additional diagnostic tests needed (eg, x-ray, magnetic resonance imaging); special instructions (eg, handouts, when to return to clinic).

“Time-out” Procedure

The “time-out” procedure is a standardized protocol used to prevent mistakes prior to medical procedures and enhance communication among team members. A time-out involves the immediate members of the procedure team (eg, individual performing the procedure, anesthesia providers, nurse). During the time-out, the team members agree, at a minimum, about the following:

- patient identity

- correct site

- procedure to be done

Formal Oral Communication

Military briefings are a form of formal oral communication. Military briefings include informational briefings, operations orders briefings, course of action briefs, military decision-making processes, and rehearsals. Each service has a specific way in which these briefings are planned and carried out. See Table 11-1 for a list of resources available to prepare formal oral communications. Checklists are also useful in planning and delivering briefings. Various checklists are created at the service as well as unit levels and can be found in respective service field manuals and similar publications (see Table 11-1). Other checklists relevant for MMOs include “SOAP” notes and “time-out” checks before procedures (Exhibit 11-3 provides examples). Rehearsals (often called rehearsal of concept, or ROC, drills in the military) can allow leaders to ensure their subordinates understand the upcoming operation and know how and when to act and how to communicate during the operation (“operation” refers to any collective task that a group may be attempting to accomplish).

TABLE 11-1

MILITARY-SPECIFIC COMMUNICATION REQUIREMENTS

Topic

Service

Manual

Title

Written Communication

General

Army

AR 25-50

Preparing and Managing Correspondence^1

DA Pam 600-67

Effective Writing for Army Leaders^2

Air Force

Air Force Manual 33-326

Preparing Official Communications^3

Navy

SECNAV Manual M-5216.5

Correspondence Manual^4

EXSUM

Army

TRADOC Regulation 1-11

Staff Procedures^5 (Chapter 3.5)

Navy/Marine Corps

[No number]

A Guide to Writing an Effective Executive Summary^6

Oral Communication

Formal

Army

Field Manual 6-0

Commander and Staff Organization and Operation^7

Air Force

Air Force Handbook 33-337

The Tongue and Quill^8

Briefing

Joint

Joint Forces Staff College Publication 1

The Joint Staff Officers Guide^9 (Chapter 5)

AR: Army Regulation; DA Pam: Department of the Army Pamphlet; EXSUM: executive summary; SECNAV: secretary of the Navy; TRADOC: Training and Doctrine Command

1. https://armypubs.army.mil/epubs/DR_pubs/DR_a/pdf/web/r25_50.pdf

2. http://www.au.af.mil/au/awc/awcgate/army/p600_67.pdf

3. http://static.e-publishing.af.mil/production/1/saf_cio_a6/publication/afman33-326/afman33-326.pdf

4. https://www.marines.mil/Portals/59/Publications/SECNAV%20M%205216.5.pdf

5. http://www.tradoc.army.mil/tpubs/regs/tr1-11.pdf

6. https://www.med.navy.mil/sites/nmcphc/Documents/environmental-programs/risk-communication/Appendix_E_Guide_to_Writing_Effective_Executive_Summary.pdf

7. https://armypubs.army.mil/ProductMaps/PubForm/Details.aspx?PUBNO=FM+6-0

8. http://static.e-publishing.af.mil/production/1/saf_cio_a6/publication/afh33-337/afh33-337.pdf

9. http://www.au.af.mil/au/awc/awcgate/pub1/index2000.htm

Combat orders enable a leader to communicate in a timely manner (see Chapter 18). There are three types of combat orders: operation order (OPORD), warning order (WARNO), and fragmentary order (FRAGO). The OPORD is utilized by a commander to effect the coordinated execution of an operation. A WARNO normally precedes the full operation order and is a preliminary notice that the complete order is to follow. A FRAGO is used to communicate updates or changes to an existing order. The OPORD follows a five-paragraph format, which is shared among the US armed forces and NATO allies. These orders are given in written and oral formats.

Counseling and Feedback

Providing subordinates with evaluation of their performance is a critical part of leadership in the military. Evaluation is accomplished in a number of informal and formal ways. “On-the-spot” feedback is an example of informal evaluation in which the leader makes a necessary corrective action to undesirable behavior or provides praise for a job well done. Formal evaluation takes place through counseling (written and oral), performance evaluation, and awards. As mentioned earlier, it is important to provide subordinates with expectations of their behavior and performance. These expectations are communicated during formal counseling sessions, often in the form of performance objectives to be accomplished.

Good behavior should be rewarded through various methods. The first is public praise, such as positive words spoken in front of peers at a staff meeting. Good behavior can also be recognized with coins, certificates of appreciation, and awards. Awards should be used to recognize performance that goes above and beyond duties as assigned. Specific guidance for these processes can be found in service regulations, department instructions, and other similar publications (eg, Army Regulation [AR] AR 600-8-22[54] and AR 215-1,[55] Navy Bureau of Medicine and Surgery Instruction 1650.1A,[56] and Air Force Instruction 36-2803[57]).

Behavior that detracts from the unit’s mission, disparages others, or is in general conduct unbecoming a military member should also be addressed. For the most part, this kind of behavior should be corrected in private. Leaders need to hold all their subordinates accountable for their actions to facilitate mission success. To do this, the leader must sometimes correct bad behavior. The process by which undesirable behavior can be addressed includes both informal leader-subordinate interactions and formal actions (eg, counseling statement, reprimand, or admonition; see service-specific publications such as AR 600-8-104, Army Military Human Resources Management,[58] and AFI 36-2907, Unfavorable Information File Program[59]). Proactive and constructive feedback, including assertive communication and the effective use of praise, can facilitate good leader-subordinate relationships while increasing morale and resilience in groups.

There are also tools available to facilitate unit-level feedback. After action reviews (AARs), for example, are an excellent venue to assess the performance of a unit. AARs are important to define best practices as well as ensure process improvement. Originally developed by the Army and described in Training Circular (TC) 25-20, Leader’s Guide to After-Action Reviews,[60] AARs are now used in all services as well as in many nonmilitary settings. The formal process to conduct an AAR includes statements regarding (a) a description of events that occurred, (b) things that went well, and (c) things that can be improved. Whether or not the AAR is conducted in a formal or informal manner, this form of communication is a valuable tool in the operation of any organization.

OTHER COMMUNICATION CONSIDERATIONS

Addressing Difficult Topics

A communication challenge that MMOs often face is the need to address difficult material or topics. The burden is often on leaders to handle uncomfortable topics[2] and on medical providers to address negative health issues. In these situations, it is best to ensure consistency of message, appropriate tone, and timeliness. Allowing the situation to linger because of personal worry, embarrassment, or fear may only make things worse. Followers want to know that their leader is in control, and patients look to the provider for answers and guidance. However, rash decision-making is not a good option either. As mentioned in the attachment to this chapter, the “first mover advantage” should be used in situations when the leader is expected by followers to act immediately, when the followers or others (critics) are already discussing the situation, and especially when silence will be perceived as indifference. A leader who delays communication in these instances loses the ability to control the outcome of the conversation or situation.[2] In these circumstances it is also important to be aware that words matter and different words can have different impacts, which are additional reasons to plan and prepare for difficult communications.

Importance of Communication to the Military Family

While beyond the scope of this chapter, consideration of similarities and differences when communicating with military family members compared to the military member should not be overlooked. Dependents play vital support roles in the medical care and life of the service member, and he MMO should be aware of any unique circumstances. The MMO must recognize the unique stressors and dynamics associated with military life that may be operating in their patients’ and patients’ family lives. According to the civilian literature, the four most important factors for a family member of a patient when receiving bad news from a medical provider are (1) the provider’s attitude, (2) clarity of the message, (3) privacy, and (4) the provider’s ability to answer questions. Also, it is important for MMOs to be aware of and educated about the different rules for disclosure of information when treating service members versus dependents (see Chapter 5).

RESOURCES

Key components of communication for MMOs include purpose, direction, motivation, style, and planning. These are discussed in the attachment to this chapter. Other resources include Garcia’s book, Power of Communication: The Skills to Build Trust, Inspire Loyalty, and Lead Effectively,[2] and Dyche’s article, “Interpersonal Skill in Medicine.”[17] As mentioned, each service has published communication manuals listed in Table 11-1; the services have also posted writing advice on the following websites:

- http://www.armywriter.com/army-writingreferences.htm

- http://www.navywriter.com/

- http://www.airforcewriter.com/

SUMMARY

Effective communication is important for military and medical leadership. MMOs must strive to develop, refine, and master social and interpersonal skills to become effective communicators and leaders. In military leadership and medicine, saying the right thing in the right way may not be enough. Skillful communication should be considered a “force multiplier” to be used alongside other important technical and tactical competencies in the MMO’s toolkit.

REFERENCES

1.   US Army. Be, Know, Do: Leadership the Army Way: Adapted from the Official Army Leadership Manual. San Francisco, CA: Jossey-Bass; 2004.

2.   Garcia HF. Power of Communication: The Skills to Build Trust, Inspire Loyalty, and Lead Effectively. Upper Saddle River, NJ: FT Press; 2012.

3.   King A. The word of command communication and cohesion in the military. Armed Forces Soc. 2006;32:493–512.

4.   Hawkins BL, Preston P. Managerial Communication. Santa Monica, CA: Goodyear Publishing Company; 1981.

5.   Stohl C, Redding WC. Messages and message exchange processes. Process Commun Behav Organ. 1988;25:451–502.

6.   Holmboe ES, Edgar L, Hamsta S. The Milestones Handbook. Chicago, IL: Accreditation Council for Graduate Medical Education; 2016: 20. http://www.acgme.org/Portals/0/MilestonesGuidebook.pdf. Accessed June 21, 2017.

7.   US Department of Health and Human Services. Communicating Health: Priorities and Strategies for Progress. Washington, DC: Government Printing Office; 2003.

8.   Lipkin MJ, Putnam SM, Lazare A, et al, eds. The Medical Interview: Clinical Care, Education, and Research. Heidelberg and New York; Springer; 2011.

9.   Roter D. The enduring and evolving nature of the patient–physician relationship. Patient Educ Couns. 2000:39(1):5–15.

10.   Mead N, Bower P. Patient-centeredness: a conceptual framework and review of the empirical literature. Soc Sci Med. 2000:51(7):1087–1110.

11.   Tressolini C. Health Professions Education and Relationship-Centered Care: Report of Pew-Fetzer Task Force. San Francisco, CA: Pew Health Professions Commission; 1994.

12.   Joos SK, Hickam DH, Gordon GH, Baker LH. Effects of a physician communication intervention on patient care outcomes. J Gen Intern Med. 1996:11(3):147–155.

13.   Levinson W, Chaumeton N. Communication between surgeons and patients in routine office visits. Surgery. 1999:125(2):127–134.

14.   Roter DL, Hall JA, Katz NR. Patient-physician communication: a descriptive summary of the literature. Patient Educ Couns. 1988:12(2):99–119.

15.   Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med. 2001:76(4):390–393.

16.   Braddock CH 3rd, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999:282(24):2313–2320.

17.   Dyche L. Interpersonal skill in medicine: the essential partner of verbal communication. J Gen Intern Med. 2007:22(7):1035–1039.

18.   Michan S, Rodger S. Characteristics of effective teams: a literature review. Aust Health Rev. 2000:23(3):201–208.

19.   Friedman DM, Berger DL. Improving team structure and communication: a key to hospital efficiency. Arch Surg. 2004:139(11):1194–1198.

20.   McCue JD, Beach KJ. Communication barriers between attending physicians and residents. J Gen Intern Med. 1994:9(3):158–161.

21.   Rosenstein AH, O’Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. Am J Nurs. 2005:105(1):54–64.

22.   Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004:79(2):186–194.

23.   Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med. 2003:31(3):956–959.

24.   Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems approaches to surgical quality and safety: from concept to measurement. Ann Surg. 2004:239(4):475–482.

25.   Loxley A. Collaboration in Health and Welfare: Working With Difference. London, England: Jessica Kingsley; 1997.

26.   Headrick LA, Wilcock PM, Batalden PB. Interprofessional working and continuing medical education. BMJ. 1998:316(7133):771–774.

27.   Bates MJ, Fallesen JJ, Huey WS, et al. Total Force Fitness in units, part 1: military demand-resource model. Mil Med. 2013:178(11):1164–1182.

28.   Riggio RE, Riggio HR, Salinas C, Cole EJ. The role of social and emotional communication skills in leader emergence and effectiveness. Group Dynamics Theory Res Pract. 2003:7(2):83–103.

29.   Chemers M. An Integrative Theory of Leadership. Mahwah, NJ: Lawrence Elrbaum Associates; 1997.

30.   Leary MR. Self-presentational processes in leadership emergence and effectiveness. In: Giacalone GR, Rosenfeld P, eds. Impression Management in the Organization. Hillsdale, NJ: Erlbaum, 1989: 363–374.

31.   Zaccaro SJ. Organizational leadership and social intelligence. In: Riggio RE, Murphy SE, Pirozzolo FJ, eds. Multiple Intelligences and Leadership. Hillsdale, NJ: Lawrence Erlbaum; 2002: 29–54. LEA’s Organization and Management Series.

32.   Kenny DA, Zaccaro SJ. An estimate of variance due to traits in leadership. J Appl Psychol. 1983;68:678–685.

33.   Aditya R, Hause RJ. Interpersonal acumen and leadership across cultures: Pointers from the GLOBE study. In: Riggio RE, Murphy SE, Pirozzolo FJ, eds. Multiple Intelligences and Leadership. Hillsdale, NJ: Lawrence Erlbaum; 2002: 215–240. LEA’s Organization and Management Series.

34.   Snyder M. Self-monitoring of expressive behavior. J Pers Soc Psychol. 1974:30(4) 526–537.

35.   Snyder M. Public Appearances, Private Realities: The Psychology of Self-Monitoring. New York, NY: WH Freeman; 1987

36.   Halverson, SK, Murphy SE, Riggio RE. Charismatic leadership in crisis situations: a laboratory investigation of stress and crisis. Small Group Res. 2004:35(5):495–514.

37.   Kerse N, Buetow S, Mainous AG 3rd, Young G, Coster G, Arroll B. Physician-patient relationship and medication compliance: a primary care investigation. Ann Fam Med. 2004:2(5):455–461.

38.   Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communication: a review of the literature. Soc Sci Med. 1995:40(7):903–918.

39.   Schneider J. Kaplan SH, Greenfield S, Li W, Wilson IB. Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection. J Gen Intern Med. 2004:19(11):1096–1103.

40.   Smith VA, DeVellis BM, Kalet A, Roberts JC, DeVellis RF. Encouraging patient adherence: primary care physicians’ use of verbal compliance-gaining strategies in medical interviews. Patient Educ Couns. 2005:57(1):62–76.

41.   Riggio RE. Assessment of basic social skills. J Pers Social Psychol. 1986:51(3):649–660.

42.   Horwitz IB, Horwitz SK, Brandt ML, Brunicardi FC, Scott BG, Awad SS. Assessment of communication skills of surgical residents using the Social Skills Inventory. Am J Surg. 2007: 94(3):401–405.

43.   Riggio RE. Interpersonal sensitivity research and organizational psychology: Theoretical and methodological applications. In: Hall JA, Bernieri FJ, eds. Interpersonal Sensitivity: Theory and Measurement Mahwah, NJ; Lawrence Erlbaum Associates; 2001: 305–317. LEA Series in Personality and Clinical Psychology.

44.   Riggio RE, Zimmerman J. Social skills and interpersonal relationships: Influences on social support and support seeking. Adv Personal Relationships. 1991;2:133–155.

45.   Goleman D. Working with Emotional Intelligence. New York, NY: Bantam; 1998.

46.   Mayer J, Salovey P. What Is Emotional Intelligence? Emotional Development and Emotional Intelligence: Education Implications. New York, NY: Basic Books; 1997.

47.   Festinger L, Back KW, Schachter S. Social Pressures in Informal Groups: A Study of Human Factors in Housing. Stanford, CA: Stanford University Press; 1950.

48.   Miller N, Campbell DT. Recency and primacy in persuasion as a function of the timing of speeches and measurements. J Abnorm Psychol. 1959:59(1):1–9.

49.   Lumsdaine AA, Janis IL. Resistance to “counterpropaganda” produced by one-sided and two-sided “propaganda” presentations. Public Opinion Q. 1953:17(3):311–318.

50.   Hovland CI, Weiss W. The influence of source credibility on communication effectiveness. Public Opinion Q. 1951:15:635–650.

51.   Margolis RH. What do your patients remember? Hear J. 2004:57(6):10–12.

52.   Carney DR, Cuddy AJ, Yap AJ. Power posing brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychol Sci. 2010:21(10):1363–1368.

53.   Cuddy AJ, Wilmuth CA, Carney DR. The benefit of power posing before a high-stakes social evaluation. Harvard Business School Working Paper, No. 13-027, 2012. https://dash.harvard.edu/bitstream/handle/1/9547823/13-027.pdf?sequence=1. Accessed June 21, 2017.

54.   Department of the Army. Military Awards. Washington, DC: HQDA; 25 June 2015. Army Regulation 600-8-22.

55.   Department of the Army. Morale, Welfare, and Recreation Programs and Nonappropriated Fund Instrumentalities. Washington, DC: HQDA; 24 September 2010. Army Regulation 215-1.

56.   Department of the Navy. Navy Medicine Military Awards Program. Falls Church, VA: Department of Medicine, Bureau of Medicine and Surgery; 21 September 2015. BUMED Instruction 1650.1.

57.   Department of the Air Force. Air Force Military Awards and Decorations Program. Washington, DC: USAF; 2013. Air Force Instruction 36-2803.

58.   Department of the Army. Army Military Human Resources Management. Washington, DC: HQDA; 2 August 2012. AR 600-8-104.

59.   Department of the Air Force. Unfavorable Information File Program. Washington, DC: USAF: 26 November 2014. AFI 36-2907

60.   Department of the Army A Leader’s Guide To After-Action Reviews. Washington, DC: HQDA; 30 September 1993. Training Circular 25-20.

ATTACHMENT: KEY COMPONENTS OF MILITARY COMMUNICATION FOR MEDICAL OFFICERS

Clarity in military communication has long been recognized as critical. As military operations became increasingly complex, military communication styles became more rigorous. In 1897, Eden Swift introduced a stylized field order based on Prussian staff experience.[1] This format evolved under the influence of the US Army’s new Staff College at Fort Leavenworth, Kansas, and became a global military standard.[2] Military services today share a passion for clarity in communication; modern business and other public communications have benefited from the military example and history. Currently, five key components of effective communication are recognized, as discussed below.

Purpose. Communication that provides purpose demonstrates to the receiver the leader’s or speaker’s vision for necessary subsequent action.[3] Providing purpose ensures the receivers of the communication have a “bigger picture” idea about the work or tasks they are being asked to carry out. When followers are able to see or understand the greater purpose of their tasks, they may be more invested in a successful outcome.

Direction. In addition to purpose, military communication should provide direction. Direction includes additional information regarding the intent of the leader or speaker, and also conveys expectations of how or to what standard the tasks must be accomplished. As the US Marine Corps manual Warfighting makes clear, communicators, regardless of format, must “establish what we want to accomplish, why, and how. Without a clearly identified concept and intent, the necessary unity of effort is inconceivable.”4(p82) When followers are given clear and specific guidance, they are more likely to accomplish the task in a timely manner and in a way consistent with the desires of the leader. Followers may have the ability to meaningfully contribute to the way in which a task is carried out. For this reason, the leader must be adaptive in how he or she communicates direction. Often a focus on the standard (eg, deadline, quality, quantity) will convey enough information to allow for effective and efficient completion without the leader specifically stating “how” to do it.

Motivation. Effective military communication should inspire an individual to complete the task while setting expectations. If expectations are ambiguous or not met, it leads to disappointment. For this reason expectations must not only be set, but also managed. If the situation changes and expectations must be altered, it is better to alter the expectations than allow them to go unmet altogether.

Communication is a facet of human interaction; it is shaped by human nature in both sending and receiving. As the purposes of stylized communication have become broader, the need for more complex communications has become clear. Many modern communications experts have based their studies on military doctrine. One of the more successful was Professor Helio F. Garcia. According to Garcia, the ultimate goal of communication is changing how people think, motivating them to action. Communication will therefore invariably be shaped by emotions and subject to the “complexities, inconsistencies, and particularities which characterize human behavior.”5(p188) In some situations, a communicator cannot meet emotion coming from a listener with a logical argument. Emotional communications must first be met with an emotional response, and then guided to logic. For example, an aggrieved individual must be addressed first with regret, sorrow, or at least empathy, regardless of the end goal of the communication.

Style. Effective communicators consider the following: the goal of the communication; the audience; how to engage the audience to get them to care; what actions or words are needed to get the audience to care; and ways to connect with the audience about things the audience cares about.[5] Effective communicators successfully engage an audience by using logic, personal character, and passion simultaneously, often beginning with the audience’s perspectives in mind. This ability is especially important in crisis situations when followers and critics will look to leaders for a response.[5] The “first mover advantage” is a concept gleaned from Marine doctrine,[5] in which a communicator is able to define a crisis, his or her motives, and the next steps involved in a situation before any other party is able to intervene or interject.

See Garcia’s Power of Communication[5] for a complete description including impactful examples of utilizing this concept in communication. Briefly, in a crisis situation, silence and delay may make a problem worse. Action, however, is not just about speed; a “first mover” must have a “predisposition to make sound decisions quickly and communicate them effectively.”5(p81) In dangerous or rapidly evolving situations (eg, on the battlefield, in the emergency room), taking initiative in communication can lead to greater influence over others, because this initiative allows the speaker to define the issue, his or her motives, and actions. Often, the longer it takes to gain control the situation or communication, the harder it is to do so.[5] This concept can also be applied in less serious situations, such as in instances where allowing an issue to linger before addressing it (eg, poor performance of a subordinate, rumors spreading through a department) will weaken the leader’s ability to effectively manage the outcome and ultimately prevent him or her from providing support that followers need and upon which they rely.

Planning. Planning communication is not just about figuring out what to say, but also includes consideration for how others will react to what is said and how it is said, predicting and anticipating listeners’ expectations and meeting them, establishing goals, assigning resources, and imposing conditions. Something as simple as preparing for the setting in which the communication will take place (ie, the functional space) can make or break a communication.

In planning, do not overestimate the audience’s ability to pay attention; people see the world through their own frame and think they capture the world as it is, but they miss a lot. A communicator must first understand what frames are important to the audience (beyond demographics and concerns). This assessment is necessary to demonstrate that the speaker knows who the audience is and communicates understanding of the listeners’ perspective. The audience will feel well-regarded and deduce that the speaker has taken time to consider their alternative view. This consideration is especially true in stressful or emotional situations, whether leading a team in combat conditions or speaking to patients about their health. Individuals also experience “cognitive tunneling” or an inability to shift attention away from a threat, which impairs their ability to hear, listen, and remember effectively. Again, the Marine Corps is clear that the human factors are critical: “Our philosophy must not only accommodate but must exploit human traits.”4(p78) Therefore, the burden is on the communicator to ensure he or she is thoroughly considering the listener and planning for the communication.

1.   Swift E. Field orders, messages and reports. J US Cavalry Assoc. 1897;Sep:221–228.

2.   Corlett CH. Evolution of field orders. Coast Artillery J. 1925;62:502–513.

3.   Hamlen A, Wells S, Di Desidero L. The Marine Corps University Communications Style Guide. 9th ed. Quantico, VA: Marine Corps University; 2016: 4. http://www.au.af.mil/au/awc/awcgate/usmc/mcu_comm_style_guide.pdf. Accessed September 28, 2018.

4.   US Marine Corps. Warfighting. Quantico, VA: USMC; 1997. USMC Doctrine Publication 1. https://www.marines.mil/Portals/59/Publications/MCDP%201%20Warfighting.pdf. Accessed September 28, 2018.

5.   Garcia HF. Power of Communication, The Skills to Build Trust, Inspire Loyalty, and Lead Effectively. Upper Saddle River, NJ: FT Press; 2012.

Chapter 12

ENLISTED SERVICE MEMBERS

ALTHEA GREEN, PHD*

INTRODUCTION

HISTORY OF ENLISTED SERVICE MEMBERS IN MILITARY MEDICINE

RANK STRUCTURE

Junior Enlisted Promotions

Noncommissioned Officer/Petty Officer Promotions

ROLE OF NONCOMMISSIONED/PETTY OFFICERS

Standard Bearer

Chain of Command and Support Channel

Relationship Between Officers and Noncommissioned or Petty Officers

Supporting the Chain of Command

Backbone of the Units

Unit History and Traditions

Supervising and Training Junior Enlisted Members

An Important Balance

ENLISTED TRAINING

Technical Training

Specialty and Leadership Training

Unit Training

ASSIGNMENT OF ENLISTED PERSONNEL

Garrison Healthcare Units

Operational Units

SPECIAL CATEGORY ENLISTED MEDICAL PERSONNEL

Independent Duty Medical Technician

Independent Duty Corpsman

Special Forces Medical Sergeant

SUMMARY

*Command Sergeant Major, US Army (Retired); Director, Recruitment and Outreach, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

“The American soldier is a proud one and he demands professional competence in his leaders. In battle, he wants to know that the job is going to be done right, with no unnecessary casualties. The noncommissioned officer wearing the chevron is supposed to be the best soldier in the platoon and he is supposed to know how to perform all the duties expected of him. The American soldier expects his sergeant to be able to teach him how to do his job. And he expects even more from his officers.”

—General Omar N. Bradley, from a speech at the US Military Academy, May 20, 1952[1]

INTRODUCTION

It is important for military medical officers to understand how enlisted members fit into the general scheme of the military as well as their role in military medical practice. Since the inception of the US military, one of its hallmarks has been the involvement of enlisted members in almost every facet of military operations. In both warfighting units and support units, including medical units, enlisted personnel constitute the majority of uniformed personnel. Enlisted medical personnel provide patient care, laboratory and diagnostic services, pharmacy support, and patient records maintenance; they also operate, maintain, and repair medical equipment. The enlisted service members are led by noncommissioned officers (NCOs) who have been promoted up through the ranks. These individuals form the foundation of the military health system.

This chapter provides an overview of the enlisted service members typically involved in military medicine operations. It includes a brief history of the enlisted medical force, then discusses how enlisted service members are integrated into military medical practice. The discussion will include:

- rank structure of enlisted personnel;

- the roles of NCOs and petty officers (POs, NCOs in the Navy and Coast Guard);

- training of enlisted personnel;

- assignment of enlisted personnel; and

- special categories of enlisted medical personnel.

HISTORY OF ENLISTED SERVICE MEMBERS IN MILITARY MEDICINE

When George Washington’s Continental Army formed the Army and Navy medical services in 1775, provisions were made to detail enlisted personnel to assist the medical officers. Based on the recommendations of the Hospital Department’s director general, the Second Continental Congress authorized the employment of enlisted men as hospital stewards on July 17, 1776.[2] While hospital stewards initially had no official rank in the Army and consisted of soldiers detailed from the line, they played a key role in providing healthcare for troops. They had to be able to read and write, with some background in mathematics, chemistry, or pharmacy. Few soldiers of the era had these abilities. The duties of hospital stewards included assisting the surgeon in minor surgical procedures, dispensing medicine, and supervising attendants and other civilians who worked in the hospitals. Hospital stewards were also responsible for procuring vegetables, meat, and bread from the local farmers and bakers when the normal supply system was interrupted. Some stewards worked in the military apothecary supervising the production of medicine. Based on the isolated nature of some medical officer assignments and the need for scientifically educated associates, both the Army and the Navy established dedicated enlisted corps in the late 19th century.

As their roles expanded after the Civil War, these enlisted members were given the added responsibility to purchase whatever was necessary for use in the care of the sick and wounded, and were expected to handle major administrative and logistical functions in the hospital. Dr Edward Cutbush (Figure 12-1), a prominent Navy physician, published the first manual on hospital administration in 1808.[2] In it, he specified the duties of a hospital steward, including discipline of staff and patients, personnel management, food service, medical supply, and overall administration of the hospital.[2] Cutbush also emphasized that a steward needed to be honest and above reproach.[2] These types of administrative duties have remained in the wheelhouse of hospital stewards and medical NCOs/POs even as their duties have evolved over time.

Throughout the years, the size and functions of the services’ medical departments have waxed and waned. When the Air Force Medical Service was established in 1949, it included a complement of enlisted personnel. Today, the medical services of the Army, Air Force, and Navy all include an enlisted corps. Unlike the hospital stewards of old, these enlisted personnel are likely to occupy a diverse range of military occupations in fixed healthcare facilities as well as operational units. Their services can be generally categorized into the following functions: force health protection, health service support operations, and health support planning.[3] It is important to note that although the enlisted members are an integral part of the medical department of each of the services, they also form a separate corps of specially trained personnel within the departments. Like their officer counterparts (medical, dental, nurse, etc) the enlisted corps is headed by a senior NCO, usually the senior enlisted advisor to the surgeon general. Army medicine’s enlisted corps birthday is recognized as March 1, 1887, and the Navy recognizes June 17, 1898, as the birthday of its Hospital Corps.

RANK STRUCTURE

Because of the nature of today’s operations, medical officers perform duty alongside enlisted members of any of the services, so it is important to understand the general rank structure of each service. Although each has its own unique rank designation, they are similar in grade structure: the enlisted grades range from E-1 to E-9, and similar to the officer grades, the lower numbers reflect junior rank. While it is not unusual for some enlisted personnel to start their careers at the grades of E-3 or E-4, junior members typically have less responsibility within their organizations. The services’ enlisted ranks correspond with each grade, ranging from private/seaman/airman to command sergeant major/master chief PO/command chief master sergeant. Leadership responsibility generally increases as the grade increases. (The Public Health Service is a commissioned corps and does not have enlisted members.) Figure 12-2 lists the enlisted ranks in each service and depicts their insignia.

Figure 12-1. Dr Edward Cutbush (1772–1843), a Navy surgeon from 1799 to 1829; portrait published in Annals of Medical History, December 1923.
Reproduced from: Naval History and Heritage Command, NH 92584 (https://www.history.navy.mil/content/history/nhhc/our-collections/photography/numerical-list-of-images/nhhc-series/nh-series/NH-92000/NH-92584.html).

Junior Enlisted Promotions

Each of the services has a system that allows their enlisted personnel to advance through the ranks. For the Army and Air Force, the unit commander is the promotion authority for promotions to the grades of E-2, E-3, and E-4. These promotions are automatic, based on service members’ time in service and time in grade. The Navy limits these automatic promotions to E-2 and E-3. Commanders are also allowed to perform accelerated promotions at the junior grades based on specific criteria. Promotions to the higher ranks also vary among the services.

Noncommissioned Officer/Petty Officer Promotions

The Army uses a semi-centralized system to determine promotions to the grades of E-5 and E-6. This process is based on a point system that begins at the unit level, where administrative points are awarded. A soldier receives points for duty performance as well as various accomplishments, such as military decorations, physical fitness test scores, military and civilian education, and weapons qualification scores. The soldier must also appear before a promotion board comprised of NCOs and chaired by a sergeant major (SGM) or command sergeant major (CSM). Board members ask a series of questions and score each candidate in four separate areas. The average board points are added to the administrative points and the candidate is placed on the recommended promotion list. Promotions from the list are made based on vacancies within military occupational specialties.

Figure 12-2. Rank insignia of the US Armed Forces.
Reproduced from: https://www.army.mil/e2/downloads/rv7/symbols/ranks.pdf.

Navy promotions to grades E-4 through E-7 are competitive and based on advancement exams conducted at the local level. The Navy uses a promotion point system called the Final Multiple Score, which considers the whole person by calculating a candidate’s performance, experience, and knowledge. Performance, documented in fitness reports, is shown by a person’s work ethic and achievements. Experience is indicated by elements such as time-in-service and time-in-rate, and knowledge is demonstrated by how the candidate performs on the promotion examination.

The Air Force promotes its personnel to E-5, E-6, and E-7 using the Weighted Airman Promotion System (WAPS). An airman receives points based on time-in-grade, as well as his or her scores on the promotion fitness examination and the specialty knowledge test. Points are also awarded for awards and decorations, as well as for enlisted performance ratings. The points are totaled, and those with the most WAPS points are selected for promotion.

All of the services use some type of centralized board process to determine promotion selections to the highest enlisted grades. The Army and Navy use a centralized system for promotions to the grades of E-7, E-8, and E-9. Selection panels review candidates’ personnel records and select the best qualified for promotion based on set criteria. For E-8 and E-9 promotions, the Air Force uses a combination of WAPS points and a centralized promotion board that reviews the individual promotion record. The WAPS points are the same as used in E-5 through E-7 promotions, except there is only one promotion test, the Air Force supervisory examination.

ROLE OF NONCOMMISSIONED/PETTY OFFICERS

It is important to understand the special role that NCOs/POs have in serving as a lynchpin between the officer and enlisted ranks. NCOs trace their roots to the beginnings of American military history. They helped Washington preserve the Continental Army at Valley Forge, and today are unrivaled by any military in the world. These service members are more than just ordinary soldiers, sailors, or airmen. Rather, the corps of NCOs/POs is comprised of trained professionals who have risen through the ranks and have been led and mentored by other senior members of their profession. They are integral to the functioning of every military organization; they provide the glue that holds their units together. NCOs/POs are found at every level of organizations in garrison, at sea, and while deployed. In medical units, the role of the NCO/PO is the same as in any other military unit, to support the chain of command, lead, and take care of the enlisted members. Table 12-1 depicts some of these relationships and roles, just a few of the myriad roles that exist within the military health system and the services. Most of these roles are formally prescribed by authorization documents, but it is not unusual for unit leaders to devise officer–NCO/PO pairings because they are necessary for the optimal functioning of the organization.

TABLE 12-1

EXAMPLES OF OFFICER–NONCOMMISSIONED OR PETTY OFFICER SUPPORT RELATIONSHIPS

Officer Position

Corresponding Noncommissioned or Petty Officer Position

Surgeon general of the Army/Navy/Air Force

Command sergeant major/force master chief/chief master sergeant

Hospital commander

Hospital senior enlisted leader/command sergeant major

Section officer in charge

Section noncommissioned officer/petty officer in charge

Clinic officer in charge

Clinic superintendent/noncommissioned officer or petty officer in charge

Brigade surgeon

Operations noncommissioned officer

Company/flight commander

First sergeant

Platoon leader

Platoon sergeant

Head nurse

Ward master

Standard Bearer

The NCO/PO is expected to be the standard bearer of the organization, someone who not only espouses the standards but also enforces them. These standards vary slightly across the services and are based on regulations, each service’s mission, customs, and traditions. Each service has and follows its own creed and core values, which provide a value structure that all service members—officer and enlisted—are expected to live by and demonstrate. Although each service subscribes to slightly different values (Exhibit 12-1), ethical leadership is a common pillar of life in the military. NCOs/POs are expected to take a leadership role, not only in modeling service values, but also in teaching them to others.

Chain of Command and Support Channel

A foundational feature of every military organization, the chain of command establishes the lines of authority and communication, as well as the requisite levels of responsibility and accountability for conducting day-to-day mission operations.[4] The chain of command promotes unity of purpose by facilitating an efficient communication process for commanders to convey their guidance and intent to members of their organization, ensuring that orders are accurately and effectively communicated. It also provides a mechanism for members of the unit to share their concerns, achieve clarity for complex issues, and resolve problems.

The NCO/PO support channel parallels, supplements, and reinforces the chain of command. It is comprised of NCOs/POs from senior to junior level, and is used for exchanging information, issuing instructions, and accomplishing the day-to-day business of the organization. This support channel provides an essential link in the chain of command because it allows NCOs/POs to add their perspective and experience to assist commanders and officers in accomplishing the mission. It is important to note that the NCO/PO support channel must never supersede the commander’s role.

Relationship Between Officers and Noncommissioned or Petty Officers

The morale of a unit, as well as how effectively its mission is accomplished, is a direct reflection of the relationship between the officers and NCOs/POs of the organization. Officers and NCOs/POs must work together to accomplish their unit’s mission. Although their roles are established by the various Tables of Organization & Equipment and Tables of Distribution & Allowances, this works best when they know and trust each other. New medical officers are typically paired with NCOs/POs who have more service experience. For example, a new medical platoon leader may have 1 or 2 years of service, and the platoon NCO a decade of operational experience. In these situations, NCOs/POs have the opportunity to show their abilities and determination to support and enforce the units’ standards and mission, as well as demonstrate effective leadership of the enlisted force. A key competency for success is the NCO/PO’s ability to understand and explain the commander’s intent. This understanding, coupled with the earned trust to execute it, is the foundation of the officer–NCO/PO relationship. In more senior assignments the years of experience may become more equal, but the NCO/PO will always play a key role in helping the officer achieve the mission. Their relationship greatly contributes to unity of command, ensures continuity of mission, and instills confidence that orders will be carried out promptly and effectively. The benefit of this system is that it ensures no disruption or loss of momentum to the mission in the absence of the commissioned officer leader.[5]

EXHIBIT 12-1

MILITARY SERVICE VALUES

- Army Values: Loyalty, Duty, Respect, Selfless Service, Honesty, Integrity, Personal Courage.

- Navy and Marine Corps Values: Honor, Courage, Commitment.

- Air Force Values: Integrity First, Service Before Self, Excellence in All We Do.

- Public Health Service Values: Leadership, Service, Integrity, Excellence

Developing a positive and professional relationship between the commissioned officer and enlisted leader requires diligence and frequent self-assessment. Each role comes with its own responsibilities and expectations of performance. A positive and professional relationship between these two leaders creates and sustains a healthy and productive organizational/command climate. NCOs/POs who enjoy a close relationship with their officers find it one of the most satisfying parts of their service. It is important to remember that the officer is in command, and the NCO/PO is a principal advisor and a source of competence and counsel who enhances the officer’s ability to command effectively.[5]

In military units, newly commissioned officers will benefit greatly from the advice and counsel of seasoned enlisted leaders who will help guide them in their role as the officer in charge or commander of the platoon, flight, or section. According to First Sergeant Jeffrey J. Mellinger:

A new lieutenant is a precious thing, a rare commodity, enthusiastic and eager to learn. Don’t take advantage of him, but train him, correct him when he needs it (remembering that diplomacy is part of your job description), and be ready to tell the world proudly that he’s yours. If you are ashamed of him, maybe it’s because you’ve neglected him or failed to train him properly. Do something about it. Show a genuine concern that he’s learning the right way instead of the easy way. But be careful not to undermine his authority or destroy his credibility. Remember that order and counter-order create disorder…. As the senior and most experienced NCO in the platoon, you must pass on the benefit of [your] wisdom and experience to your platoon leader as well as to the soldiers.[6]

As officers gain more experience, they develop a more refined and informed perspective, and they are often paired with NCOs/POs of similar experience level. The relationships between NCOs/POs and officers tend to be more reciprocal as officers move up in rank and time in service. Nevertheless, the professional development and maturation of officers can be shaped positively by their interaction with the right NCOs/POs throughout their careers. Vignette 12-1 provides a constructed illustration based on actual experience of a platoon sergeant establishing a relationship with a new officer, while Figure 12-3 shows a PO working with an officer in common pursuit of mission goals.

Vignette 12-1. Sergeant First Class (SFC) Johnson met his new platoon leader, Second Lieutenant (2LT) Vaughn, at the Division Reception Station. The lieutenant had been on the island just 2 weeks, and this was her first permanent duty assignment. She had already completed installation in-processing, and had also been issued two duffel bags of field gear. SFC Johnson took his new platoon leader to meet with the company commander while he went to check on the troops in the motor pool, who were getting ready for a field exercise in a few days. The commander wanted to brief 2LT Vaughn on the upcoming exercise and make sure she was ready for it. SFC Johnson spent a few minutes getting an update from the squad leaders, then linked back up with 2LT Vaughn at the commander’s office.

SFC Johnson then took his new platoon leader to the platoon area and showed her the designated area for storage of her gear. 2LT Vaughn noticed that each soldier was assigned a similar area, and she could see the gear neatly stored inside. Next, SFC Johnson took 2LT Vaughn to the office they were to share. After a few pleasantries, SFC Johnson got down to business. He pulled out a platoon roster and a training schedule. They were getting ready for a major field training exercise, and he knew it was his job to make sure his platoon leader was ready to go.

Figure 12-3. A US Navy chief, left, and a US Navy lieutenant junior grade, center, both medical professionals with a provincial reconstruction team, talk with a director of public health, right, during a key leader engagement in Afghanistan. US Navy photo by Lt. J.G. Matthew Stroup.
Reproduced from: http://www.dodlive.mil/2012/12/14/provincial-reconstruction-team-farah/.

Army company/detachment commanders and their first sergeants (as well as their less common sister service counterparts) have a special relationship. This is usually the first time an officer has command of service members with the authority to administer punishment. The command team is generally comprised of an officer with 4 to 6 years of service and a senior NCO/PO with two or three times as much service. It is important that the senior NCO/PO is disciplined and mature, and provides sound advice to the company commander, especially in matters of the administration of justice. A dysfunctional command team will negatively affect the morale of the unit. On the other hand, a positive and professional relationship between the NCO/PO and officer will create and sustain a healthy and productive organizational/command climate. In 1825, Major General Jacob Brown wrote:

There is no individual of a company, scarcely excepting the captain himself, on whom more depends for its discipline, police, instruction, and general well-being, than on the first sergeant. This is a grade replete with cares and with responsibility. Its duties place its incumbent in constant and direct contact with the men, exercising over them an influence the more powerful as it is immediate and personal; and all experience demonstrates that the condition of every company will improve or deteriorate nearly in proportion to the ability and worth of its first sergeant.[7]

Supporting the Chain of Command

Commanders and commissioned officers set policies and standards, and NCOs/POs ensure discipline and adherence to standards by all of the unit’s personnel—enlisted, officer, and civilian. All leaders should work together to accomplish the mission, and members of the NCO corps are expected to lead by example. Because of the level at which they operate, NCOs/POs have the greatest influence on how an organization’s goals are achieved. NCOs/POs are the technical and functional experts within their organizations, and subordinates and superiors alike draw upon the expertise and experience of these leaders to achieve mission objectives and depend on them as leaders and managers. They are expected to acquire and employ resources efficiently and effectively, and think critically to prevent and solve problems. They must also be able to clearly communicate up and down the chain of command and NCO/PO support channel, as well as laterally across matrix organizations (a typical structure of many healthcare organizations where staff has dual reporting relationships; eg, an NCO working in the hospital as a laboratory technician might also be the senior NCO in a platoon in the troop command for the hospital). One of their most important responsibilities is to provide the commander and officer corps with unique insights and perspectives of the enlisted members while providing an enlisted voice in matters concerning operations, administration, readiness, and the well-being of the force.

Backbone of the Units

NCOs/POs are known as the “backbone” of the armed forces. Their job is to complement the officer and enable the force by both accomplishing their organization’s mission and ensuring their subordinates’ welfare. They are able to achieve this by virtue of the command authority derived from their delegated leadership position, as well as general military authority granted to all who wear the chevrons of the NCO/PO. This empowers them with the responsibility and authority to maintain good order and discipline at all times, whether on or off duty.[5] Through their training and experience, NCOs/POs develop professional qualities, competencies, and traits that complement the officer corps, and they provide an indispensable and irreplaceable linkage between command guidance and mission execution.[4] In many respects, they provide the social order and structure that underpin high-functioning military organizations.

Unit History and Traditions

NCOs/POs have special responsibilities with regard to maintaining the history and traditions of their organizations. They are typically charged with all things ceremonial within the unit. The senior NCO/PO each unit is traditionally known as the “Keeper of the Color.” This designation traces its roots to the position of color sergeant, the individual on the battlefield who carried the colors and directed the movements of a unit. Over the years, with advances in firepower, flags were no longer used in this manner, but flags and guidons continue to play an important role in defining unit identity and building cohesion and esprit de corps. The high honor bestowed to a unit’s senior enlisted member as custodian of its flag or guidon is a tremendous responsibility and reflects the continuity of the unit in a very personal way.

The responsibility of NCOs/POs to preserve the unit’s traditions and heritage includes teaching new service members about the history of these important aspects of military service, including training in drill and ceremony. Drill and ceremony, including parades, reviews, retreat, and other recognitions, add pageantry to military life but also symbolize the shared values, courage, and discipline essential to any successful military organization (Figure 12-4). Drill and ceremony is the foundation for instilling and developing discipline in units of all sizes, and remains one of the finest methods for developing confidence and troop leading abilities in subordinate leaders.[5] This discipline forms the basis for adherence to service values as well as a culture that motivates service members to subordinate their personal needs to the good of the organization.

Figure 12-4. The Joint Base Elmendorf-Richardson’s color guard prepares to present the colors during a Memorial Day Ceremony at Delaney Park Strip in Anchorage, Alaska, May 29, 2017. Air Force photo by Staff Sgt. James Richardson.
Reproduced from: https://www.defense.gov/Photos/Photo-Gallery/igphoto/2001754130/.

Supervising and Training Junior Enlisted Members

Another important responsibility is the supervision and training of the unit’s junior enlisted service members. The NCO/PO must ensure that their subordinates maintain proficiency not only in their technical skills, but also in other military competence areas such as survival skills and unit-required training. While the NCO/PO has responsibility for maintaining these requirements, training of medical skills is often a joint effort with the medical officer. Likewise, the NCO/PO, who often has the most military experience, is expected to share that practical knowledge and experience with his or her medical officer.

An Important Balance

While the duties of NCOs/POs are numerous and must all be taken seriously, the most important is taking care of enlisted service members. NCOs/POs do this by developing a genuine concern for their subordinates’ well-being, knowing and understanding their soldiers well enough to train them as individuals and teams to operate proficiently. This requires NCO/PO leaders to become involved in the lives of their subordinates in more ways than simply being a supervisor in the workplace. This responsibility includes all aspects of teaching, coaching, and mentoring, from advising about career development to providing guidance and assisting with family concerns.

Effective leaders work diligently in developing relationships of mutual trust and respect with their people. This type of relationship will allow soldiers, sailors, and airmen to grow confident in their ability to perform well under the most difficult and demanding circumstances. However, as discussed above, NCOs/POs must never appear to supersede the official chain of command or impede the accomplishment of the mission. They must understand their supporting role in providing guidance and executing the orders of the officers appointed over them. Vignette 12-2 is a constructed illustration of how NCOs/POs and officers work together to accomplish the unit mission while taking care of the needs of service members.

Vignette 12-2. Commander (CDR) Jones was the officer in charge (OIC) of the Pediatrics Clinic and had some concerns about her clinic petty officer in charge (POIC). The POIC, Hospital Corpsman First Class (HM1) Douglas, had arrived late to work five times in 2 weeks, and had even called in once to say he would not be coming in to work at all. CDR Jones had spoken with HM1 Douglas, who told her the reason for the tardiness and absences was that he was having trouble finding child care. CDR Jones was puzzled because she was not aware that HM1 Douglas had a child, but she was also concerned because she had detected the smell of alcohol on his breath.

CDR Jones enlisted the help of the NCO/PO support channel. She discussed the issue with Senior Chief Petty Officer (SCPO) Gilman, the POIC of the Department of Medicine. SCPO Gilman advised CDR Jones that HM1 Douglas was not suitable to perform the duties of clinic POIC until the issue was resolved. In light of this issue, SCPO Gilman temporarily replaced HM1 Douglas with Technical Sergeant (TSgt) Cason, the assistant NCO in charge of the clinic. SCPO Gilman then met with HM1 Douglas and CDR Jones. Douglas initially denied any problems, but eventually admitted to arriving late for work and being absent due to oversleeping; however, he did not admit to having an alcohol or drug problem. SCPO Gilman informed HM1 Douglas that he was temporarily being reassigned from clinic POIC duties and she would provide him with further instructions after she met with the company first sergeant.

SCPO Gilman then met with the company first sergeant and verified HM1 Douglas’s family status. There was no evidence that Douglas had a child. She also discussed Douglas’s absences and his reporting for duty with the smell of alcohol on his breath. She recommended the commander refer HM1 Douglas for drug and alcohol screening and treatment. SCPO Gilman scheduled a meeting for HM1 Douglas, the company commander, and the first sergeant. She met with HM1 Douglas and notified him of the meeting. She also completed a written counseling to document the discussions, actions taken, and the way ahead.

This vignette showed how members of the NCO/PO support channel work with the chain of command to accomplish the organization’s mission. Commander Jones, the clinic officer in charge, was able to engage with the NCO/PO support channel to address the issue with his clinic PO. The department’s petty office in charge, Senior Chief Petty Officer (SCPO) Gilman, had the authority to affect change within the clinic enlisted leadership. SCPO Gilman and the unit’s first sergeant, both members of the NCO/PO support channel, also worked together to get the commander’s involvement to refer HM1 Douglas for drug and alcohol screening and treatment. The NCO/PO support channel was also able work with the chain of command to intervene to assist HM1 Douglas as well as to make the necessary adjustments to support the clinic’s mission.

ENLISTED TRAINING

Technical Training

Today’s enlisted medical force is among the most skilled and technically proficient in the military. Most medical service members receive their initial technical training at the Medical Education and Training Campus (METC) at Fort Sam Houston, Texas. METC is a state-of-the-art Department of Defense healthcare education campus that trains enlisted medical personnel from all of the military services, including the Coast Guard. Each year nearly 18,000 enlisted medical service members graduate from 48 different medical programs conducted at the METC.[8]

Training programs are grouped as follows:

- ancillary services (nutrition/dietetics, occupational therapy, physical therapy, pharmacy);

- dental services (dental assisting, dental laboratory);

- diagnostic services (medical laboratory, radiology, nuclear medicine);

- healthcare support (biomedical equipment maintenance/repair, medical logistics, health care administration);

- nursing and specialty medical (cardiovascular, cardiopulmonary, independent duty medical technicians, ophthalmology, otolaryngology, respiratory, surgical, urology); and

- public health (behavioral health, preventive medicine).

A complete listing of courses offered at the METC can be found in the program catalog. The Army’s combat medical specialist/healthcare specialist, as well as the Air Force’s medical technicians and the Navy’s corpsmen, are also trained at the METC. Many of these training programs are conducted in two phases in which students complete the didactic portion of their training at METC and then transition to various fixed medical facilities in the United States for the clinical phase (Figure 12-5).

Figure 12-5. A US Air Force diagnostic imaging technician examines a computed tomography scan at the US Air Force Hospital Langley at Langley Air Force Base.
Reproduced from: https://media.defense.gov/2016/Mar/03/2001498776/-1/-1/0/160219-F-UN009-006.jpg.

On August 21, 2015, Airman 1st Class Spencer Stone, along with two childhood friends, foiled a terror attack on a train from Amsterdam to Paris. After Stone used a chokehold to neutralize the gunman, his instincts as a trained medic took over as he rushed to save the life of a fellow passenger who was bleeding from a bullet wound. Realizing the need to stop the bleeding, Stone put his fingers into the open wound on the victim’s neck and applied pressure directly on the artery to stop the bleeding. Stone was able to react to the situation and use his lifesaving skills because of the training he received as a Basic Medical Technician Corpsman Program student at METC.[9]

Specialty and Leadership Training

The military services also conduct specialty training at various camps, posts, and stations, including Fort Sam Houston. Each of the services also require their members to attend leadership training to prepare them to serve in positions of increased responsibility. Called professional military education (PME), this training can include a combination of technical training and general military leadership techniques. As NCOs/POs increase in rank, the training tends to be more leadership focused than technical.

Arguably the most important promotion and transition for an enlisted service member is when they first transition from the junior enlisted rank to that of a NCO or PO. With promotion comes additional responsibility and authority, accompanied by higher accountability. This promotion is more than just a raise in pay; it often reflects a shift in roles from being led to learning how to lead others. Leadership education and training are designed to help equip service members with the skills and information they need to be effective leaders. PME provides NCOs/POs with progressive and sequential leader, technical, and tactical training relevant to the duties, responsibilities, and missions they will perform. The professional development of the NCO/PO corps is something that distinguishes the US military from other military services around the world.

Basic leadership training incorporates a variety of leadership-related subjects that also help build a foundation for self-development. As NCOs/POs advance in rank, they attend successively higher levels of professional military education. As service members advance through their career, they will encounter certain windows of opportunity for completing leadership courses, either online or in residence. Courses consist of resident, mobile, and distributed-learning platforms designed to influence and provide the leadership foundation upon which each service bases its future NCO/PO corps. This training is essential to developing a highly trained and effective force. Each of the services sets specific milestones for completing online courses and attending in-residence NCO and senior NCO academies. The senior NCO academies conduct a capstone course to prepare NCOs/POs for the senior enlisted rank.

For Army NCOs, the training and education process begins with an initial branch-immaterial leadership development course; followed by a basic branch-specific level; then an advanced branch-specific level; and finally a branch-immaterial senior-level course. The Army Medical Department NCO Academy provides sergeants, staff sergeants, and sergeants first class with the technical, tactical, and leadership/trainer skills necessary to be successful in Army operations as squad/platoon sergeants and first sergeants. Airmen are also required to complete distance learning courses before attending the academies. The Navy requires a combination of home-station and in-person training at its leadership academies.

Earning college credit toward a degree or completing additional professional military courses are also important endeavors as service members progress in expertise and rank, and this should be encouraged. Additionally, special recognition programs are available for those who demonstrate the aptitude and motivation to compete.

Unit Training

Training of the medical enlisted force does not end at the doors of the schoolhouse, but continues at units and organizations to which troops are assigned. NCOs/POs have primary responsibility for training the enlisted force, but accomplishing this becomes a team effort that also depends on officers and civilians. Keeping the force skilled and technically proficient, as well as assisting service members in meeting general military requirements such as physical fitness, requires an ongoing emphasis both in garrison and operational units.

ASSIGNMENT OF ENLISTED PERSONNEL

Enlisted personnel can be found in almost every aspect of medical practice. After initial technical training, they are assigned to either garrison-based healthcare facilities or operational units. Although each of the services operates a distinct medical system within the military health system, both garrison and operational medicine are becoming more joint (Figure 12-6).

Figure 12-6. A medical team comprised of a US Air Force lieutenant, a US Air Force captain, a US Army sergeant, and a US Air Force lieutenant colonel prepare a patient for surgery at Craig Joint Theater Hospital on Bagram Airfield, Afghanistan.
Reproduced from: https://www.defense.gov/Photos/Photo-Gallery/igphoto/2001126859/.

Garrison Healthcare Units

Enlisted personnel are often assigned to garrison healthcare organizations directly after initial entry training, where they work side-by-side with civilian staff. The NCOs/POs are responsible for ensuring that new service members are fully integrated into the organization. In addition to technical and military readiness training, a key requirement is maintaining the standards of healthcare accrediting agencies, such as the Joint Commission and the Commission of Anatomical Pathologists. Leaders must also take measures to ensure their personnel remain current in their common military tasks and drills, which are also important for unit readiness.

Operational Units

Medical personnel assigned to operational units must be able to fully integrate with and earn the trust and respect of the supported personnel. Army personnel are often assigned to operational units immediately following technical training, while Navy personnel may be assigned to operational Navy or Fleet Marine Force units. Regardless of their assignment, personnel often have additional, nonmedical roles to play in support of their operational unit. For example, medical personnel on a submarine must also understand how to fight fires and perform other tasks required of the crew. Such ongoing relationships between medical personnel and operational personnel underscore an important cultural component to maintaining readiness.

One of the challenges of enlisted personnel in these units is balancing military readiness requirements with technical competency, especially for those service members who are not able to practice their medical skills on a routine basis. Leaders must take a proactive stance to ensure their personnel maintain competency in all of their critical skills.

In March 2008, Specialist Monica Lin Brown became the second female soldier since World War II to be awarded the Silver Star for extraordinary heroism. Brown was serving as a combat medic with the 82nd Airborne Division when she was involved in a firefight while supporting a patrol in Afghanistan.[10] Vignette 12-3 provides a detailed account of Brown’s actions that earned her the award.

Vignette 12-3. In March 2008 Specialist Monica Lin Brown was awarded the Silver Star for extraordinary heroism on April 25, 2007. Brown, then a private first class (PFC), was serving as a combat medic with the 4th Squadron, 73d Cavalry Regiment, 4th Brigade Combat Team, 82nd Airborne Division. On that day she was on a combat patrol with her platoon moving to Jani Khel, Afghanistan, for a leader engagement with village elders. The element consisted of five vehicles: four M1151 Up-armored HMMWVs and one Afghan National Army Ford Ranger. They were moving in column formation when the trail vehicle struck a pressure plate improvised explosive device (IED) on the driver’s side rear tire, which ignited the fuel tank and fuel cans mounted on the rear of the vehicle. The explosion of the fuel tank and cans engulfed the vehicle in an intense fireball. This initiated a planned ambush, which commenced after the explosion.

The patrol began to take small arms fire, which began to concentrate on the IED site as the platoon medic, PFC Brown, moved on foot to evaluate the casualties. She was exposed to the small arms fire until the maneuver element could swing around and begin suppressing the enemy as she treated the wounded soldiers. After making an initial assessment and treating them in order of severity, she moved the casualties, with the aid and direction of the platoon sergeant, into the wadi the engulfed vehicle was hanging over, approximately 15 m from the vehicle. The enemy fighters then engaged the patrol with mortar fire. PFC Brown threw her own body over the casualties to shield them as the mortars were impacting 75 to 100 m away. Approximately 15 mortars impacted within close range of the casualties. PFC Brown continued treatment until the onboard 60-mm mortar, 5.56-mm ammunition, and 40-mm grenade rounds on board the burning vehicle began to explode. Again disregarding her own safety, PFC Brown shielded the casualties with her own body as large chunks of shrapnel and 5.56-mm rounds from the vehicle began flying through the air.

The patrol leader arrived on site and found it incredible that PFC Brown was still alive and treating the casualties amid the extremely dangerous conditions. The platoon sergeant was able to move her and the wounded soldiers to a more protected position as the explosions became even more intense, and she continued treatment even as the platoon returned fire in close vicinity. She shielded the wounded from falling brass and enemy fire once again, ensuring the casualties were stabilized and ready for MEDEVAC.[10]

SPECIAL CATEGORY ENLISTED MEDICAL PERSONNEL

Three groups of enlisted service members deserve special mention: the Air Force’s independent duty medical technician (IDMT), Air Force specialty code 4N0X1C; the Navy’s independent duty corpsman (IDC), Navy enlisted classification HM-8425/8494; and the Army’s Special Forces medical sergeant, military occupational specialty 18D. As the first two names imply, these service members are specially trained to operate independently in many different types of environments; however, the degree to which they can perform medical skills varies and is not related to their titles. Generally, their role is to serve under the supervision of a doctor or licensed provider in garrison; however, these special medical personnel are most often deployed to remote locations or to areas where there is no physician.

Independent Duty Medical Technician

The IDMT is an Air Force specialty with training conducted at the METC. Graduates of the program often deploy with Special Forces, security forces, or civil engineer units, but they sometimes deploy with Army and Navy units. IDMT training is also mandatory for 4N0X1 airmen prior to assignment at remote or isolated duty stations; assignments for medical support of nonmedical field units; or assignments for medical support to other government agencies or joint service missions as directed by the Department of Defense.[11] IDMT training includes obtaining medical histories; performing examinations, assessments, and treatments; and documenting patient care in the absence of a physician; as well as emergency medical, dental, and surgical procedures to stabilize patients prior to medical evacuation. IDMTs also receive instruction in general knowledge and procedural skills for medical administration, monitoring medical aspects of command-designated special interest programs and health promotion, advanced medication administration and dispensary operation, and basic laboratory procedures. The training program also addresses procedures for conducting occupational health services, preventive medicine, field hygiene, and food/water safety inspections in lieu of public health and bioenvironmental health personnel. The IDMT can operate independently when serving at remote sites in deployed settings or in approved alternative care locations; however, in all other cases, the IDMT provides care under the supervision of a preceptor (a designated physician or dentist who provides oversight, professional guidance, support, and training to the IDMT in all areas of medical/dental treatment related to their scope of practice).[11]

Independent Duty Corpsman

An IDC is a special hospital corpsman with the most diverse duty stations in the Navy, ranging from ships and submarines to shore duty throughout the United States and abroad, including service with Special Operations units such as the SEALs, special boat units, Marine raider battalions, and Marine reconnaissance units. IDCs are often assigned to isolated duty stations or vessels where there is no medical officer. All IDCs attend a 1-year course at the Navy’s Surface Warfare Medicine Institute in San Diego, California.[12] These corpsmen fulfill a variety of critical duties in support of Navy and Marine Corps missions as clinical or specialty technicians in more than 38 occupational specialties, including key administrative roles at military treatment facilities around the world. They also assist in the treatment and prevention of disease, serving side-by-side with medical officers, doctors, dentists, and nurses.[12]

Special Forces Medical Sergeant

Special Forces medical sergeants provide medical care and treatment in support of conventional and unconventional warfare. Their training consists of 1 year of formal medical training along with approximately 12 to 18 months of additional training specific to their role as Special Forces soldiers. The training is conducted at the Special Warfare Medical Group/Joint Special Operations Medical Training Center and the Special Warfare Training Group, both of which are part of the John F. Kennedy Special Warfare Center and School/Special Operations Center of Excellence at Ft Bragg, North Carolina. These NCOs have a working knowledge of dentistry, veterinary care, public sanitation, water quality, and optometry.

The duties of a Special Forces medical sergeant include ensuring detachment unit readiness, establishing and supervising medical and dental facilities to support conventional or unconventional operations with emergency, routine, and long-term medical care,[13] as well as many other nonmedical duties. They provide initial medical and dental screening and perform a wide range of medical and ancillary services, including limited laboratory, radiology, and pharmacy requirements.[13] Special Forces personnel often work in remote areas far from medical care. To support these operations, Special Forces medical sergeants are skilled in trauma management and treat emergency and trauma patients in accordance with established medical and tactical combat casualty care principles.

SUMMARY

In considering how enlisted members fit into military medical practice, an officer’s best option is to start with an understanding of the NCO/PO corps. While the enlisted members are the foundation of the military services, NCOs form their backbone. As such, they are responsible not only for the most of the day-to-day operations of military organizations, but they also bear primary responsibility for the welfare of the enlisted members. NCO/POs, who often have more time-in-service than officers, also have responsibility for assisting in training new officers. As officers achieve more rank and experience, their relationships with their NCO/PO counterparts become more reciprocal, but the NCOs/POs with whom they have had meaningful interactions throughout their careers will have shaped their maturation as officers.

REFERENCES

1.   Bradley ON. American military leadership. Army Inf Digest. 1953;Feb:5,6. https://babel.hathitrust.org/cgi/pt?id=mdp.39015084468829;view=1up;seq=87. Accessed July 27, 2017.

2.   US Army Medical Department Office of Medical History. AMEDD NCO/enlisted soldier history. http://ameddregiment.amedd.army.mil/nco/historynco.html. Accessed July 27, 2017.

3.   US Department of Defense. Health Service Support. Washington, DC: DoD; 2012. Joint Publication 4-02. http://www.dtic.mil/doctrine/new_pubs/jp4_02.pdf.

4.   The Noncommissioned Officer and Petty Officer: Backbone of the Armed Forces. Washington, DC: National Defense University Press; 2014.

5.   Hogan D, Fisch A, Wright R. The Story of the Noncommissioned Officer Corps: The Backbone of the Army. Washington, DC: Center of Military History; 2009.

6.   Mellinger JJ. Open letters to three NCOs. Infantry. 1989;May-Jun:17–21. http://www.benning.army.mil/infantry/magazine/issues/1989/MAY-JUN/pdfs/MAY-JUN1989.pdf. Accessed July 27, 2017.

7.   Letter from MG Jacob Brown to the Secretary of War, November 17, 1825. 19th Congress, 1st Session. American State Papers: Military Affairs. 3:110. https://memory.loc.gov/cgi-bin/ampage?collId=llsp&fileName=018/llsp018.db&recNum=120. Accessed July 27, 2017.

8.   Medical Education & Training Campus 2016 Program Catalog. Joint Base San Antonio–Fort Sam Houston, TX; METC; 2016. http://www.metc.mil/Catalog/METC_2016_Program_Catalog.pdf. Accessed December 27, 2016.

9.   Hearst T. METC prepares future medics for any situation. Joint Base San Antonio News website. http://www.jbsa.mil/News/News/Article/617569/metc-prepares-future-medics-for-any-situation/. Published September 17, 2015. Accessed December 22, 2016.

10.   US Army Medical Department Office of Medical History. Army Medical Department Silver Star citation: Monica Lin Brown. http://ameddregiment.amedd.army.mil/silverstar/oifoef/oifoef1.html. Accessed July 27, 2017.

11.   Secretary of the Air Force. The Air Force Independent Duty Medical Technician Program. Washington, DC: USAF; 2013. Air Force Instruction 44-103. http://static.e-publishing.af.mil/production/1/af_sg/publication/afi44-103/afi44-103.pdf. Accessed January 3, 2017.

12.   US Navy. Training, Certification, Supervision Program, and Employment of Independent Duty Hospital Corpsmen (IDCs). Washington, DC: USN; 2007. OPNAV Instruction 6400.1C.

13.   US Department of the Army. Enlisted MOS Specifications. Washington, DC: HQDA; 2016. DA Pamphlet 611-21. https://www.milsuite.mil/book/groups/smartbookdapam611-21. Accessed January 3, 2017.

Chapter 13

COMBINED HEALTH SERVICES SUPPORT OPERATIONS

MARTIN C. BRICKNELL, MD, PHD*

INTRODUCTION

WHY COALITIONS OR ALLIANCES?

HISTORICAL EXAMPLES OF MILITARY MEDICAL COLLABORATION

PRINCIPLES OF MULTINATIONAL MEDICAL SUPPORT

MULTINATIONAL INTEGRATED MEDICAL UNITS

INDIGENOUS FORCES AS PART OF A COALITION

KEYS TO SUCCESS IN MULTINATIONAL MEDICAL COLLABORATION

CONCLUSION

*Lieutenant General, Surgeon General, Headquarters Joint Medical Group, Coltman House, Defence Medical Services (Whittington), Tamworth Road, Lichfield, Staffordshire; Professor of Conflict and Health, Conflict and Health Research Group, King’s Centre for Global Health, Kings College, London, United Kingdom

INTRODUCTION

Future military operations are likely to be conducted in a combined, joint, interagency, or multinational (CJIM) environment. This chapter examines the opportunities and challenges associated with partnering in a CJIM environment to deliver the military medical mission. The chapter opens by considering the strategic purpose of coalitions or alliances and how they enhance efficiency and effectiveness in health service support. The chapter then examines the principles of multinational medical support and the compromises nations must accept if this type of operation is to be successful. The United States and the United Kingdom (UK) have participated in multinational integrated medical units (MIMUs) over the past 2 decades, and lessons learned in these operations will be highlighted in the MIMU section. It is vital to consider efforts in working and partnering with the medical services of indigenous security forces as part of the CJIM environment, which will be introduced in the section on indigenous forces. Health sector capacity building, however, is too big a subject to cover fully here. This chapter will focus on generic organizational learning; readers should consult higher command authorities and legal staff before entering into formal relationships with other nation’s medical services.

WHY COALITIONS OR ALLIANCES?

The international order is defined by the existence of sovereign states with unitary authority within their geographical boundaries. Relationships between sovereign states are determined by international law and states’ obligations within the alliances and agreements they have made in the global arena. It is extremely unlikely that any future conflict will be characterized by a single sovereign nation from the developed world entering a conflict with another single nation. Most developed nations’ security strategies1,2 are underpinned by the treaties and alliances that govern the balance of power among nations. For the United States and the UK, the two primary alliances are the United Nations (UN) and the North Atlantic Treaty Organization (NATO). However, there are many other alliances, often based on regional or technical security cooperation requirements. The ABCA Armies program (United States, Great Britain, Canada, Australia, and New Zealand) was set up in 1947 to optimize interoperability, training, and equipment among the Englishspeaking armies that fought together in World War II. Similar arrangements are in place for other services: the Air and Space Interoperability Council for air forces, AUSCANNZUKUS for navies, and Five Eyes for intelligence.

Nations are highly likely to seek international partners when they plan to use military force as an instrument of national power. Thus, nations invest a considerable amount of time and resources in building relationships with their allies to achieve the maximum effectiveness of collaborative action during combat. This enables the mobilization of political opinion, the summative action of military force, and sharing of costs (money and casualties) so that the cumulative effect in mobilizing power against an adversary is synergistic.

Effective coalition or alliance collaboration is especially important and effective in military medicine, for the care of military casualties is not dependent on unique differences determined by political boundaries, and most nations have difficulty mobilizing the medical staffing and resources to manage their casualty flow independently. Between nations within long-standing alliances, medical collaboration is likely to focus on interoperability so that both nations can care for casualties of the other nationality, and each can have complete confidence in the other’s competence. These goals are most critical when the total deployment of medical services can be reduced by burden sharing between nations. In areas where developed-world military forces are attempting to have a stabilizing effect, it is likely there will be a medical capability-building requirement. Exhibit 13-1 lists examples of current military medical alliances and organizations.

In addition to collaboration on the organizational design of the medical support system, it is also important to consider the value of clinical information exchange between nations. This includes conventional mechanisms of knowledge exchange such as clinical conferences and publication of results of clinical research. Some alliances have more structured mechanisms such as standardization agreements for clinical practice, clinical equipment, and information exchange between nations. Therefore, it is essential that military medical personnel have the organizational and interpersonal skills to be effective in working with medical personnel from other nations and cultures as part of their contribution to effective coalition and alliance operations.

EXHIBIT 13-1

CURRENT MILITARY MEDICAL ALLIANCES AND ORGANIZATIONS

International Committee of Military Medicine. Purpose is to maintain and strengthen the bonds of professional collaboration between members of the armed forces medical services of all states.
http://www.cimm-icmm.org/index_en.php

North Atlantic Treaty Organization Committee of the Chiefs of Military Medical Services. The senior committee for medical care within NATO. Acts as the central point for the development and coordination of military medical matters and for providing medical advice to the NATO Military Committee.
http://www.coemed.org/comeds

Confédération Interalliée des Officiers Médicaux de Réserve (Interallied Confederation of Medical Reserve Officers). To contribute positively to the organization and readiness of the military health services of NATO member nations, thereby enhancing their effective function both nationally and internationally. Further, to promote in every possible way the standardization and interoperability of those medical services during peace or war.
http://www.ciomr.org/

Asia-Pacific Military Health Exchange. Annual conference for military healthcare professionals from across the Indo-Asia-Pacific region to discuss health topics affecting the region and to collaborate on issues such as disaster response, medical readiness, and improvements in the delivery of healthcare.
https://community.apan.org/conf/apmhe/

American British and Canadian Australian Armies (ABCA) Quadripartite Working Group on Health Service Support. Working group of health service support representatives of participating armies; principal activity involves the progression of standardization tasks on health service support issues identified and prioritized by armies.

HISTORICAL EXAMPLES OF MILITARY MEDICAL COLLABORATION

Almost all military operations of the 20th and early 21st century have been based on coalitions or alliances. This short section will highlight some key observations about the breadth of issues addressed as part of combined medical planning. The military medical histories of both World War I and World War II contain descriptions of the inter-allied coordination mechanisms for medical care of each nation’s casualties. This was especially important on the western front in both wars to ensure both effective dispersion of military casualties in the United Kingdom as the strategic base for the British Armed Forces, and the strategic embarkation of North American casualties (US and Canadian) prior to the long sea journey back to their home nation.

After World War II, conflict shifted to Asia. Japan became an important strategic hub for allied casualties during the Korean War. The conflict in Vietnam introduced the complexity of medical capacity-building for indigenous security forces and the consideration of using military medicine to help care for civilian casualties of the conflict. In Western Europe during the Cold War, NATO developed sophisticated mechanisms for coordinating the medical evacuation system as part of military planning to counter the threat of invasion by Warsaw Pact forces from the east. Figure 13-1 shows a comparison of command arrangements published in the 1986 NATO Interoperability Handbook.

The campaign to liberate Kuwait was the biggest military operation of the late 20th century. In addition to the UK and United States, New Zealand, Norway, Romania, Singapore, and Sweden contributed medical units to the coalition. These units were integrated into the medical plan and contributed particularly to the medical treatment of enemy prisoners of war.3–5

International peacekeeping efforts in the Balkans during the 1990s were initially conducted under UN command but shifted to NATO control after the Dayton Peace Accord. NATO also acted as the alliance mechanism to command military operations in Kosovo. NATO provided the forum for coordinating medical support arrangements, including coordination with indigenous health systems and international agencies.[6] This included the development of MIMUs in Sipovo, Bosnia and Camp Bondsteel in Kosovo.[7]

Figure 13-1. Comparison of NATO medical command arrangements.
Reproduced from: NATO Interoperability Handbook. London, UK: British Army; 1986: Figure 4-1. Army Code No. 71376, February 1986.

The initial phase of Operation Iraqi Freedom, the invasion of Iraq, was a bilateral operation involving the UK and United States. The number of coalition troops from contributing nations varied during the subsequent counter-insurgency campaign. However, the United States provided the leadership framework for the organization of medical support across the theater of operations, including the medical capability program for Iraqi security forces.

In Afghanistan, NATO and the United States operated alongside each other until it became a unified theater command during 2006 under the UN-mandated International Stabilisation Afghanistan Force (ISAF). Medical support was coordinated at the strategic level by the Allied Command Operations Headquarters in Mons, Belgium. Operational coordination was achieved through multinational medical steering groups for each ISAF region and organized by the NATO Joint Force Command at Brunssum. The medical director and joint medical staff branch at ISAF headquarters in Kabul directed in-theater medical support.[8]

The same type of coordination occurred in the clinical domain. In the First World War, lessons from the medical treatment of casualties were shared at a series of inter-allied medical conferences in 1917, and common clinical treatments were published in a series of collaborative books.[9] During World War II, the UK and United States actively coordinated in medical research. The most prominent example of this collaboration was the introduction of penicillin as the first true antibiotic.[10] This collaboration is currently maintained through a broad series of NATO medical working groups that produce NATO standardization agreements. The research community collaborates through health and medical research groups within the NATO Technical Co-operation Council Programme. The shared experience of combat casualty care between the United States and UK in Iraq and Afghanistan has led to fully transparent information exchange between both nations’ joint theater trauma registries.

PRINCIPLES OF MULTINATIONAL MEDICAL SUPPORT

Coalitions or alliances exist to increase the collective effort of nations to achieve their aims. The nations involved agree to delegate authority to coalition/alliance commanders for defined purposes and tasks. However, nations are likely to retain a sovereign veto over activities conducted by their forces, including rules of engagement and risk. Thus, nations are likely to nominate a “national contingent commander” who executes this authority within the coalition. Nations retain responsibility for the provision and quality of medical support to their forces even if they have delegated the arrangements for delivery of this medical support to a coalition or other nation.[11]

Multinational medical support aims to provide a solution to the challenges of providing medical support to the CJIM operating environment through collaborative planning, coordinated deployment, and mutually agreed employment of the medical force. This has the potential to provide greater efficiency in the use of medical resources by reducing duplication, and to promote greater effectiveness by making niche specialist national capabilities available to the whole entitled population at risk.

Multinational medical support is underpinned by formal processes and procedures agreed upon by all nations. NATO has the most sophisticated hierarchy of such agreements, which are formally published as standardization agreements. These agreements are intended to be binding on alliance nations, so medical personnel employed on NATO operations must be familiar with these documents in addition to national medical policies and procedures. ABCA bases its standardization on NATO documentation and has published its own Coalition Health Interoperability Handbook as high-level guidance.[12] The UN also has specific guidance for the medical support arrangements and standards for its peacekeeping operations.[13]

Nations may contribute to multinational medical support in one of four ways[14]:

- Coexistence. Medical capabilities exist concurrently at the same time and in the same place in the military operation. Even at this low level of interaction, it is important to have an agreed-on means of communication between medical units. This situation may occur because the variation in capability, language, and clinical practice is so great that it is not practical for military patients to be shared between facilities.

- Cooperation. Specific arrangements have been made to allow exchange of information between national medical facilities. Also, national contingent commanders may make their medical facilities available to patients from other nations.

- Coordination. In these circumstances, national medical facilities have been formally declared as part of the multinational force and therefore the medical staff in the coalition/alliance command chain have specific authority over national medical facilities. This might include the authority to direct the admission of patients to the facility or to move the facility in accordance with the coalition/alliance commander’s plan.

- Integration. Nations may agree to combine medical resources into an integrated medical force such that all medical capability of the force is under a unified command. This might be at a task-force level, whereby nations contribute discrete medical forces (eg, an ambulance troop from one nation and medical detachments from other nations under a single command headquarters); or it might be at the level of a MIMU, in which personnel from more than one nation are employed in a single unit.

The coalition/alliance command system must include a medical staff branch with sufficient medical staff to provide medical advice to the planning process, to coordinate medical operations and evacuation, to collate medical reports, and to provide technical guidance to the military force. The command surgeon/medical director (there is a difference between US and NATO terminology for the same role) must establish the extent of his or her authority over each medical unit in theater. It is likely that Role 1 (immediate medical support to battalion or smaller elements) will be a national responsibility, and Role 2 and 3 (deployed hospital care) may have a stronger command relationship to the coalition headquarters. Figure 13-2 shows a combined, joint medical evacuation rehearsal of concept drill in Afghanistan.

MULTINATIONAL INTEGRATED MEDICAL UNITS

Because human physiology and pathophysiology are the same regardless of nationality or ethnic background, casualties can receive medical care independent of the national provider. Military medical units may be formed with contributions from more than one nation as MIMUs. These have successfully delivered coalition medical support in many operations, particularly in Afghanistan. In Kandahar, the NATO Role 3 facility was successively led by Canada and then the United States, incorporating medical personnel from Canada, the United States, the UK, Australia, Holland, and other countries, from all three service branches of each nation. In Helmand, the UK led the Camp Bastion Role 3 facility, incorporating personnel from the UK, United States, Denmark, Estonia, and other nations.

Successful operation of a MIMU is dependent on effective leadership and staff coordination from the defense ministry or department down to functional level within the unit itself. The NATO experience has demonstrated the value of a multinational medical management steering group (MMMSG), chaired by the coalition strategic headquarters and attended by representatives from each nation and the in-theater command chain. The MMMSG owns the formal technical agreement that binds each nation to the MIMU and supervises the detailed coordination of the capability requirement, the joint manning document and credentialing arrangements, the financial arrangements, the force generation and rotation arrangements, and the dispute settling mechanism.

Figure 13-2. Combined, joint medical evacuation rehearsal of concept drill, Regional Command South, Kandahar, Afghanistan 2009.

The MMMSG will establish the command arrangements and the contribution of personnel by each nation. In addition to the key role of the commanding officer, the UK experience is that the senior clinician (the deployed medical director in UK terminology or deputy commander for clinical services in US Army terminology) has a pivotal role in establishing a collaborative professional forum among the senior clinical staff from each nation.[15] The MMMSG must determine if national personnel are employed as discrete clinical teams or if the clinical teams are to be multinational. The UK experience suggests that it is better to create a single identity for the MIMU by mixing all personnel rather than to risk nations forming national clinical cliques. It is likely that a nation will volunteer to act as lead nation and take responsibility for overall tactical organization of the MIMU. Lead nation responsibility may include coordination of predeployment training, provision of medical equipment, confirmation of credentialing, and development of clinical protocols and procedures.

At a minimum, all nations will need to establish a national contingent commander and a national patient liaison officer. It is the UK experience that it is preferable to conduct organizational and clinical training for the whole contingent before deployment if possible. This allows the contingent to get to know each other, to establish professional relationships, and to identify any variations in clinical practice or professional duties that require clarification to ensure effective teamwork. At a personal level, it is vital to recognize the importance of flexibility and open-mindedness when assigned to a multinational medical unit or as part of a coalition medical force. Everyone is the product of their own national culture, but there is not necessarily a single right way to approach clinical care for patients.

Some countries have clearly prescribed clinical practice guidelines for the clinical management of defined conditions (Joint Theater Trauma System Clinical Practice Guidelines in the United States and Clinical Guidelines for Operations in the UK). Wherever possible, clinical leaders should negotiate an agreement that clarifies which national guidelines are the authoritative reference for clinical practice in a MIMU. Additionally, there is likely to be variation in the employment of clinical specialists, particularly nurses. For example, the US employs certified registered nurse anesthetists and physician assistants to undertake duties that are the prerogative of registered medical practitioners in many countries. These differences will need to be identified and agreement reached on the scope of practice for these clinicians within the clinical team.

Additional variations and issues will need consideration. Trade names for drugs vary among nations, so it is essential that international non-proprietary names be used for all prescriptions. International variation in testing and accountability for blood products is likely to require the administration of national blood products to casualties from specific nations if the national blood supply systems can support it (otherwise specific dispensations may be required). Finally, it will be necessary to establish a mechanism for mediation of differences of practice between clinicians in order to ensure that variations in individual clinical practice do not undermine confidence in the multinational medical system. The command team should set up internal team meetings to ensure effective collaboration and accommodate national sensitivities.

INDIGENOUS SECURITY FORCES AS PART OF A COALITION

As stated earlier, it is highly likely that local or indigenous security forces will be part of a coalition operation. The mission may involve capacity-building with these forces, including supporting the development of their medical capabilities. Security operations will likely be conducted with indigenous security forces alongside international coalition forces. This type of coalition medical activity is very different from working with established Western partnerships. The international coalition may allow indigenous casualties to be treated by coalition medical units in an emergency, but it is highly unlikely that the local medical capability will be sufficiently competent to treat international casualties. Therefore, it will be necessary to establish collaboration and coordination mechanisms that include the medical services of indigenous security forces. This collaboration can be divided into two types: medical planning and medical capability development.

The principles of planning for medical arrangements for indigenous security force casualties are no different from those that apply to international coalition forces. A clinical pathway from point of injury to rehabilitation is required, including coordination for medical evacuation from the field and transfer from coalition facilities to indigenous facilities. It is possible that the local medical system is different for the army and police, so arrangements for casualties from these services may vary. Coalition medical staff will need to consider the ethical issues associated with handing over indigenous casualties to medical facilities with lower capabilities and the possibility of worse patient outcomes. This is a matter partially controlled by International Law, Protocol 1, 1977, of the Geneva Convention (see Chapter 6, The Law of Armed Conflict and Military Medicine), as well as by rules of engagement issued by higher headquarters.

It is imperative that medical officers become aware of these rules prior to taking up their duties, as well as knowing how to obtain exceptions to them (see the discussion of rules of engagement and ethically driven exceptions in Chapter 5, Military Law and Ethics). There may be value in establishing a formal framework for analyzing ethical issues such as the “four-quadrant” approach (medical implications, patient preferences, quality of life, contextual factors) so that the clinical team has an agreed-upon methodology for examining these issues.[16] Figure 13-3 shows a coalition medical planning meeting in Kandahar in 2010 attended by representatives from the UK, United States, Canada, Afghan army, Afghan public health department, and the US Agency for International Development.

The subject of indigenous medical capability development for partner security forces is too great to cover fully within this chapter. However, a number of key issues should be considered within the subject of coalition/multinational medical support. Medical capability development must be underpinned by a strategic analysis of the requirement and subsequent plan that includes an assessment of the resources needed to achieve the desired outcomes. Ideally this would be agreed upon by the coalition and include the assignment of international medical forces to the tasks. This plan should cover all of the DOTMLPF (doctrine, organization, training, materiel, leadership, personnel, facilities) domains of a capability solution. Local partners should also agree to the plan, which should be sensitive to local cultural and clinical practices.

KEYS TO SUCCESS IN MULTINATIONAL MEDICAL COLLABORATION

The foundations for success are based on the cultural alignment of the collaborating nations. Medical support is underpinned by the provisions of international humanitarian law and the Geneva Conventions, which dictate the ethical behavior of medical personnel during conflict. Medical support should be based on collaborative planning that provides for all casualties of conflict, including international coalition troops, indigenous security forces, civilians, and enemy combatants. The role of medical organizations and personnel in this effort will be determined by coalition agreements and national limitations. The coalition medical leadership team will need to understand these agreements and limitations by seeking information through formal and informal channels.

All members of the coalition medical leadership team need to understand their own and partner nations’ doctrine and clinical practice, including anything covered by international agreements.[17] This requires a significant amount of predeployment preparation. The team will need to invest in developing personal relationships, which requires a substantial amount of time out of the office visiting coalition medical facilities and units. All personnel need to be sensitive to differences in national culture, even if speaking a common language. In the end, leadership success is based on appealing to a sense of collective commitment to caring for patients that transcends national politics.

Figure 13-3. Medical planning for Operation Hamkari, Kandahar, Afghanistan, 2010. UK, US, Canadian, Afghan army, and Afghan public health representatives are collaborating.

CONCLUSION

Coalitions and alliances are the most likely frameworks for future military operations. These are built from continuous exchange and dialogue among personnel from all the nations involved. It is vital to commit time and resources to enable the development of personal relationships among the multinational personnel, which provide the foundations for success. These relationships range from formal senior-level talks, through information sharing at conferences, practicing interoperability in military exercises, and down to individuals attending education courses in each participating nation. The medical services are ideally positioned to be exemplars in this field because of a strong focus on patients, a culture of knowledge sharing, and having few political or security constraints.

REFERENCES

1.   US Department of Defense. Quadrennial Defence Review 2014. Washington, DC: DoD; 2014. http://archive.defense.gov/pubs/2014_Quadrennial_Defense_Review.pdf. Accessed June 30, 2017.

2.   National Security Strategy and Strategic Defence and Security Review 2015. London, England; HMSO; 2015. CM9161. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/555607/2015_Strategic_Defence_and_Security_Review.pdf. Accessed June 30, 2017.

3.   Dauphinee WE. Stretching the Resources: Medical Support for Canada’s Military Commitment to the Gulf War. http://history.amedd.army.mil/booksdocs/AMEDDinODS/AMEDDODS1Dauphinee.pdf. Accessed June 30, 2017.

4.   Bricknell MCM. The evolution of casualty evacuation in the British Army in the 20th century (Part 3) – 1945 to present. J R Army Med Corps. 2003;149:85–95. doi:10.1136/jramc-149-01-20.

5.   Leitch RA. The impact of enemy prisoners of war on medical planning—lessons from Operation Desert Storm. J US Army Med Dep. 1994;Jan-Feb:19–22. http://history.amedd.army.mil/booksdocs/AMEDDinODS/AMEDDODSADSLeitch.pdf. Accessed June 30, 2017.

6.   Thornton R, Cordell RF, Edmonds KE. Humanitarian aid operations in Republica Srpska during Operation Resolute 2. J R Army Med Corps. 1997;143:141–145. doi:10.1136/jramc-143-03-02.

7.   Jenkins I. The changing world of military health care. J R Army Med Corps. 2004;150:234–238. doi:10.1136/jramc-150-04-02.

8.   Bricknell MCM. Reflections on medical aspects of ISAF IX in Afghanistan. J R Army Med Corps. 2007;153:44–51. doi:10.1136/jramc-153-01-11.

9.   General Principles Guiding the Treatment of Wounds of War: Conclusions Adopted by the Inter-Allied Surgical Conference Held in Paris, March and May, 1917. London, England: HMSO; 1917.

10.   MacNalty AS, ed. Medical Services in War. The Principal Medical Lessons of the Second World War. London, England: HMSO; 1968.

11.   UK Ministry of Defence. Foundations of medical support. In: Allied Joint Medical Support Doctrine. London, England; Ministry of Defence; 2015: Chap 1. AJP 4.10 (B).

12.   Coalition Health Interoperability Handbook. 2nd ed. Ft Sam Houston, TX: Army Medical Department Center and School; 2009. Quadripartite Advisory Publication 82.

13.   United Nations. Medical Support Manual for United Nations Field Missions. 3rd ed. New York, NY: UN; 2015. http://dag.un.org/handle/11176/387299?show=full. Accessed June 30, 2017.

14.   UK Ministry of Defence. Multinationality and medical support structures. In: Allied Joint Medical Support Doctrine. London, England; Ministry of Defence; 2015: Chap 10. AJP 4.10 (B).

15.   Mahoney PF, Hodgetts TJ, Hicks I. The deployed medical director. J R Army Med Corps. 2011;157(3 Suppl 1):S350–S356.

16.   Bernthal EMM, Russell RJ, Draper HJA. A qualitative study of the use of the four quadrant approach to assist ethical decision-making during deployment. J R Army Med Corps. 2014;160:196–202. doi:10.1136/jramc-2013-000214.

17.   Cordell RF. Multinational medical support to operations: challenges, benefits and recommendations for the future. J R Army Med Corps. 2012;158:22–28. doi:10.1136/jramc-158-01-06.

Section II

OPERATIONAL HEALTH SERVICE SUPPORT

Section Editor:

JAMES F. SCHWARTZ, LTC (RET), MEDICAL SERVICE CORPS, US ARMY

US Marines with 1st Air Delivery Platoon, Landing Support Company, 1st Marine Logistics Group, prepare blood units in preparation of an air delivery at Marine Corps Air Station Yuma, Arizona, March 28, 2018. This training is intended to test the viability of dropping units of blood by air to austere environments when ground delivery is not an option. (US Marine Corps Photo by Cpl. Kyle McNan)
Reproduced from: https://www.dvidshub.net/image/4284311/air-blood-delivery-with-1st-marine-logistics-group.

Chapter 14

INTRODUCTION TO HEALTH SERVICE SUPPORT

JAMES F. SCHWARTZ,* MEGAN C. MULLER,† AND CONRAD R. WILMOSKI‡

INTRODUCTION

THE MILITARY HEALTH SYSTEM

The Health Service Support Mission

The Role of the Medical Officer on the Command Staff

HEALTH SERVICE SUPPORT PRINCIPLES

Conformity

Continuity

Proximity

Mobility

Control

Flexibility

A REPRESENTATIVE MEDICAL LAYDOWN IN A JOINT OPERATIONS AREA

RESOURCES

SUMMARY

*Lieutenant Colonel (Retired), Medical Service Corps, US Army; Assistant Professor and Chief of Staff, Department of Military & Emergency Medicine, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Major, Medical Service Corps, US Army; Executive Officer, 264th Medical Battalion, 32nd Medical Brigade, Joint Base San Antonio-Fort Sam Houston, Texas

‡Major, Medical Service Corps, US Army; Sustainment Branch, Concepts and Capabilities Division, Health Readiness Center of Excellence, Capability Development Integration Directorate, Joint Base San Antonio-Fort Sam Houston, Texas

INTRODUCTION

Scenario: You recently completed your graduate medical education training following medical school and have been assigned as the medical officer in a ground combat unit. You joined your unit 30 days before it deployed to the theater of operation almost 2 months ago. Your unit has been in theater for 45 days and has been assigned its first combat mission to establish control of a town that has been used by the enemy as a safe haven and for smuggling operations. Your commander calls together the unit staff and provides some initial planning guidance. As the medical officer, it is your responsibility to work with the staff and develop the health service support (HSS) plan for the upcoming mission. How do you undertake this planning?

Providing an answer to this important question, this chapter will begin the process by which a new military medical officer (MMO) can achieve success by protecting and caring for those entrusted to them on operational missions, such as the one described above, or others across a full—and often unpredictable—spectrum of military and unified operations with a health and healthcare support element. It will begin with an overview of military HSS by explaining the overall mission and composition of the Military Health System (MHS); the overall HSS mission as outlined in joint and service doctrine1–6; and the multiple roles of an MMO within an operational unit. The chapter will then further discuss HSS principles, joint medical capabilities, the separate roles of care, and the different forms of en route care delivery. Finally, a notional medical laydown in schematic form for a joint operations area (JOA) is depicted to provide an understanding of how medical unit and responsibilities fit within the larger operational context.

The principles of HSS and the associated joint medical capabilities are modified and adapted according to the particular military operation, geographic and environmental conditions, nature of the enemy, service association for the main operational effort and command (ie, Army, Navy, Marine Corps, Air Force, or interagency or coalition operations). By the conclusion of this chapter, an MMO should have comprehensive understanding of the flexibility, breadth, and depth of HSS.

THE MILITARY HEALTH SYSTEM

When an MMO is assigned to a ground combat unit (coalition and joint, joint, Army, Marine, or Special Operations), their focus is at a tactical level. That is to say, the MMO and their fellow uniformed health protection and healthcare professionals will be designing a support plan for the sustainment of health, illness management, and injury or combat casualty care for a discrete number of warrior combatants, usually under 1,000. The plan will involve a single operation limited in time and space to the objective and responsive to the enemy’s actions. The MMO will begin by developing a solid understanding of the operational environment, the health threats and risks associated with the environment, and the medical capabilities supporting the mission. But before considering this specific plan, it is instructive to have a broader understanding of the MHS and what resources are available to the MMO.[7] In many ways, the planning for this operation began much earlier and much farther away from the deployed location.

The MHS is a global, comprehensive, integrated system composed of deployed combat and noncombat (humanitarian relief, disaster management, national event response) contingency medical services; peacetime healthcare delivery; public health services; health education and training; medical materiel development and medical logistics; and biomedical research and development (see “This Is the Military Health System” video in Resources, below). The MHS, which includes the services’ medical capabilities, provides a continuum of health services from austere operational environments through remote, fixed medical treatment facilities to major tertiary care medical centers distributed across the continental United States (CONUS). The MHS supports the operational mission by fostering, protecting, sustaining, and restoring health. All efforts, whether direct preventive services and care delivered to the warfighter in the Army, Navy, Air Force, Marine Corps, or Coast Guard, or care provided to the families of these uniformed personnel or the extended military family of retirees and their families, are aimed at enhancing the fundamental goal of the US military to defend the nation through readiness to engage threats to national security at home and abroad.

Although closely partnered with other federal health agencies, the MHS is funded, organized, resourced (staffed and equipped), and controlled separately from other executive branch agencies such as the Department of Veterans Affairs, Department of Homeland Security, Department of Health and Human Services, National Institutes of Health, and Centers for Disease Control and Prevention.

The joint medical capabilities of the MHS are grouped under two functional areas: protection and sustainment. Protection is the preservation of the effectiveness and survivability of mission-related military and nonmilitary personnel, equipment, facilities, information, and infrastructure deployed or located within or outside the boundaries of a given operational area. Force health protection measures promote, improve, or conserve the behavioral and physical well-being of service members to enable a healthy and fit force, prevent injury and illness, and protect the force from health hazards. These measures or actions enable commanders to deploy a medically ready force to the operational environment and protect the force during deployment.

Sustainment encompasses the provision of logistics and personnel services, including the health services required to maintain and prolong operations until the mission is successfully completed. HSS is the operationalization of these critical protection and sustainment processes, that is, all support and services performed, provided, or arranged to promote, improve, conserve, or restore the mental or physical well-being of personnel. HSS is the organized system of the military’s medical capabilities and resources designed to deliver healthcare to the force while in the operational environment.

The Health Service Support Mission

The key elements of HSS are codified for the entire MHS and the military medical force in the Joint Publication 4-02, Healthcare Service Support.[2] This “Joint Pub” reinforces the concepts described above, defining health service support as:

All services performed, provided, or arranged to promote, improve, conserve, or restore the mental or physical well-being of personnel, which include, but are not limited to, the management of health services resources, such as manpower, monies, and facilities; preventive and curative health measures; evacuation of the wounded, injured, or sick; selection of the medically fit and disposition of the medically unfit; blood management; medical supply, equipment, and maintenance thereof; combat and operational stress control; and medical, dental, veterinary, laboratory, optometric, nutrition therapy, and medical intelligence services.[2]

The HSS mission includes casualty management,8–15 patient movement,16–20 medical logistics, and health information management. In outlining the capabilities within HSS, Joint Pub 4-02 recognizes the volatile, complex, and ambiguous nature of 21st century armed conflict and health crises. Accordingly, the HSS mission supports various operational environments, including:

- combat operations;

- stability and civil-military operations;

- defense support to civil authorities;

- limited contingency/civil response;

- multinational operations;

- Special Operations missions;

- operations involving chemical, biological, radiological, nuclear, or explosive weapons; and

- contractor support.21–23

The Role of the Medical Officer on the Command Staff

Each service organizes the command staff a little differently, but the primary duties of any staff are typically the same: supporting the commander; assisting subordinate commanders, staffs, and units; and informing units and organizations outside the headquarters or immediate circle of the commander and the commander’s staff. The command staff typically consists of three staff sections: the coordinating staff, special staff, and personal staff. The coordinating staff functions are comprised of manpower and personnel, intelligence, operations, logistics, plans, and communications. These staff positions are usually identified by a shorthand alphanumeric designation of the numbers 1 through 9, with a prefix derived from the service. Army and Marine Corps units commanded by general officers are designated with a “G,” while staffs commanded by other commanders, typically colonels and lieutenant colonels, are designated by an “S.” US Air Force staffs are designated by an “A,” and Navy staffs are designated by an “N,” regardless of whether they are commanded by a general officer. For example, Army battalion personnel functions are designated as “S-1,” intelligence as “S-2,” operations as “S-3,” sustainment as “S-4,” and so on.

A special staff officer assists the commander, staff, and subordinate units with administrative, technical, or tactical expertise. A personal staff officer has a unique relationship with the commander, working directly under the immediate control of, and with direct access to, the commander. A medical officer assigned to a command staff could be designated as either a personal or special staff officer, depending on the commander.

Although there are variations at each command level, all military medical staff officers have similar duties and responsibilities, which focus on the health and readiness of the command, health and medical training, planning, force health protection, and HSS. Although an MMO may never participate in a combat patrol or flying mission, they have a critical role in the accomplishment of those missions: ensuring service members are healthy and fit to conduct the mission (“medically ready”); that unit medical and nonmedical personnel are trained to apply and administer lifesaving first aid; and that a viable, integrated medical concept of support addressing all key medical functional areas through all appropriate roles of care is planned, trained, and rehearsed in support of the mission.

An MMO’s success as a staff officer hinges on their relationship with the commander, fellow staff officers and noncommissioned officers, and subordinates. Duties are not restricted to day-to-day troop care. MMOs must get out of the clinic, participate in unit physical training, and attend social events. Success is couched in willingness to be a team player; MMOs should be willing to do any job asked of them by the command (“not my job” should never be part of their lexicon). MMOs must do their homework, finding out everything they can about the unit—its mission, organization, equipment, and operating procedures. MMOs must be involved in the decision-making process and provide realistic advice and opinions, not just information. They must anticipate and forecast problems, apply critical thinking to the situation, and be prepared with viable solutions. For example, monitoring medical operations over the radio, the MMO might hear that the supporting forward surgical team is overwhelmed with patients just as the unit is preparing to conduct a raid. The MMO should alert the commander of the risks of the impending operation in the event a service member needs forward surgical intervention.

MMOs must also be prepared to lead. An MMO on the command staff not only advises the commander and assists the staff in all medical areas, but also will most likely have the added responsibility of leading a staff section, such as a command surgeon section or cell, or a medical platoon, element, or department; in some cases they may command a medical organization. The MMO will wear many hats and be expected to do all of them well; the service members of the organization are depending on it.

Lastly, the MMO must realize that they are not alone on the staff; the other staff officers and members of the team are there to help. Many times the MMO will work under the primary staff officer for logistics or sustainment during mission planning and provision of organizational support. Some commanders may request that the MMO work through the unit deputy commander or executive officer, or keep them informed of issues. Working on a staff can be a balancing act; it takes time and effort on the MMO’s part to develop working relationships and figure out the unit’s unique, informal “rules of engagement.” Through it all, the MMO has the responsibility to provide the best medical advice to the commander, staff, and subordinate units.

HEALTH SERVICE SUPPORT PRINCIPLES

The MMO’s ability to provide effective healthcare begins with an understanding of how to integrate six basic doctrinal principles, regardless of the setting (whether in a tactical field environment or in the traditional “brick and mortar” military medical treatment facility [MTF]). As stated in the Prehospital Trauma Life Support manual, “principles are those things that must be present, accomplished or ensured by the health care provider in order to optimize patient survival and outcome.”[24] The principles, which should be considered in all elements of critical thinking and planning, are:

1. Conformity. Support the commander’s plan.

2. Continuity. Progressive, phased roles of care.

3. Proximity. Right place, right time.

4. Mobility. Keep up with the forces.

5. Control. Orchestrate medical resources.

6. Flexibility. Meet changing requirements.

Each of these six doctrinal principles requires an understanding of their constituent elements. For example, the principle of continuity requires that the MMO understands the different roles of care, and the service-specific capabilities and facilities within each role. To support continuity, the MMO must also understand how patients are moved from one role of care to the next, through ground, maritime surface, and aerial evacuation, and what en route care is available with each mode of transportation. The six principles are discussed in detail below.

Conformity

It is imperative that the HSS plan conforms to the commander’s tactical and operational plan (Exhibit 14-1). The MMO must have a solid understanding of the unit’s mission, and how health services can best support mission accomplishment. For the MMO, this begins even before the unit is assigned the mission; as discussed above, MMOs must have a proactive working relationship with fellow unit staff officers and access to the commander. Once the mission is assigned, the MMO must be involved in the earliest stages of planning. Early involvement helps ensure that the HSS plan will conform to the tactical plan; early involvement gives the MMO the greatest chance to provide medical influence in the planning; and early involvement ensures synchronization of medical forces. Lastly, once the HSS plan is developed, it should be rehearsed with the personnel who must execute it, as well as with those the plan will support.

EXHIBIT 14-1

THE CONFORMITY PRINCIPLE IN ACTION: THE DANGERS OF FAILING TO SYNCHRONIZE THE MEDICAL PLAN WITH THE OPERATIONAL PLAN

The U.S. Invasion of Grenada. On 21 October 1983, with the designation of Commander Joint Task Force 120, intensive operational planning was begun for Operation URGENT FURY. However, no combat support planners, including medical representatives, were invited to participate. Consequently, no estimate of logistical supportability was completed prior to execution, and the required medical support system did not develop. The short lead time and the absence of a designated task force surgeon to coordinate medical services at the joint level left each service to plan medical support within the scope of its own organic assets, with little or no joint coordination of such activities as casualty care management, whole blood procurement, and aeromedical evacuation. Erroneous assumptions may have been made as well. For example, the commander of the 82nd Airborne Division was informed that two amphibious ships, United States Ship (USS) Guam (LPH 9) and Trenton (LPD 14), which were in the vicinity of Grenada, could provide significant medical and surgical support. The record is unclear, but this inaccurate information may have been responsible for his ultimate decision to keep Army medical support to a minimum.

The hostilities lasted ninety-six hours—123 casualties and eighteen deaths were recorded—and brought combat wounded to both Guam and Trenton. No significant or sustainable tactical medical asset was established within the combat zone during the hostilities, nor were there triage facilities ashore. Without trained and experienced triage corpsmen or officers, casualties were not sent in an orderly and logical flow to the proper receiving facilities. There were no established medical communication nets between the Army and Navy, let alone with Trenton and Guam; Army helicopter pilots, unfamiliar with the Navy ships and their silhouettes, brought casualties to whichever flight deck was most convenient. On several occasions the better-equipped Guam was overwhelmed with both minor and lower-priority delayed casualties, while Trenton, which had no surgical capability, laboratory, or blood bank, was sent critical casualties. In essence, medical assets were squandered and overutilized simultaneously.

____________

Reproduced from: Smith AM, Bohman HR. Medical command and control in sea-based operations. Naval War College Rev. 2006;59(3):53–71.

To begin the HSS plan, the MMO, working with the staff, should review any plans and orders, including accompanying annexes and appendices. Orders, whether verbal or written, are used to communicate directives from the superior to the subordinate command. Orders convey the situation, mission, execution, administration and logistics (or sustainment), and command and control (or signal) for a specific operation. For example, in joint, Navy, Marine Corps, and Air Force plans and orders, specific HSS planning data can be found in the administration and logistics paragraph of the base plan or order, as well as annexes—Annex C: Operations (Force Protection); Annex D: Logistics/Combat Service Support; and Annex Q: Medical Services. In Army plans and orders, HSS information can be found in the sustainment paragraph of the base plan or order; in Annex E: Protection; and in Appendix 3 of Annex F: Sustainment. Although HSS information is located in these key areas, the MMO should review the entire plan for specific HSS planning data and tasks.

Continuity

As the MMO begins developing the HSS plan, they should analyze the medical capabilities from point of injury (POI) or wounding to CONUS-based healthcare; in other words, the MMO should look for a system of continuity of care. Five overarching joint medical capabilities build this continuum:

1. first responder care,

2. forward resuscitative care,

3. theater hospitalization,

4. definitive care, and

5. en route care.

Corresponding to these five capabilities are specific roles or functions referred to as roles of care (previously referred to as “levels” or “echelons” of care, these terms have been replaced in joint and coalition parlance to “roles of care”). The following is an explanation of the joint medical capabilities and corresponding role of care. It is important to understand that, as the patient progresses through the roles of care, each role possess those capabilities and resources found at the lower role; that is, Role 2 includes the capabilities and resources found at Role 1 in addition to the enhanced capabilities and resources required for Role 2.

First responder care capability, sometimes referred to as unit-level care, is defined by time requirements and can be divided into three categories: self-aid or buddy aid, emergent care, and primary care. The purpose of first responder care is to provide immediate care, stabilize the patient, and prepare the patient for evacuation to next role of care. Emergent care includes hemorrhage control; airway management; intravenous access and therapy; oral and intramuscular medications; initial management of penetrating eye injuries, fractures, burns, and thoracic trauma (including needle and tube thoracotomy); electronic vital sign monitoring; and en route care. Primary care includes physical exams, health screening, and treatment of common illnesses and minor injuries. Tactical Combat Casualty Care (TCCC) procedures are consistent with the first responder care capability.

Organizations and capabilities that are limited to first responder care, primary care, and emergent care capability are typically designated as Role 1. Examples include self-aid/buddy-aid, combat lifesavers, medics, corpsmen, and independent duty medical technicians; Army medical platoons, medical company treatment squads, and ambulance crews; Marine Corps medical platoons, shock trauma platoons, and ambulance crews; Air Force squadron medical elements; and Navy destroyer, cruiser, frigate, and submarine medical departments. Combat lifesavers are nonmedical personnel who have been designated by the command to receive additional medical training beyond basic first aid. This is an additional duty and does not substitute for the service member’s primary duties. The standard is typically one combat lifesaver per crew, squad, team, or equivalent size unit.

A Role 1 tactics, techniques, and procedures (TTP) example is as follows: the medical platoon of a maneuver battalion operates what is commonly known as the battalion aid station (BAS). The medical platoon has the ability to split into two treatment teams that can operate for a limited time in split-based operations for close-in support of the maneuver battalion or when the BAS must move to a new location.

Forward resuscitative care capability is defined as advanced emergency medical treatment performed as close to POI as possible; this capability includes lifesaving and limb-saving surgical interventions, sometimes referred to as “salvage surgical procedures” or “damage control resuscitation.” The purpose of forward resuscitative care is to provide stabilization to achieve the most efficient use of lifesaving and limb-saving treatment. Organizations and capabilities that are limited to forward resuscitative care (in addition to Role 1 first responder, primary, and emergent care), are typically designated as Role 2. Role 2 capabilities also include laboratory facilities, radiography, limited patient holding, operational dental care, blood products, preventive medicine support, and behavioral mental health. Examples of Role 2 medical treatment facilities are as follows:

- Army brigade support medical company.

- Army medical company (area support).

- Marine Corps medical battalion (surgical company).

- Air Force expeditionary medical support (health response team).

- Air Force expeditionary medical support (EMEDS) 10-beds facility.

- Navy aircraft carriers (CVN) and amphibious assault ships (LHD) have a Role 2 capability aboard.

Another example is the Army forward surgical team (however, a 2017 force design update is transitioning the forward surgical team to a new organization called the “forward resuscitative and surgical medical team”).

A Role 2 TTP example is the following: the Marine Corps surgical company is designed to support regimental-size operations. The company provides resuscitative surgery, medical treatment, temporary holding, and casualty preparation and evacuation. The surgical company consists of a headquarters sections and four surgical platoons. Each surgical platoon consists of one forward resuscitative surgery system (FRSS), one shock trauma platoon, one radiograph unit, one ward, one en route care system (ERCS), one ambulance section (consisting of two vehicles), and an attached dental platoon. The surgical company should be located in close proximity to an airfield capable of casualty evacuation by rotary- or fixed-wing aircraft. The FRSS may be reinforced with a shock trauma platoon to provide an early far-forward resuscitative surgery capability.

Theater hospitalization care capability provides a full range of healthcare services, including primary inpatient and outpatient care; emergent care; and enhanced medical, surgical, and ancillary capabilities. Theater hospitalization care is focused on either returning the patient to duty (within the theater evacuation policy) or stabilizing the patient for continued evacuation to a definitive care facility. Organizations and capabilities that are typically associated with theater hospitalization care capability are designated as Role 3. Examples include:

- Army combat support hospital.

- Air Force EMEDS (+25 beds).

- Air Force theater hospital.

- Navy hospital ship (T-AH).

- Navy expeditionary medical facility.

(Note that as with the forward surgical team, the combat support hospital will be transitioned to a modular field hospital system of components capable of expanding from 32 to 240 beds, per the 2017 force design update.) The Marine Corps does not possess a Role 3 capability and relies on sister services for Role 3 support.

A Role 3 TTP example follows: Air Force EMEDS and theater hospital packages provide treatment and holding bed capacity and theater-level medical services for deployed forces or specific population groups. Their primary mission is to provide forward stabilization, resuscitative care, primary care, dental services, and force health protection, and to prepare casualties for evacuation to the next role of care. The modular and scalable design of these packages allows the Air Force to deploy medical capabilities ranging from small teams that provide highly skilled medical care for a limited number of casualties to a large medical system that can provide specialized care to a population at risk of over 6,500. EMEDS capabilities are grouped into distinct medical support packages that provide an incremental buildup of capability: EMEDS health response team, EMEDS +10, and EMEDS +25. The Air Force theater hospital is built by adding medical specialty and augmentation unit type codes to an EMEDS +25 foundation.

Definitive care capability includes the full range of acute, convalescent, restorative, and rehabilitative care facilities outside the theater of operations. Definitive care capability is care rendered to definitively manage a patient’s condition, which leads to recovery and rehabilitation, followed by either return to duty, or discharge from the service followed by transition to the services of the Department of Veterans Affairs. Definitive care capability is available both outside the continental United States (OCONUS) and in CONUS. Organizations and capabilities that are typically associated with definitive care capability are designated as Role 4. Examples include Landstuhl Regional Medical Center, located in Germany; Navy Medical Center San Diego; and Walter Reed National Military Medical Center in Bethesda, Maryland.

En route care capability involves transitory medical care, patient holding, and staging capabilities during transport from the POI, wounding, or illness through successive roles of medical care, to a medical facility that can meet the needs of the patient. Patients are moved via a patient movement system, which includes surface, ground, and air medical and nonmedical platforms, and the regulating of patients to the appropriate medical facility. En route care is typically designated as Role 1. The purpose of en route care is the continuation of care during movement from first responder care to definitive care without clinically compromising the patient. En route care involves determining how stable a patient is. There are three categories of stability:

1. A stable patient is expected to withstand a 12-hour intratheater evacuation or a 48-hour intertheater evacuation under en route standards of care.

2. A stabilized patient is characterized by a secure airway, controlled or absence of hemorrhage, adequately treated shock, and immobilized major factures. This patient may require emergency medical intervention, but not surgical intervention, during evacuation.

3. An unstable patient is one whose physiological status is in fluctuation, and emergent treatment, surgical intervention, or both are anticipated during the evacuation.

En route care capability can take three forms: casualty evacuation (CASEVAC), medical evacuation (MEDEVAC), and aeromedical evacuation (AE). MEDEVAC and AE are coordinated and regulated by the medical system; CASEVAC is not. CASEVAC refers to the unregulated movement of casualties via nonmedical maritime surface, ground, or air platforms, typically without onboard en route medical care. Because these platforms are unregulated, meaning the evacuation mission has not been coordinated by or with the medical community and is technically operating outside the casualty management system, casualties might not be transported to the appropriate medical facility for the care needed. CASEVAC missions are often generated from an opportune of lift asset, referring to the practice of repurposing a transportation asset once that asset has completed its primary mission. For example, a soldier working at a remote forward operating base (FOB) has his foot crushed by a tactical vehicle. The FOB has Role 1 capability, a unit-level first responder, but this patient needs at least a Role 2 capability. A helicopter just offloaded supplies to the FOB. In this scenario, the helicopter provides an opportunity to evacuate the casualty to a medical facility that can meet the casualty’s medical needs.

In contrast, MEDEVAC refers to the regulated movement of casualties via designated or dedicated maritime surface, ground, or air platforms. These platforms have an en route care capability aboard, and the patient’s movement has been coordinated to match medical needs with facility capabilities. Designated platforms are those with a nonmedical primary mission, but that have been selected to provide patient movement for a specific time or event. Dedicated platforms are specifically designed or configured and equipped to conduct MEDEVAC, their primary mission. They are externally marked with the Red Cross, and the crews are specifically trained to conduct the MEDEVAC mission. All the services have dedicated ground ambulances; only the Army has dedicated MEDEVAC aircraft. (Note: The Committee on TCCC uses the term tactical evacuation, or TACEVAC, to identify the movement of a casualty by either CASEVAC or MEDEVAC from the POI to a Role 2 or 3 MTF.[24])

Different approaches to medical care and evacuation are always evolving in response to emerging challenges in the operational environment. A en route care TTP example is as follows: The Marine Corps has recently developed the ERCS as a means to bridge evacuation between forward resuscitative care and theater hospitalization. The ERCS is a modular system designed to provide equipment and supplies for the care of two critically injured or ill but stabilized casualties for up to a 2-hour MEDEVAC flight onboard Marine Corps aircraft.

EXHIBIT 14-2

THE MOBILITY PRINCIPLE IN ACTION

So medics can go where the warfighters go, Mine-Resistant, Ambush-Protected (MRAP) ambulances [were] used in Iraq and Afghanistan…. with fighting forces deploying these new vehicles, the need for an ambulance that could accompany them with similar protection was evident. Over nine months in 2007 a modified MRAP for ambulance duty was designed, developed, tested and produced.

____________

Reproduced from: MRAP ambulances provide protection, “rolling ERs.” US Army website. http://www.army.mil/article/15552/. Published January 5, 2009. Accessed July 1, 2018.

EXHIBIT 14-3

THE CONTROL PRINCIPLE IN ACTION

For combat operations in Iraq, the CFLCC [Coalition Forces Land Component Commander] staff was expanded with soldiers, marines, airmen, and allied officers and troops. Shortly after assuming command, [Lt. Gen. David] McKiernan welcomed Brig. Gen. George Weightman, Medical Corps (MC), aboard as his (first ever) CFLCC Command Surgeon. Almost immediately, Weightman deployed forward to Kuwait to serve in that capacity and also as the commander of the 3d MEDCOM [Medical Command] (Forward). Per Joint Publication 4-02, he was responsible for the planning and execution of the medical support for the operation for that much larger patient base that Joint Publication 4-02 defined. He discovered that the initial plan, Operations Plan 1003V, needed substantial updating and modification as actual combat operations were considered.

Weightman noticed that the I MEF [Marine Expeditionary Force] did not have any MEDEVAC capability and requested augmentation for that purpose. As the CFLCC Surgeon, he had to find the capability for that force. Initial planning called for five MEDEVAC units to deploy to support the operation. He resolved to assign one to directly support the I MEF when the units arrived (it was one of more than 40 U.S. Army units of varying sizes that augmented the I MEF). As he requested necessary medical support units to deploy to the theater, he noticed that the Secretary of Defense was delaying his requests. This was a deliberate action because Secretary Donald Rumsfeld wanted to push combat units into the theater first, assuming that a campaign quickly initiated and conducted yielded fewer casualties and required less support. However, Weightman continuously pushed to bring his medical units forward.

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Reproduced from: Whitcomb D. Call Sign – DUSTOFF: A History of U.S. Army Aeromedical Evacuation from Conception to Hurricane Katrina. Ft Detrick, MD: Borden Institute; 2012: 255.

AE refers to the Air Force system of regulated intratheater or intertheater movement of casualties between MTFs. AE is typically accomplished via fixed-wing assets with onboard en route care provided by critical care air transport teams (CCATTs). Note: These fixed-wing platforms are not dedicated platforms, but designated to conduct specific AE missions. (Refer to Annex A to Appendix B of Joint Pub 4-02, Healthcare Service Support, and AFTTP 3-42.5, Aeromedical Evacuation (AE), for a detailed discussion on AE. For a complete discussion on the patient movement system refer to Appendix B of Joint Pub 4-02. For a summation of the joint medical capabilities and roles of care, refer to Joint Pub 4-02. Publications are listed in Resources, below.)

Proximity

Tied closely to the principle of continuity are the principles of proximity and mobility. Whereas continuity strives for a seamless continuum of care, proximity ensures that access to care is timely and appropriate by striking a balance between positioning care as close to the supported unit as possible, without jeopardizing the tactical plan or patient care, or overexposing the medical asset to operational risks. The tactical and enemy situation, the ability to provide command and control, operational factors such as evacuation time and distance, and the availability of evacuation resources all play key roles in determining exactly how “proximate” care should be located.

Mobility

As maneuver units move away from their base of medical support, the lines of evacuation extend and the time to care increases. The principle of mobility (Exhibit 14-2) ensures that medical elements and units have the ability to move personnel and equipment and maintain supportable distances to the maneuver units. Mobility also ensures that medical elements and units are afforded similar sustainment and survivability protection as that of the maneuver units they are supporting. The services have designed most, if not all, Role 1 and 2 MTFs with the mobility principle in mind, providing internal assets to move personnel and equipment, as well as assigning similar or identical treatment and evacuation platforms to those used in the supported maneuver units (eg, an M1126 Stryker combat vehicle unit supported by M1133 Stryker MEDEVAC vehicles at the Role 1 and 2 MTFs). Although unit design can provide the capability to move and ensure protection, an effective and efficient evacuation system to rapidly move patients to the next role of care is paramount to maintaining mobility, specifically for Role 1 and 2 MTFs. Carrying a patient “forward” ties up transportation assets that would otherwise be used to move unit personnel or equipment, and potentially jeopardizes the patient’s medical condition.

Control

The principle of control (Exhibit 14-3) ensures medical commanders and command surgeons have the authority to tailor and position scarce medical assets where the need is the greatest. Control implies the ability to effectively communicate with medical assets. It also ensures that the scope and quality of medical treatment meet professional standards, policies, and US and international law.

Flexibility

The principle of flexibility ensures that medical elements and units are prepared and empowered to shift medical resources to meet medical demands and patient density across their area of operations.

A REPRESENTATIVE MEDICAL LAYDOWN IN A JOINT OPERATIONS AREA

Figure 14-1 depicts a representative (notional) mature medical footprint of the joint medical capabilities and the distribution of the roles of care across a JOA. The scenario is a general overview of treatment and evacuation capabilities from POI to Role 4. It helps show how an MMO for a deployed combat battalion or equivalent ground force would work within the overarching medical plan for the entire theater. The MMO primarily manages wounds, injuries, and illnesses at the unit level and at the point of combat wounding or injury. The combat battalion and its medical capabilities are restricted to first responder/Role 1 (unit level) activities to throughout the discontinuous battle space.

The diagram does not depict medical infrastructure such as medical command and control, dental, preventive medicine, logistics, laboratory, evacuation, and veterinary units that would be deployed within the JOA. Many of these types of units would be deployed along with either Role 2 and 3 MTFs or in the Role 2 or 3 operational areas.

The scenario is notional, although it is described from the doctrinal perspective. Doctrine provides a frame of reference which can be modified as the situation dictates. (The reader should refer to the services’ publications for greater detail on the HSS system, many of which are listed in Resources, below. Each service component develops its medical resources to support its service-specific mission, which results in the development of different types of organizations with varying levels of capability, mobility, and survivability. Although joint medical resources may have similar nomenclature to describe the unit, they are not usually interchangeable.)

Figure 14-1. Notional medical footprint, point of injury to Role 4.

Figure 14-2. Casualty movement and treatment, point of injury to Role 1.

On the far right of the notional medical footprint is a ground combat battalion conducting an assault on “Objective Lion” (Figure 14-2). The unit has a Role 1 medical capability and armored ground ambulances for ground evacuation. As combat units conduct the assault, combat lifesavers and medics/corpsmen assigned to the combat units will provide first responder care at the POI (in addition to self-aid/buddy aid). Casualties are evacuated from the POI to a casualty collection point (CCP). Movement from the POI to the CCP is by any means possible—buddy carries, drags, litter carries, walking wounded, or vehicles of opportunity (CASEVAC). CCPs might not be staffed, but they often have a senior medic/corpsman who performs triage, treats casualties, and prepares them for further evacuation to the unit aid station (Role 1 MTF). Casualties are evacuated from the CCP to the aid station by any means possible, including ground ambulances (MEDEVAC) if available; in this case armored ground ambulances. The call for a MEDEVAC platform begins with a standardized 9-line MEDEVAC request (Exhibit 14-4). Integrating medics/corpsmen into the combat units and positioning the aid station to provide responsive care to the maneuvering force adheres to the principle of proximity.

EXHIBIT 14-4

9-LINE MEDEVAC REQUEST

Line 1. Location of the pick-up site.

Line 2. Radio frequency, call sign, and suffix.

Line 3. Number of patients by precedence.

A: Urgent

B: Urgent surgical

C: Priority

D: Routine

E: Convenience

Line 4. Special equipment required.

A: None

B: Hoist

C: Extraction equipment

D: Ventilator

Line 5. Number of patients.

A: Litter

B: Ambulatory

Line 6. Security at pick-up site.*

N: No enemy troops in area

P: Possible enemy troops in area (approach with caution)

E: Enemy troops in area (approach with caution)

X: Enemy troops in area (armed escort required)

*In peacetime, list instead number and types of wounds, injuries, and illnesses.

Line 7. Method of marking pick-up site.

A: Panels

B: Pyrotechnic signal

C: Smoke signal

D: None

E: Other

Line 8. Patient nationality and status.

A: US Military

B: US Civilian

C: Non-US Military

D: Non-US Civilian

E: Enemy Prisoner of War

Line 9. NBC contamination.*

N: Nuclear

B: Biological

C: Chemical

*In peacetime, instead provide terrain description of pick-up site.

Recall that Role 1 is to provide immediate lifesaving measures or primary care services; Role 1 does not have the ability to properly hold a patient. Also, the Role 1 MTF must maintain its ability to move and keep up with the maneuvering force—the principle of mobility. (Another technique used to ensure both proximity and mobility to the maneuver force is for the battalion aid station to split into two treatment teams and conduct split-based operations). At the aid station, the casualty is seen by a physician or physician assistant, sometime referred to as the battalion surgeon (in some cases, a Nurse Corps officer may be assigned as the battalion surgeon). The physician (or senior healthcare provider) decides whether to evacuate the patient to a higher role of care or return the patient to duty. If the patient requires additional treatment, the casualty must be evacuated to a Role 2 or higher. (Note: typically a casualty is referred to as a “patient” once the casualty has entered into the medical care system, ie, a role of care MTF.)

Figure 14-3. Patient movement and treatment, Role 1 to Role 2.

Role 1 evacuation assets have responsibility for evacuating casualties from areas forward of the Role 1 MTF and typically do not evacuate beyond the Role 1 facility. This ensures the Role 1 evacuation assets remain forward to evacuate casualties from the objective to the Role 1 MTF. Evacuation from Role 1 to Role 2 is the responsibility of the Role 2 MTF: the higher role evacuates from the lower role. In the notional footprint, the Role 2 MTF has a mix of armored track and wheeled ambulances, and has prepositioned and collocated the armored track ambulances forward, at the Role 1 MTF (Figure 14-3). Again, this reinforces the principle of mobility, as well as the concept that medical units are afforded similar sustainment and survivability protection to that of the maneuver units they support.

A casualty at the Role 1 MTF requiring further treatment is loaded onto a Role 2 ambulance (in this case an armored track ambulance) for evacuation to the Role 2 MTF. Armored ambulances afford good crew and patient protection, but tend to be slower than wheeled vehicles. In an effort to shorten evacuation time while still affording the protection that may be needed in forward areas, the Role 2 MTF may establish an ambulance exchange point (AXP). In AXP operations, the armored track ambulance and wheeled ambulance meet at a designated location to exchange the casualty from the track vehicle to the wheeled vehicle. Once the exchange is complete, the track ambulance returns to the Role 1 MTF, while the wheeled ambulance continues the evacuation to the Role 2 MTF. This technique has the additional advantage of keeping crews familiar with routes, locations, and forward or rearward areas. AXPs can also be used to transfer a casualty from a ground vehicle to an air platform when there are significant antiaircraft threats in the forward maneuver areas.

Many Role 2 MTFs can deploy a mobile treatment capability, designed to reinforce, augment, or reconstitute the Role 1 capability, in case the Role 1 MTF becomes overwhelmed with casualties, needs to relocate, or loses capabilities due to enemy actions. The mobile capability may also be positioned at an AXP to provide stabilization and treatment and expedite the turnaround time for forward ambulances. Likewise, some Role 3 facilities can deploy a mobile surgical capability forward to augment Role 2 facilities that do not have organic surgical capability.

Figure 14-4. Ambulance shuttle system.

Another technique for employing ambulances is the shuttle system (Figure 14-4). Typically established when using “like-type” vehicles (eg, all wheeled vehicles), the ambulance shuttle system provides an efficient means for positioning ambulances where the need is the greatest, while allowing for the continuous movement of patients between MTFs. As depicted in the notional footprint, ambulances are stationed along the route between the Role 1 and Role 2 MTFs. As the ambulance at the load point receives a casualty and begins transport to the Role 2 MTF, the ambulance at relay point 1 advances forward to the load point, while an ambulance at relay point 2 moves forward to relay point 1. If two load points are established, it might be necessary to set up an ambulance control point to help direct ambulances to specific load points. By keeping ambulances dispersed along the route, the system also avoids excessive massing of ambulances and minimizes the potential loss to enemy actions, particularly in forward areas. The system also simplifies command and control and facilitates administrative and maintenance actions.

At Role 2, the casualty receives emergency medical treatment and undergoes advanced resuscitation procedures, including damage control surgery (in the case of an Army medical company, a forward surgical team must be attached for surgical capability). Additionally, Role 2 MTFs provide a patient holding capability along with various ancillary services such as radiography, dental care, laboratory services, behavioral health, blood products, and preventive medicine. With the patient holding capability, patients suffering from a soft tissue injury that does not require orthopedic surgery (eg, severe ankle sprain) or moderate severity respiratory illness (eg, pneumonia) could be held at Role 2 for recovery rather than being sent to Role 3. Holding patients at Role 2 keeps them in close proximity to their operational unit and expedites a faster return to duty. It also keeps specialties and bed space open at the Role 3 MTF to handle hospitalization cases.

A patient will be evacuated from Role 2 to a Role 3 MTF for further care if (a) the patient does not recover in an appropriate amount of time, typically within 72 hours for many Role 2 MTFs; (b) the patient’s condition worsens; or (c) the patient is recovering from damage control surgery. Evacuation from Role 2 to Role 3 (Figure 14-5) is typically accomplished by echelon-above-brigade ground ambulance units (note: Role 3 MTFs do not have organic ground ambulance vehicles). At Role 3, the patient receives a full complement of hospital and surgical services. The patient is then returned to duty at their operational unit, or stabilized for further evacuation to Role 4.

Figure 14-5. Patient movement and treatment, Role 2 to Role 3.

In the notional medical footprint, a Role 2 facility has been set up in close proximity to Role 3. In this instance, the Role 2 facility will also assume what is commonly referred to as an “area support role,” meaning the Role 2 MTF will provide medical support to units falling within a defined area that do not have internal Role 2 medical support. Typically, all Role 2 and 3 MTFs assume an area support role for basic troop medical care, as well as providing some evacuation and specialty units such as dental, veterinary, preventive medicine, and laboratory. In the notional medical footprint, the Role 3 MTF is also “pushing” a medical capability in support of outlying units and operations. Most Role 3 MTFs have the ability to deploy medical capabilities such as trauma response, resuscitative surgery, preventive medicine, veterinary services, and casualty staging to meet emergent medical needs. The Air Force refers to this technique as “hub and spoke operations.” (Refer to the services’ doctrinal publications for specific Role 3 capabilities.)

In the notional footprint, MEDEVAC aircraft are stationed forward in the brigade/group support area. These aircraft are assigned the responsibility of clearing casualties from maneuver units in the forward areas and transporting them to Role 2 and Role 3. Based on the tactical situation, MEDEVAC aircraft may fly as far forward as the POI or a CCP for casualty pickup. In some situations, when multiple causalities are spread across the unit’s maneuver space, the Role 1 MTF may be a more beneficial casualty pickup site.

If a casualty is evacuated from the POI or CCP by air (via helicopter or a V-22 Osprey), the MEDEVAC or CASEVAC aircraft will bypass the Role 1 MTF and proceed directly to the Role 2. Alternatively, transporting the casualty directly from Role 1 to Role 3 may be practicable after considering the time and distance to the Role 3, the patient’s condition, and the tactical situation. Once the casualty is at Role 2, MEDEVAC aircraft assigned the responsibility of moving casualties from Role 2 to Role 3 will continue the evacuation mission. Additional air ambulance units, typically Air Force aircraft augmented with aeromedical crews (and CCATTs if needed), transport casualties between Role 3 MTFs to provide additional medical or surgical capabilities, to redistribute patient censuses, or to free up beds in anticipation of additional casualties accompanying a planned or existing combat operation. This patient movement among Role 3 facilities also allows for patient staging areas for continued strategic evacuation out of the JOA to a Role 4 MTF. In addition to moving patients, ground and air MEDEVAC platforms can facilitate the movement of emergency medical supplies, medical personnel, and medical communications. (Refer to ATP 4-02.2, Medical Evacuation, and NTTP 4-02.2M/MCRP 4-11.1G, Patient Movement, in Resources, below.)

Figure 14-6. Patient movement to Role 4.

Evacuation from Role 3 to Role 4 MTFs (Figure 14-6) is usually accomplished by Air Force fixed-wing aircraft staffed by AE crews; depending on the patient’s need, these aircraft may be augmented with a CCATT. The evacuation of a patient out of theater is governed by the theater patient movement policy, sometimes referred to as the theater evacuation policy. This policy establishes the maximum number of days a patient can be held in theater for treatment prior to further movement or return to duty. The policy takes effect once a patient is admitted to a Role 3 facility. In the notional scenario, the theater policy is established as a maximum of 7 days. This does not mean a patient must be held for 7 days, particularly if the patient will clearly be unable to return to duty within the prescribed time; in these cases the patient would be moved as soon as clinically feasible.

A shorter theater patient movement policy will result in a reduced theater medical footprint (fewer beds, specialties, logistics, etc), but a greater demand on patient movement assets and the personnel replacement system. A longer theater patient movement policy will result in the opposite. In the notional medical footprint, patients are moved to a contingency aeromedical staging facility, collocated with the Role 3 MTF at the airbase, in preparation for movement to Role 4. (If air mobility requirements exceed military resources, the Department of Defense may employ the Civil Reserve Air Fleet, which employs selected US civilian air carriers, through contracts, to conduct the AE mission. Refer to the Civil Reserve Air Fleet website and AFTTP 3-42.5, Aeromedical Evacuation (AE), in Resources, for additional information.) Role 4 MTFs, located either OCONUS or in CONUS, provide a full range of acute, convalescent, restorative, and rehabilitative care with the purpose of rehabilitating, returning to duty, or discharging the patient.

Figure 14-7. Medical support to amphibious operations.

During an amphibious operation (Figure 14-7), as combat units initially push onto the beach, self-aid/buddy aid, combat lifesavers, and corpsmen assigned to combat units will constitute the first medical response. As combat units progress forward, unit aid stations with a physician and additional corpsmen will push onto the beach to provide additional first responder support. Initially, the wounded are evacuated from the POI to a CCP by any means possible. As previously described, a senior corpsman at the CCP will perform triage, continue administering treatment, and prepare casualties for further evacuation to the unit aid station (Role 1 MTF), where the casualty will be seen by a physician.

Evacuation from Role 1 to Role 2 or Role 3 is provided by small boat, LCAC (landing craft, air cushion), helicopter, or V-22 Osprey. These assets may be either dedicated, designated, or an opportunity of lift. If the casualty is evacuated from the POI or CCP by air (helicopter or V-22), the air evacuation platform will bypass Role 1 and proceed directly to Role 2 or 3. Determining where to evacuate the casualty to, Role 2 or 3, depends on numerous factors such as the casualty’s condition, the facility’s capabilities, and evacuation time to the MTF. As combat units move further inland, a Role 2 MTF with surgical capability may be established ashore to enhance the proximity of forward resuscitative care to the maneuvering force. Once an airhead is established, an aeromedical staging facility may be set up to transition patients from the Role 3 (hospital ship) to a Role 4 definitive care capability. Figure 14-8 provides an overview of each service’s patient flow from POI to Role 4.

Figure 14-8 (left and previous page). Overview of patient movement flow in each service.
*The ERCS is a modular system that comes equipped with two special medical emergency evacuation device (SMEED) platforms, which are designed to carry patient movement items (eg, oxygen and patient monitoring devices) on board Marine Corps aircraft. The ERCS provides equipment and supplies for the care of two critically injured or ill but stabilized casualties for up to a 2-hour MEDEVAC flight. The ERCS is staffed by critical care nurses, emergency nurses, and specifically trained hospital corpsmen.

AE: aeromedical evacuation

AECT: AE control team

AELT: AE liaison team

AEW: air and space exp wing

AMD: air mobility division

AOC: air operations center

ASF: aeromedical staging facility

ATO: air tasking order

BAS: battalion aid station

BES: beach evacuation station

BSMT: brigade support medical company

CCP: casualty collection point

CVN: Navy aircraft carrier (nuclear)

ERCS: en route care system

FRSS: Forward Resuscitative Surgery System

FST: forward surgical team or fleet surgical team

HN: host nation

IAW: in accordance with

JFACC: joint force air component commander

LF: landing force

LHD/A: landing helicopter dock/assault

MAO: medical administrative officer

MC(AS): medical company (area support)

MRCO: medical regulating control officer

MRT: medical regulating team

MTF: medical treatment facility

OCONUS: outside the continental United States

PAD: patient administration director

PMRC: patient movement requirements center

POI: point of injury

STP: shock trauma platoon

TGRO: TRICARE global remote overseas

TMT: treatment

USAF: US Air Force

Graphic created by Uniformed Services University of the Health Sciences, Education and Technology Innovation Support Office. Graphic concept adapted from Navy Tactics, Techniques and Procedures 4-02.2M/MCRP 4-11.1, Patient Movement (May 2007).

RESOURCES

Doctrine

Policy and practice will change over time. Doctrine, that is, published official guidelines and policies, will change in content but military references will retain their numeric designation. These publications can be monitored over time for key principles and practices.

- Chairman of the Joint Chiefs of Staff. Command and Control of Joint Air Operations. Washington, DC: JCS; 10 February 2014. Joint Publication 3-30.

- Chairman of the Joint Chiefs of Staff. Healthcare Service Support. Washington, DC: JCS; 26 July 2012. Joint Publication 4-02.

- Chairman of the Joint Chiefs of Staff. Joint Operations Planning, Washington, DC: JCS; 11 August 2011. Joint Publication 5-0.

- Headquarters, Department of the Army. Terms and Military Symbols. Washington, DC: HQDA; 16 November 2016. Army Doctrine Reference Publication 1-02.

- Headquarters, Department of the Army. Medical Evacuation. Washington, DC: HQDA; 25 October 2016. Army Techniques Publication (ATP) 4-02.2.

- Headquarters, Department of the Army. Army Health System Support to Maneuver Forces. Washington, DC: HQDA; 9 June 2014. ATP 4-02.3.

- Headquarters, Department of the Army. Casualty Care. Washington, DC: HQDA; 10 May 2013. ATP 4-02.5.

- Headquarters, Department of the Army. Brigade Support Battalion. Washington, DC: HQDA; 2 April 2014. ATP 4-90.

- Headquarters, Department of the Army. The Infantry Battalion. Washington, DC: HQDA; 28 December 2017. ATP 3-21.20.

- Headquarters, Department of the Army. Army Health System. Washington, DC: HQDA; 26 August 2013. Field Manual 4-02.

- Headquarters, Department of the Navy, US Marine Corps. Health Service Support Operations. Washington, DC: USMC; 10 December 2012. Marine Corps Warfighting Publication (MCWP) 4-11.1.

- Headquarters, Department of the Navy, US Marine Corps. Marine Corps Planning Process. Washington, DC: USMC; 24 August 2010. MCWP 5-1,

- Department of the Navy, Office of the Chief of Naval Operations. Naval Expeditionary Health Service Support Afloat and Ashore. Washington, DC: CNO; January 2008. Navy Warfare Publication (NWP) 4-02.

- Department of the Navy, Office of the Chief of Naval Operations. Navy Planning. Washington, DC: CNO; December 2013. NWP 5-01.

- Department of the Navy. Patient Movement. Washington, DC: USN; May 2007. Navy Tactics, Techniques and Procedures 4-02.2M/MCRP 4-11.1.

- Headquarters, Department of the Air Force. Medical Operations. Washington, DC: USAF; 29 September 2015. Air Force Doctrine Document 4-02.

- Headquarters, Department of the Air Force. Aeromedical Evacuation (AE). Washington, DC: USAF; 1 November 2003. Air Force Tactics, Techniques and Procedures (AFTTP) 3-42.5.

- Headquarters, Department of the Air Force. Expeditionary Medical Support (EMEDS) and Air Force Theater Hospital (AFTH). Washington, DC: USAF; 27 August 2014. AFTTP 3-42.71.

Websites

- This Is the Military Health System [video]. https://youtu.be/USJfvasA6Yk. Published May 7, 2013. Accessed September 19, 2018.

- US Air Force, Air Mobility Command. Civil Reserve Air Fleet. https://www.amc.af.mil/About-Us/Fact-Sheets/Display/Article/144025/civil-reserve-air-fleet/. Published April 26, 2017. Accessed September 19, 2018.

SUMMARY

An MMO’s success depends on understanding of how their duties are tied to the primary need to protect soldiers, sailors, airmen, marines, and coast-guardsmen from injury, illness, and combat wounds. MMOs must understand their role within the unit commander’s staff as a medical caregiver, medical planner, and advisor. The MMO’s partnership with their fellow principal staff officers and the trust they develop with the commander are paramount. Essential to the MMO’s mission success is an understanding of and employment of the six principles of HSS; the five joint medical capabilities; the four roles of care; and three forms of en route care.

- The six principles of HSS are conformity, continuity, proximity, mobility, control, and flexibility. No principle is more important than another, and each principle is dependent on the other principles to optimize patient survival and outcome.

- The five overarching joint medical capabilities range from self-aid or buddy aid, to emergent care and primary care (first responder care); to advanced emergency medical treatment performed as close to POI or illness as possible (forward resuscitative care); to the full range of in-theater healthcare services, including primary inpatient and outpatient care, emergent care, and enhanced medical, surgical, and ancillary capabilities (theater hospitalization); to the full range of acute, convalescent, restorative, and rehabilitative care sites outside the theater of operations (definitive care). Tying these capabilities together is the en route care capability.

- Within these overarching joint medical capabilities is a framework that ascribes a specific role or function to medical capabilities and casualty management resources: the four roles of care. Role 1 is unit-level care, and is most closely associated with first responder care. Role 2 is most closely associated with forward resuscitative care. Role 3 is most closely associated with theater hospitalization care, and Role 4 is most closely associated with definitive care. Each role possess those capabilities and resources found at the lower role.

- En route care capability in the patient movement system can take three forms: CASEVAC, MEDEVAC, and AE. CASEVAC refers to the unregulated movement of casualties via nonmedical surface, ground, or air platforms; MEDEVAC refers to the regulated movement of casualties via designated or dedicated surface, ground, or air platforms; and AE refers to the Air Force’s system of regulated intratheater or intertheater movement of casualties between MTFs.

REFERENCES

1.   Chairman of the Joint Chiefs of Staff. Doctrine for the Armed Forces of the United States. Washington, DC: JCS; 25 March 2013. Joint Publication 1.

2.   Chairman of the Joint Chiefs of Staff. Healthcare Service Support. Washington, DC: JCS; 26 July 2012. Joint Publication 4-02.

3.   Headquarters, Department of the Air Force. Medical Operations. Washington, DC: USAF; 29 September 2015. Air Force Doctrine Document 4-02.

4.   Headquarters, Department of the Army. Army Health System. Washington, DC: HQDA; 26 August 2013. Field Manual 4-02.

5.   Headquarters, Department of the Navy, US Marine Corps. Health Service Support Operations. Washington, DC: USMC; 10 December 2012. Marine Corps Warfighting Publication 4-11.1.

6.   Department of the Navy, Office of the Chief of Naval Operations. Naval Expeditionary Health Service Support Afloat and Ashore. Washington, DC: CNO; January 2008. Navy Warfare Publication, 4-02.

7.   MHS Review Senior Oversight and Working Group. Military Health System Review: Final Report to the Secretary of Defense. Washington, DC: Department of Defense; August 2014.

8.   Beitler AL, Wortmann GW, Hofmann LJ, Goff JM Jr. Operation Enduring Freedom: the 48th Combat Support Hospital in Afghanistan. Mil Med. 2006;171(3):189–193.

9.   Chambers LW, Green DJ, Gillingham BL, et al. The experience of the US Marine Corps’ Surgical Shock Trauma Platoon with 417 operative combat casualties during a 12 month period of Operation Iraqi Freedom. J Trauma. 2006;60(6):1155–1161;discussion 1161–1164.

10.   Earwood JS, Brooks DE. The seven P’s in battalion level combat health support in the Military Operations in Urban Terrain environment: the Fallujah experience, summer 2003 to spring 2004. Mil Med. 2006;171(4):273–277.

11.   Hughes JR, Miller MA, Farr WD, Hughes TM. Survey of US Army commanders’ experiences with brigade/battalion surgeons at Fort Hood, Texas. Mil Med. 2006;171(3):240–245.

12.   Lin H, Ancheta A, Uzcategui L, Plurad D. Surgery in expeditionary strike group. Mil Med. 2009;174(3):241–244.

13.   Murray CK, Reynolds JC, Schroeder JM, Harrison MB, Evans OM, Hospenthal DR. Spectrum of care provided at an echelon II medical unit during Operation Iraqi Freedom. Mil Med. 2005;170(6):516–520.

14.   Peoples GE, Gerlinger T, Craig R, Burlingame B. The 274th Forward Surgical Team experience during Operation Enduring Freedom. Mil Med. 2005;170(6):451–459.

15.   Stevens RA, Bohman HR, Baker BC, Chambers LW. The US Navy’s forward resuscitative surgery system during Operation Iraqi Freedom. Mil Med. 2005;170(4):297–301.

16.   Beninati W, Meyer MT, Carter TE. The critical care air transport program. Crit Care Med. 2008;36(7 Suppl):S370–376.

17.   Brewer TL, Ryan-Wenger NA. Critical care air transport team (CCATT) nurses’ deployed experience. Mil Med. 2009;174(5):508–514.

18.   Clarke JE, Davis PR. Medical evacuation and triage of combat casualties in Helmand Province, Afghanistan: October 2010-April 2011. Mil Med. 2012;177(11):1261–1266.

19.   Hurd WW, Montminy RJ, De Lorenzo RA, Burd LT, Goldman BS, Loftus TJ. Physician roles in aeromedical evacuation: current practices in USAF operations. Aviat Space Environ Med. 2006;77(6):631–638.

20.   Pizzola JL. MEDEVAC miscategorization. Mil Med. 2010;175(9):655–658.

21.   D’Amore AR, Hardin CK. Air Force expeditionary medical support unit at the Houston floods: use of a military model in civilian disaster response. Mil Med. 2005;170(2):103–108.

22.   Hartgerink BJ, Chapman LE, Stevenson J, Donahue TF, Pagliara C. Utilization of surgical resources during the USNS COMFORT humanitarian mission to the Americas, June to October 2007. Mil Med. 2010;175(9):638–646.

23.   Stuart JJ, Johnson DC. Air Force disaster response: Haiti experience. J Surg Orthop Adv. 2011;20(1):62–66.

24.   National Association of Emergency Medical Technicians (NAEMT). PHTLS: Prehospital Trauma Life Support. Military 8th ed. Burlington, MA: Jones & Bartlett Learning; 2016: 897.

Chapter 15

HEALTH INFORMATION SYSTEMS

MICHAEL J. STONE, MBA, MHA*

INTRODUCTION

DEFINITIONS

Information Systems

Health Information Systems

Health Information Technology

Telehealth

RELEVANCE OF INFORMATION SYSTEMS TO MILITARY HEALTHCARE PROVIDERS

TYPES OF HEALTH INFORMATION SYSTEMS

PRINCIPLES OF EFFECTIVE MILITARY HEALTH INFORMATION SYSTEM EMPLOYMENT

Requirements Identification

Health Information Systems as a Component of a Comprehensive Health Delivery System

Cyber Security

Affordability and Sustainability

Provider and End-User Efficiency

MILITARY-SPECIFIC HEALTH INFORMATION SYSTEMS REQUIREMENTS

Interoperable

Operationally Viable

Sustainable and Dynamic

OTHER HEALTH INFORMATION SYSTEMS CONSIDERATIONS FOR MILITARY MEDICAL OFFICERS

Procurement and Requirements Definition

Virtual Health Information Systems in Military Operations

Dependents in a Joint Military Environment

SUMMARY

*Lieutenant Colonel, Medical Service Corps, US Air Force; Assistant Professor, Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

Just as battlefield information is critical to understanding and managing the tactical and operational environment, medical information is critical for the uniformed medical community to conduct essential medical operations. Whether it is a simple communication system such as a handwritten prescription medication order or a more advanced treatment system such as the proper application of concentrated energy to eradicate cancer cells, health information systems (HISs) are keystones of medical operations in theater and at home.

HISs play an integral role in military medicine. To maximize their effectiveness, medical officers must accurately identify requirements of HISs and constantly work to improve prevention of disease, non-battle, and combat injuries; to enable diagnosis; to mitigate the effects of these illnesses and injuries; to optimize recovery; and to eliminate waste from healthcare delivery procedures.

DEFINITIONS

Information Systems

An information system (IS) is any mechanism whereby information can be communicated and acted on by one or more actors. For example, a checklist created for the week at the office is a system designed to keep individual and team energies and efforts appropriately focused. Epidemiological data comprises an IS designed to focus the limited resources and expertise of the medical and sanitation community on the key points of disease transmission. The data collected can help researchers discern the origin of a disease outbreak and potential action points to end an infectious epidemic. Finally, the magnetic resonance imaging scanner combines information-gathering tools to enable proper application of medical procedures or resources. ISs are primarily comprised of electronic devices but can either include or be completely fabricated of paper and pencil or handwritten components.

Health Information Systems

HISs span a broad range of data management capabilities from locally developed, field-expedient methods to formal, system-wide electronic tools and databases.

The health information system provides the underpinnings for decision-making and has four key functions: data generation, compilation, analysis and synthesis, and communication and use. The health information system collects data from the health sector and other relevant sectors, analyses the data and ensures their overall quality, relevance and timeliness, and converts data into information for health-related decision-making.[1]

The primary goal of HISs in military medicine is to exploit information to render high-quality health promotion and healthcare delivery at the right time, in the right place, and using the right resources. The combination of resources that comprise HISs in the Department of Defense (DoD) deliver information integral to the provision of effective health promotion and healthcare. They also aggregate information to advance knowledge in disease and injury prevention and management.

The DoD uses various health information systems in its effort to provide comprehensive support to the entire community (eg, the TRICARE online patient portal mobile and the Military Health System GENESIS electronic records). The DoD is improving healthcare by investing in new HIS technology, modernizing health record systems, and promoting interoperability among different platforms for improved continuity of care for service members and military beneficiaries.

Health Information Technology

“The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of healthcare information, data, and knowledge for communication and decision making”[2] clearly defines technology. It is a broad concept that deals with knowledge and practical application of tools and systems.

For health information technology, “technology” represents computers and communications elements that can be networked to build systems for moving health information.[3] The Defense Health Agency Health Information Technology Office (J6) is tasked with enabling joint, integrated healthcare to the entire DoD community.

Telehealth

Telehealth is a collection of means or methods for enhancing healthcare, public health, and health education delivery and support using telecommunications technologies.[4] The DoD uses telehealth to help ensure the health of service members and other TRICARE beneficiaries by providing access to care for a wider range of medical conditions and geographic locations, including remote areas where service members may be injured.

RELEVANCE OF INFORMATION SYSTEMS TO MILITARY HEALTHCARE PROVIDERS

Effective health promotion and sustainment, as well as healthcare delivery in military operations, hinges on accurate, timely, and complete information regarding patients, potential patients, and their environments. Prevention of injuries, illnesses, and combat wounds and their early detection, mitigation, and comprehensive treatment and management are heavily reliant upon data and information. Examples of ISs for healthcare include tests for coliform bacteria in a water source, lipstick for marking casualties in mass casualty triage, and the most sophisticated imaging technology pinpointing the location of shrapnel. Simple through highly technical resources are employed as components of ISs that are essential means of preserving health and life on the battlefield.

The impact of these systems is felt from point of injury to home station rehabilitation as patients experience a continuum of effective healthcare without suffering preventable complications, safety violations, or adverse side effects of therapeutic agents. Specifically, data captured at every stage of patient care provides the facts and evidence needed to render care absent adverse drug interactions or other complications that often result from missing data documenting care or medications administered. In addition, patient safety is preserved as the patient makes the journey to return to full health and function thanks to accurate capture of actions taken by medical professionals along the way. Physicians and other caregivers make informed decisions about each step in the patient’s treatment, resulting in positive cumulative effects rather than adverse reactions to the unknown. Without some type of IS, a provider cannot provide adequate care to patients or practice lifesaving preventive medicine that enables military personnel to succeed in their missions.

Military providers, similar to all other healthcare providers, require a means of capturing and maintaining information regarding their patients’ health, the risk factors of the environment or military operation, and the ability to share that information with other caregivers and commanders as needed. Military HISs deliver this capability to the provider and enable application of this data resource throughout the military member’s service and beyond. It is imperative that military HISs capture all pertinent information for timely and effective health promotion, health sustainment, and healthcare delivery. This includes preventive medicine information such as immunizations, exposure data, DNA repository information, health status, and dental health status; diagnosis; prescriptions; drug allergies and interactions; imaging data; referral results; vital signs; allergies; and operative risks.

There are inherent accountability requirements and epidemiology interests that also drive the need for HISs in the military. The DoD is constantly evaluating the requirement for medical services and weighing options, such as having all home station care rendered in civilian networks with providers activated as military operations require, or sustaining the current military medical operations structure. HISs must be fluid and interoperable among facilities of the uniformed and civilian sides of healthcare in the military health system. Additionally, force health protection efforts are heavily influenced by epidemiological data analysis enabled by effective HISs. These factors highlight the relevance of HISs in the military health system and for the military medical provider.

TYPES OF HEALTH INFORMATION SYSTEMS

As mentioned previously, ISs can be as simple as when a nurse used a tube of lipstick to mark the foreheads of patients as being triaged during the attack on Pearl Harbor. This practice remains today when nurses, medics, corpsmen, dentists, or physicians use marking pens for the same purpose in mass casualty events. Numerous types of HISs may be devised or encountered while practicing medicine in a military environment.

Triage during military operations or disaster response activities requires an IS to enable the effective and timely care of the ill, injured, or combat wounded. The systems currently employed during triage to document patients’ medical conditions range from grease pencils on laminated cards to land mobile radio systems to barcode scanning technologies. The application of handwritten information is the most basic level of HIS. This type of system requires a standard framework (foreheads, forms, standard terms, etc) and documentation resources (lipstick, grease pencil, marking pen, ballpoint pen, human blood, or other media). The requirement is for a simple system of patient category identification to enable proper medical care. Pen and paper, or other manual system of symbols and tools, comprise this basic form of HIS.

With the current level of technology, the electronic health record (EHR) serves as the most commonly recognized form of an HIS. The DoD’s EHR has been in development and refinement since at least the early 1980s, with fielding of the current AHLTA (Armed Forces Health Longitudinal Technology Application) system from 2003 to 2004. The DoD released the results of its selection of vendor for the next generation joint service EHR in 2016, with continued efforts to standardize health records across the services. The vision for this system is one that would accurately document the health status and healthcare activities of a service member, from point of entry into military service through death, within DoD and Veterans Affairs healthcare systems. This requires interoperable HISs such as the VA’s choice of EHR systems. An EHR is a system that brings in data from human actors (administrators, laboratory technicians, nurses, physician assistants, physicians, dentists, and other healthcare providers), medical devices, and other HISs to form comprehensive health records. Patients and providers may communicate virtually, and it allows the patient to have clear and accurate information that reduces or eliminates medication or procedural errors. It is typically comprised of computer hardware and software capable of assembling, storing, and manipulating data from various sources. The value and impacts of this comprehensive EHR system are compelling. Today, service members can access health and healthcare information accumulated over multiple assignments in the continental United States or abroad. The information follows them into the Veterans Affairs system for care following discharge or for disability adjudication.

A third example of an HIS is an operating room suite system. The assembly of computer software, computer hardware, and sophisticated medical devices serve as an HIS to specifically support single or multiple surgical events. These include devices monitoring vital signs, streaming video, tools supplying images, devices performing procedures, and devices directing laser or radiant energy safely and with pinpoint accuracy. This form of system brings together a conglomerate of small and large systems for a specific purpose. The contributing systems may include an EHR and even a handwritten triage system. All of them come together in a unique application of resources as a health system with a limited but critical scope and purpose. This complex system of information gathering, analysis, and directed care delivery resembles the system designed to understand, fix, and destroy the enemy on a modern battlefield. The parallels between the utility of timely and precision warfighting and health sustainment and healthcare is apparent.

HISs are prevalent in military medicine today and have great implications for medical practice. The basic constructs of the various systems are tailored to function under operational conditions. Whether it is a handwritten system, an electronic record, or a highly specialized suite of devices and applications, the ISs available in military and other medicine environments can be characterized by one of these formats.

PRINCIPLES OF EFFECTIVE HEALTH INFORMATION SYSTEM EMPLOYMENT

Requirements Identification

Identification of process requirements for medical transactions is fundamental. At technology symposia for healthcare providers, vendors present their “silver bullet” systems as the solution to all practice needs. If commercial off-the-shelf HISs are acquired without thorough evaluation for military needs, resources will likely be wasted on a solution without a problem or a partial solution for a much more complex set of problems. The military context presents a unique set of environmental and contextual requirements for health systems. Military medical providers and all HIS users play essential roles in formulating the requirements of a desired system. Considerations include identifying optimal pharmaceuticals, surgical instruments, or intensive care devices, among many other criteria. It is critical for medical providers to identify requirements accurately and look for the problems or bottlenecks in procedures. Requirements drive development of HISs and other resources to address specific problems or needs. If this process is followed closely then the analysis of the current system is more likely to result in system improvements or new system design. These systems should benefit all involved across the entire spectrum of environments in which the IS will be applied now and into the conceivable future.

It is in the accurate study of requirements and problem identification that so many projects fall short. Much like medical practitioners who do not complete a comprehensive analysis of the clinical situation before making a diagnosis, ISs are adopted as solutions to a problem when they really only address a symptom and often create more problems of their own.

Health Information Systems as a Component of a Comprehensive Health Delivery System

HISs are tools applied in concert with other resources and procedures to resolve a problem. The effectiveness of an HIS depends heavily on the procedures followed in a medical practice. For example, if a forward surgical team has very little time to stabilize a patient, then a bedside ultrasound, though a key to rapid diagnosis, cannot by itself deliver the stable patient. The ultrasound may capture gigabytes of data and provide elaborate reports when the real problem may be that the forward surgical team lacks the means to capture input from multiple devices to pinpoint an effective course of action.

Cyber Security

Cyber security in healthcare is a crucial component of all HISs. The world of networked computers with countless software installations, downloads, uses, and global access presents a dynamic playground for malicious activity. Foreign actors and others wishing mal intent to the United States and partner nations are constantly attacking by means of cyber media. Healthcare provides a soft target for this activity if systems are employed under the naive assumption that healthcare is off limits in warfare. Security against external and internal actors must be a primary consideration for all types of health systems. Current medical devices are also HISs and are not immune from attack because they present entry points to defense ISs residing elsewhere on connected networks.

Recent well-publicized events in which hackers have accessed protected personal patient information or held entire hospitals and healthcare systems hostage by denying access to their EHRs illustrates the extreme vulnerability of healthcare as a target for enemies or malicious actors. Proper active intervention and prevention efforts are critical to safeguarding the integrity and availability of information. Military providers practice in an environment where health information accessibility and interoperability must be balanced by adequate safeguards to prevent security breaches and data theft.

Affordability and Sustainability

On analysis of current battlefield operations, there is a requirement for a patient tracking system that actively functions from point of injury or illness through definitive care. One of the key principles for effectively addressing this requirement is employment of an IS that is affordable and technologically viable to implement and sustain in a changing military environment. Myriad techniques or forms of ISs could address these requirements, but realistic design as well as project and operation costs are critical considerations. The system must be operationally viable and affordable while delivering the desired capability and capacity. Unfortunately, the sky is not the limit when it comes to ISs. Resources committed to building and sustaining HISs and health information technology compete with all other medical requirements and even the resources available to the warfighting community. It is critical to employ an IS management expert in the resolution of the budget–function conflict for optimal clinical and technical solutions.

Provider and End-User Efficiency

A key complaint about current EHR implementations is that they are very inefficient. Balancing the capabilities that ISs give to the provider, benefit the patient, and meet the needs of the organization or operation is a key principle of effective systems implementation. The drive for accuracy of information and accountability for actions is at the heart of the EHR revolution. Physicians complain that they spend much longer with the EHR than they ever did with patients using a paper chart. They also indicate that the EHR does not improve care. It is focused instead on the information that can be used for better epidemiology and accounting for actions taken, such as medications prescribed or medical history.[5] Streamlining systems and making them more efficient is an important goal for any effective HIS.

MILITARY-SPECIFIC HEALTH INFORMATION SYSTEMS REQUIREMENTS

The military health system operates in fixed facilities, in forward operating mobile facilities, and at battlefield points of injury. Consideration for environmental and other constraints placed on ISs in military operations must be a priority. For example, some military operations are conducted in areas with excess heat and dust levels that require hardened devices and optimized cooling capabilities. In other cases, devices must be hardened against moisture when deployed to regions with extremely wet conditions. Often, power sources in austere environments are unstable, so information technology must be hardened against power surges to prevent damage to sensitive components. In all of these cases there is a requirement for secure communications that drives a need for infrastructure and service provision, which are difficult even under ideal conditions. Given the wide range of operational conditions and variables, a military HIS requires a robust design to ensure success. There are three key requirements that enable the successful deployment of any HIS supporting military medicine.

Interoperable

Given joint service and international partner involvement in current and future military operations, the ISs employed to support medical treatment require the capability to easily exchange information. Beyond the challenges of interoperability across the DoD, military HISs may also need to be compatible with those from partner nations, or at least be able to bridge any gaps.

In the best case, systems would be interoperable and have data and information sharing functionality across various platforms and technologies. This includes provider notes as well as any images or lab results that are rendered in the course of care from point of injury to home station. In a simpler example, handwritten patient records require the use of weatherproof paper and writing utensils.

Unfortunately, interoperability is a major unmet requirement. Electronic HISs are not typically interoperable across military facilities, organizations, or services, or even within a single enterprise in the civilian sector. The DoD and the Veterans Administration are working diligently to establish and sustain interoperable systems to ensure well-managed, cradle-to-grave medical care for service members. This is a vital component to meeting the military-unique mission. The end result would be visibility of all medical actions taken from the start of a service member’s career to their death. This not only enables mission readiness but opens doors to epidemiological research that will shape preventive medical practices of the future.

Operationally Viable

Though much of the work done with systems in military medicine takes place in fixed facilities, military personnel are deployed to austere and remote environments where ISs lack the commonly required support systems. Thus, as modeled by the example of using a tube of lipstick to facilitate communication in patient triage, a system must be able to function despite the lack of typically required resources.

There is a finite amount of bandwidth in austere environments, which sometimes may limit data sharing and storage. It is critical that the medical bandwidth requirement is voiced loud and clear while understanding the warfighter mission needs. Balance among competing requirements is essential for all aspects of military operations.

Modern technology significantly enhances the list of available options. Handheld devices and mobile computing make point of injury care support possible in virtually any location on the globe. This in turn means that patient information can follow the service member back to home station for continuity of care. Of course, the technology must be shielded from or resistant to the elements (heat, moisture, cold, turbulence, etc) as well as the operational hazards such as spills, drops, or bumps. This principle of operational viability highlights the unique requirements of the military health operational environments.

Sustainable and Dynamic

Already a significant challenge even absent the military context, HISs must stand the test of time to be effective. This means the health system must be technologically sustainable and adaptable to changing conditions. The requirement to monitor the care of service members for approximately 60 to 80 years in conjunction with the rapid evolution of technology could prove cost prohibitive. A vital component of achieving a sustainable system is the proactive involvement of medical personnel in ongoing requirements and system development. When ISs are left to administrative personnel to sustain and design, their requirements are prioritized, often at the expense of clinical functionality. Military medical providers should be actively engaged in design and modification of HISs to ensure the integrity and functionality of systems required to effectively support military operations of all kinds. With technology having a lifespan of 2 to 4 years, the systems employed must be dynamic in nature, with the primary goal of seamless continuity in care over a lengthy period of time.

OTHER HEALTH INFORMATION SYSTEMS CONSIDERATIONS FOR MILITARY MEDICAL OFFICERS

Military medical officers should be able to identify key components of ISs, assess the relevance of various forms of ISs in military medicine, discuss the challenges of deploying these ISs into austere environments, and look at specific examples and applications of HISs in the military environment.

Personnel often adapt to the systems the enterprise provides without ever giving input to development or procurement actions. This can lead to the employment of systems that lack the functionality required by clinicians to effectively care for assigned personnel under a broad range of military circumstances and conditions. Positive engagement and participation in HIS development offers a long-range benefit for all military medical providers and patients through system functional improvement.

Procurement and Requirements Definition

The process of acquiring and operationalizing a system in the joint military environment is lengthy and exhaustive. If done with a clear understanding of all requirements, the resulting resource will be an effective instrument for excellent healthcare across the full spectrum of military operations. However, lack of focus on or exclusion of requirements in the procurement process results in wasted time and effort when required patient care delivery needs go unanswered. It is critical that medical professionals make time to participate in procurement of HISs so that clinical operations are adequately considered and addressed.

Medical professionals often lament delays in implementing new technology that are seemingly caused by cyber security requirements. This is a misconception born of not considering security early in the procurement or development process. The real danger would be to ignore security requirements and sacrifice the availability, security, or integrity of both health and defense information, facilitating exploitation of the resultant security weaknesses. It is imperative that health professionals take a proactive approach to security and seek opportunities for strengthening security through their chain of command, development committees, or other available venues. Security should be built into systems and devices as they are introduced rather than being added through modification or retrofitting later, which causes operational and financial burdens. Specifically, health professionals must consider the information they are handling and recommend system operating procedures that preserve its availability, accessibility, and security while minimally disrupting the flow of patient care. For example, medical personnel can help safeguard systems by supporting and promoting introduction of proximity cards or biometric log-in components to systems that protect information with minimal disruption.

Virtual Health Information Systems in Military Operations

With current technologies, the military can exploit connectivity on almost any point around the globe to support patient–provider interactions. This can translate to a soldier or marine on the battlefield, a pilot on the flight line, or a sailor onboard a ship far out to sea getting direct treatment from a specialist back at medical center through video conference on a medic’s handheld device. Telemedicine presents military operations with the ability to take a virtual doctor or nurse into some of the most austere locations with no risk to the medical professional. Better still is the resulting level of care available to service members at the point of injury. Pictures (of dermatological conditions, for example) or digital images (of ultrasounds or x-rays) can be rapidly sent to higher echelons of care for analysis and recommendations for treatment or evacuation.

Military medical professionals must continuously think innovatively when it comes to provision of the right care at the right time, and virtual medicine establishes the ability to do so in any place. Security considerations, both generic and specifically targeted to patient protection, are key and should be a point of focus as medical personnel work to improve their reach and influence.

Dependents in a Joint Military Environment

One of the key requirements of any medical system is establishing a pool of skilled providers and a means of maintaining currency in those skill sets. The military relies on health providers to be current in the skills of their specialty when called upon to support operations. The HIS employed in the military has very similar requirements for effectiveness and currency. Family members and other dependents of military personnel provide a population capable of sustaining currency for both the health provider and the HIS through the care provided by military medical professionals. A system that can support cradle-to-grave preventive medicine and healthcare delivery for the extended military family can also do so for military personnel.

HIS capabilities of continuity of care, interoperability, global access, and virtual medical practice are developed and sustained in peacetime to guarantee availability for operations when events require them. Though care for family members does not typically occur in austere environments, it does provide the context for developing solid practice guidelines that are evidence based and patient focused. This is key to effective medical care delivery regardless of the environment.

SUMMARY

From the first instance of military medical care to the present day, HISs have played a vital role in the effective delivery of care. Ultimately, the effective, efficient, timely, and precise protection of human health and the delivery of healthcare is a function of gathering, analyzing, and making critical decisions based on data compiled over time and space. This information matures into knowledge through context, and is refined into wisdom through experience.

It is ultimately the responsibility of medical professionals to ensure that patient information is available, accurate, and safeguarded, through diligent use of the tools provided by the DoD. HISs are designed to provide these services and then leveraged to ensure the protection of the community and the military force, and to ensure provision of the best medical care. Skilled healthcare professionals must be actively involved in identifying clinical requirements, and procuring and sustaining available, accurate, and safe HISs. Input by healthcare professionals is vital to the effective employment of these systems.

REFERENCES

1.   World Health Organization. Health Information Systems: Toolkit on Monitoring Health Systems Strengthening. http://www.who.int/healthinfo/statistics/toolkit_hss/EN_PDF_Toolkit_HSS_InformationSystems.pdf. Published June 2008. Accessed January 3, 2018.

2.   Brailer D. The Decade of Health Information Technology: Delivering Consumer-Centric and Information-Rich Healthcare Framework for Strategic Action. Washington, DC: Department of Health and Human Services; 2004. Report to Secretary of Health and Human Services.

3.   Health information technology. Wikipedia Web site. https://en.wikipedia.org/wiki/Health_information_technology. Updated January 9, 2018. Accessed January 11, 2018.

4.   What is telehealth? Center for Connected Health Policy, The National Telehealth Policy Resource Center Web site. http://www.cchpca.org/what-is-telehealth. Published 2008. Accessed January 11, 2018.

5.   Irving, F. Docs say how they really feel about EHRs. Healthcare IT News. November 13, 2014. http://www.healthcareitnews.com/news/docs-say-how-they-really-feel-about-ehrs. Accessed January 11, 2018.

Chapter 16

FORCE HEALTH PROTECTION

MARY T. BRUEGGEMEYER, MD, MPH*

INTRODUCTION

History of Force Health Protection

Concept and Strategy

DEPLOYMENT HEALTH ACTIVITIES

Predeployment

Deployment

Postdeployment

DEVELOPING A DEPLOYMENT HEALTH SURVEILLANCE PROGRAM

Step 1. Identify the Population at Risk

Step 2. Conduct a Health Risk Assessment

Step 3. Develop Countermeasures

Step 4. Monitor and Report Disease and Injury

Step 5. Health Risk Communication

Step 6. Command Support

SUMMARY

*Colonel, Medical Corps, US Air Force; Assistant Professor of Preventive Medicine and Biostatistics and Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

History of Force Health Protection

Force health protection (FHP) is simply the prevention of disease and injury in order to protect the strength and capabilities of the military population. This concept was most eloquently stated in 1866 by Dr Jonathan Letterman, medical director of the Army of the Potomac, when he wrote, “A corps of medical officers was not established solely for the purpose of attending the wounded and sick …. The leading idea is to strengthen the hands of the Commanding General by keeping his army in the most vigorous health, thus rendering it, in the highest degree, efficient for enduring fatigue and privation, and for fighting.”1(p23) In fact, the military’s focus on preventive medicine can be traced to the earliest days of the republic, when General George Washington ordered the inoculation of the Continental Army against smallpox, following the recommendations of his physician in chief, and issued “Instructions for Soldiers in the Service of the United States Concerning the Means of Preserving Health: Of Cleanliness.” These measures helped preserve the army’s fighting strength and contributed to the ultimate victory over the British forces. In addition, General Washington’s policies on preserving health, in concert with those of Baron Von Steuben, the army’s first inspector general, laid the foundations for modern military preventive medicine.[1]

FHP requires continuous vigilance. History shows that deaths due to nonbattle injury and illness can be more numerous and more impactful than those due to combat. Figure 16-1 illustrates the historical fluctuations in the ratio of deaths due to nonbattle injury and illness compared to deaths due to combat across major US conflicts.[2] Many factors contribute to the fluctuations in this ratio, including knowledge of the health threats present in new theaters of operation and the knowledge and ability to develop effective countermeasures. The rise in deaths due to illness in the Spanish-American War inspired research into yellow fever, which produced critical knowledge about mosquito vectors and effective vector control programs.[3]

Illness and death that occur many years after a conflict may not be reported or associated with exposures that occurred during combat. This was the case with many veterans following the Vietnam War. Vietnam veterans’ illnesses, and their possible association with the herbicides used during the conflict, led to Public Law 102-4, the Agent Orange Act of 1991, nearly 20 years after the end of the conflict.[4] The Agent Orange Act then spurred 2 decades of epidemiological and toxicological study; however, much of the findings are still inconclusive.[4] A moderate increase in the ratio of death due to nonbattle injury and illness was also seen after the Persian Gulf War. These deaths were largely due to training and motor vehicle accidents, but the illnesses following this war, reminiscent of Vietnam veterans’ illnesses and the associated challenges in determining exposures and associations, were the impetus behind current FHP strategy, policies, and programs.[5]

Figure 16-1. Ratio of non-hostile deaths to hostile deaths in major US military conflicts.
OEF: Operation Enduring Freedom
OIF: Operation Iraqi Freedom
WWI: World War I
WWII: World War II
Data source: Defense Casualty Analysis System. https://dcas.dmdc.osd.mil/dcas/pages/casualties.xhtml. Accessed March 26, 2018.

TABLE 16-1

SUMMARY OF CURRENT DEPARTMENT OF DEFENSE POLICY AND INSTRUCTIONS FOR FORCE HEALTH PROTECTION STRATEGY

DoDD 6490.02E (3 Oct 2013)
Comprehensive Health Surveillance^1

Establishes policy for routine and comprehensive health surveillance of all DoD personnel throughout their military service

Defines data collection requirements:

- disease and injury

- medical interventions

- stress-induced casualties

- combat casualties

- medical evacuations

- occupational and environmental exposures

Mandates linkage of exposure and medical surveillance data for identifying, characterizing, and countering threats to health, well-being, and performance

Established the DoD Serum Repository

Established the Armed Forces Health Surveillance Center as the single source for DoD-level health surveillance information and designated the Army the DoD executive agent

DoDI 6490.03 (30 Sep 2011)
Deployment Health^2

Establishes policy that DoD components implement a comprehensive deployment health program that effectively anticipates, recognizes, evaluates, controls, and mitigates health threats encountered during deployments

Directs COCOMS to create operation plans that:

- List deployment health resource requirements

- Direct and document health threat assessments & occupational/environmental health (OEH) site assessments

- Determine and enforce the use of countermeasures, approved food and water sources, and personal protective equipment

- Set up theater health surveillance plans to report disease & injury rates, battle injuries, OEH exposures, and medical intelligence

- Direct health risk communication

- Specify once daily reporting of locations of all deployed personnel

Defines specific predeployment, deployment, and postdeployment health activities that must occur (see Table E4.T2 for roles and responsibilities):

Predeployment

- Administer Pre-Deployment Health Assessment (DD Form 2795)

- Administer immunizations

- Prescribe prophylactic medications and 90-day supply of other prescription medications

- Draw predeployment serum

- Establish biomonitoring baselines

- Issue personal protective equipment

- Perform tuberculosis screening based on risk

- Conduct OEH site assessments and health threat assessments

- Conduct health threat briefings and risk communication

- Develop health surveillance plan

Deployment

- Validate health threat assessment

- Conduct OEH site and exposure assessments and document in the medical record

- Perform health surveillance activities and reporting

- Conduct food and water inspections

- Document patient encounters

- Document daily personnel location

Postdeployment

- Complete Post-Deployment Health Assessment and Reassessment (DD Forms 2796/2900)

- Conduct face-to-face health assessment

- Ensure medical referrals and follow-up for deployment-related concerns

- Integrate medical and OEH assessments into the medical record

- Draw postdeployment serum

- Perform biomonitoring

- Conduct postdeployment health debriefings and risk communication

- Continue health surveillance; inform in-garrison medical community of exposures and possible health outcomes to monitor in the returned population

- Submit all OEHS data and health surveillance reports to the Armed Forces Health Surveillance Center

JP 4-02 (26 Jul 2012)
Health Services Support^3

Details FHP requirements and activities as an equal part of health services support to joint operations and defines roles and responsibilities of the joint force surgeon and the FHP staff

The FHP division’s primary function is to assist the joint force surgeon with establishing policies and procedures to deliver a healthy and fit force, prevent casualties, and maintain the health of the joint force while deployed. This will be similar to what is expected for the COCOM (see COCOM operations plan requirements) but may be tailored to the specific mission of the joint task force and the joint operations area (JOA)

Provides details into the components of the FHP strategy for the JOA:

Casualty Prevention

- All measures taken by commanders, leaders, individuals, and healthcare system to promote, improve, or conserve the mental and physical well-being of military personnel

Preventive Medicine (PRVTMED)

- Overall anticipation, prevention, and control of communicable diseases, illnesses, injuries, and exposures to endemic, occupational, and environmental threats

Health Surveillance

- The iterative process of identifying the population at risk, identifying and assessing potential exposures, communicating these risks, developing and employing countermeasures and monitoring and reporting of DNBI/BI rates

Combat and Operational Stress Control

- Programs and actions to prevent, identify, and manage adverse combat and operational stress reactions in units

Preventive Dentistry

- Primary, secondary, and tertiary measures to reduce or eliminate dental conditions that interfere with fitness for duty

Vision Readiness

- Actions to optimize visual clarity, provide devices for optical correction, and provide eye protection for all hazardous activities

Laboratory Services

- Deployed capabilities for identification of endemic diseases, occupational and environmental hazards, and CBRN agents in support of the total health environment of the JOA (not for individual patient care)

Veterinary Services

- US Army veterinary units support government-owned animal healthcare, veterinary PRVTMED, and food safety and security programs

CBRN: chemical, biological, radiological, and nuclear

COCOM: combatant command

DNBI/BI: disease and nonbattle injury/battle injury

DoD: Department of Defense

DoDD: Department of Defense directive

DoDI: Department of Defense instruction

FHP: force health protection

JP: joint publication

JOA: joint operations area

OEH: occupational and environmental health

PRVTMED: preventive medicine

(1) US Department of Defense. Comprehensive Health Surveillance. Washington, DC: Office of the Under Secretary of Defense Personnel and Readiness; October 3, 2013. DoD Directive 6490.02E. (2) US Department of Defense. Deployment Health. Washington, DC: Office of the Under Secretary of Defense Personnel and Readiness; September 30, 2011. DoD Instruction 6490.03. (3) US Joint Chiefs of Staff. Health Service Support. Washington, DC: JCS; July 26, 2012. Joint Publication 4-02.

Concept and Strategy

The new FHP concept that evolved in the decade after the Persian Gulf War is a unified strategy encompassing all preventive, clinical, and operational programs needed to maximize the health of the military population. It covers the entire career of the service member, in addition to the specific times before, during, and after deployment. FHP includes robust combat casualty care and plays a significant role in medical readiness planning and training. The strategy incorporates improved health risk communication, health surveillance, longitudinal health records, biomedical research on countermeasures, and interagency coordination based on lessons learned and recommendations from the Institute of Medicine.[5] The FHP strategy is codified in Department of Defense (DoD) Directive 6490.02E, Comprehensive Health Surveillance[6]; DoD Instruction (DoDI) 6490.03, Deployment Health[7]; and Joint Publication (JP) 4-02, Health Service Support.[8] The renewed focus on FHP led to the addition of a dedicated chapter in the most current version of JP 4-02. Key components of these documents are summarized in Table 16-1. Implementation of these directives is described in service-specific guidance.

DEPLOYMENT HEALTH ACTIVITIES

Predeployment

Although DoDI 6490.03 describes specific health activities that must occur in the time immediately preceding deployment, predeployment health activities actually begin at the outset of each service member’s career. At the most fundamental level, accession physical examinations begin the process of screening out individuals with medical conditions that preclude them from military service. The medical standards of each of the services are developed with the intent of insuring mission success and protecting the health of the individual. The basic tenet of medicine, “primum non nocere” (first, do no harm) applies to the decision to “medically clear” an individual to participate in the physically and mentally demanding environment of military training, deployment, and combat. Accession medical standards are found in DoDI 6130.03[9] and are implemented by each of the services in separate instructions.

Following accession, annual health evaluations occur throughout a service member’s military career. These annual health evaluations, known as the Periodic Health Assessment, provide an opportunity for the medical officer to both screen for disease and assess fitness and performance. At each evaluation, the service member should be screened for conditions that are not compatible with retention in the military in accordance with DoDI 6490.07.[10] In general, the medical officer should consider whether the person will be able to carry out duties both in garrison and during deployment, and how any medical condition may be affected by factors such as climate, altitude, rations, housing, duty assignment, and medical services available in theater. More specifically, the medical officer should evaluate whether the person can wear all personal protective equipment, including helmet, body armor, and chemical protective wear, when needed. In addition, the service member should be screened for completion of individual medical readiness requirements that include immunizations, dental examinations, medical equipment such as corrective lenses and gas mask inserts, and laboratory tests such as human immunodeficiency virus (HIV) or tuberculosis screening.

When a service member is identified for deployment, a specific Pre-Deployment Health Assessment must be completed and documented on DD Form 2795. This assessment is a more focused medical evaluation based on the details of the deployed mission and location. Specific medical requirements stem from the health risk assessment and occupational and environmental health (OEH) site assessments (see Developing a Deployment Health Surveillance Program, below) done by the combatant command (COCOM) or joint task force (JTF). These medical requirements are published in a health services support annex of the operations plan. Individual medical requirements include preventive countermeasures such as immunizations, prophylactic medicines, personal protective equipment, predeployment biomonitoring, DoD serum repository laboratory tests, and prescription medications as needed.

Predeployment health activities are not just focused on the individual, but also encompass medical planning at the COCOM, JTF, and unit level. As mentioned above, the COCOM or JTF must complete health risk assessments and OEH site assessments, and plan for medical resources required to accomplish the FHP mission. There must be a plan for health surveillance through all phases of deployment from the COCOM or JTF level down to the unit medical officer. Finally, health risks must be communicated to the commander and to individual members to ensure all health threats are understood and preventive countermeasures followed.

Figure 16-2. Deployment health activities that occur throughout the service member’s lifecycle.
OEHS: occupational and environmental health surveillance

Deployment

The preventive medicine team should be in theater as early as possible to validate the health risk assessment, mitigate unidentified threats, conduct additional OEH site assessments, and enforce proper base camp set-up. To accomplish these measures, the preventive medicine team should be included with the advance team whenever possible. Health surveillance in theater must be carried out from day 1, with daily recording and reporting of disease and injury cases as directed by the JTF or COCOM surgeon. If a formal reporting structure has not been developed, the unit medical officer should take the initiative to record disease and injury cases for the unit. All patient encounters must be documented and incorporated into the patient’s deployment health record.

Throughout the deployment, continuous inspection for compliance with preventive countermeasures and investigation of disease outbreaks must be done. Disease outbreaks should be recognized early and investigations conducted, recorded, and communicated. In addition, any occupational; environmental; or chemical, biological, or radiological exposure incidents should also be investigated, recorded, and documented in the individual’s deployment health record. Also, food and water inspections should be conducted regularly. If water safety depends on chlorination, daily chlorination checks are critical. Fecal contamination of drinking water will result in rapid and widespread cases of diarrheal illness with potential for adverse mission impact. Inspection of food and water sources is an FHP activity conducted by the US Army Veterinary Corps as well as US Air Force public health officers to ensure food wholesomeness, safety, quality assurance, and defense.

The revised FHP strategy that followed the Persian Gulf War increased efforts to associate deployment exposures with disease outcomes. The focus on OEH site assessments, exposure incident investigations, and documentation is a result of these revisions. Additionally, the location of deployed personnel must be recorded once daily and electronically reported to the Defense Manpower Data Center. Exposure assessments are recorded in the Military Exposure Surveillance Library (MESL). The MESL and health surveillance data are reported to and managed by the Armed Forces Health Surveillance Branch, Office of the Assistant Secretary of Defense, Health Affairs.

Postdeployment

Postdeployment health activities start with a health threat debrief and comprehensive health risk communication to ensure individual service members and the command are informed of the health threats they may have been exposed to. The postdeployment period is a prime opportunity for education about any real or perceived exposures that may have occurred and the need for completion of any postexposure prophylactic medications. Medical personnel should focus on continued surveillance of the redeployed population and must be educated about all possible health threats encountered in the deployment.

Service members must complete all mandatory postdeployment health assessments in the prescribed time period, and medical personnel should have surveillance processes in place to track compliance with this requirement. A redeployed member who has not completed these assessments or face-to-face encounters remains an unknown risk. Commanders should be briefed on the postdeployment health assessment completion rates with the same level of importance as predeployment assessments. Command support may be necessary to achieve 100% completion of these assessments.

Postdeployment health activities also focus on documentation of exposures that occurred during deployment. The Post-Deployment Health Assessment asks service members to report any known or perceived exposures. The medical officer must then evaluate each one for validity and estimation of the individual health risk. Better resources now exist to match these self-reports with known exposure sampling. Despite the efforts of the Defense Manpower Data Center and the MESL, matching area sample exposure data to individual disease risk and outcome remains challenging. For this reason, it is important that service members who report concerns about deployment exposures receive a referral to appropriately trained healthcare providers such as OEH experts who can counsel them about health risks.[11] Deployment health activities are summarized in Figure 16-2 and Table 16-1.

DEVELOPING A DEPLOYMENT HEALTH SURVEILLANCE PROGRAM

Health surveillance refers to the systematic collection, analysis, and interpretation of health-related data. It involves an iterative process of planning, acting, collecting, and reflecting with the goal of achieving a better outcome for the mission and the deployed population. Developing a health surveillance program includes identifying the population at risk, conducting a health risk assessment, developing and instituting countermeasures to prevent or reduce the health threat, monitoring and reporting disease and injury rates, health risk communication, and command support. A health surveillance program can be instituted for any population at risk, deployed or in garrison, unit-specific or DoD-wide. For the purposes of this chapter, components of a health surveillance program for a deploying population will be described. Properly executed, a health surveillance program enables the timely recognition of health risks, leading to interventions that prevent, treat, reduce, or control disease and injury.

Step 1. Identify the Population at Risk

The first critical step in deployment health surveillance is to identify the population at risk. The medical officer should be invited into the mission analysis and planning process as early as possible to facilitate this critical first step. The population at risk are those personnel who will be involved in the mission and functioning within the theater of operations or the joint operations area. They are the people who must undergo predeployment screening, monitoring for disease and injury during deployment, and postdeployment follow-up. Key questions to ask are “who is going?” and “how many?”

Answering the “who?” question should take into account both group and individual factors.

The group includes the units being tasked for a mission, which is found in the operations plan and deployment order. Each group will have specific mission tasks and include occupational subgroups, which will drive additional health risk assessments. Individual factors focus on age, preexisting health conditions, and predisposition for contracting disease or being injured. For example, risk for cardiovascular events is higher in older individuals, especially if they are traveling into areas with poor air quality. The medical officer will need to take these factors into account during the predeployment health assessment and provide proper health risk counseling to individuals and the group.

Determining how many personnel will be in the mission is needed for the risk estimate. The risk estimate is the percentage of personnel who will be affected by a particular health threat. A small group performing a critical mission may need to be more risk adverse for disease and injury because loss of even one member could impact mission accomplishment. Therefore, unit members might need to be highly disciplined about food and water sources and carry antibiotic treatment to avoid disabling diarrhea, or the unit may be ordered to avoid high-risk sports activities to prevent injury. A larger unit with some redundancy may not require preventive measures as strict or encompassing, and they should be balanced with the needs of unit morale. It is the duty of the medical officer to advise the unit commander on the risk estimate of each health threat and the feasibility of each preventive countermeasure.

Step 2. Conduct a Health Risk Assessment

A comprehensive health risk assessment is used to anticipate, recognize, and evaluate both noncombat and combat-related threats to the health of the force so that effective countermeasures can be developed and implemented. The health risk assessment starts in the predeployment period, is continuously reevaluated during deployment, and extends into the postdeployment surveillance period. A health threat can be defined as the composite of all potential actions, conditions, infections, or events that could degrade the performance or mission capability of a person or a unit. Army Techniques Publication 4-02 specifically defines the term health threat as “a composite of all ongoing potential enemy actions and environmental conditions (disease and non-battle injuries [DNBIs]) that may render a soldier combat ineffective.”12(p2-1) The enemy threat must be assessed for the potential to produce combat-related injury or illness from conventional, improvised, chemical, biological, or radiological weapons. A health threat is assessed for the potential impact on the unit as a whole.

Multiple factors, assumptions, and background elements must be considered by the medical officer when building the health risk assessment. The ongoing and systematic collection and analysis of this information is known as the medical intelligence preparation of the operational environment (MIPOE).[8] The MIPOE is the framework on which the health risk assessment is built. Table 16-2 summarizes factors to be considered in building the MIPOE and health risk assessment.

TABLE 16-2

HEALTH RISK ASSESSMENT: FACTORS TO CONSIDER

Who is going?

Number, demographics, health status, training, equipment

What is the mission?

Activities (both mission-related and off-duty), living conditions, duration, time of day, equipment, interaction with local population

When and where is the mission?

Climate, terrain, altitude, heat/cold, wet/dry, time of year, urban vs rural, pollution, animals, plants, pests

Will there be enemy contact?

Weapons capability, CBRNE threat, tactics

What are the local diseases and likelihood of exposure?

Prevalence of infectious diseases, methods of transmission, and likelihood of transmission

What is the magnitude of the threat and potential to compromise the mission?

How many of us will get sick or be injured? For how long/how seriously? Risk of death? Need for evacuation?

What can and should be done to mitigate the threat?

Feasibility and effectiveness of prevention and control strategies given the operational circumstances and available resources, education programs

CBRNE: chemical, biological, radiological, nuclear, explosive

What resources are available for building the MIPOE and health risk assessment? The first resource should be the office of the command surgeon with geographic responsibility for the area into which the JTF or unit is being deployed. The combatant command preventive medicine staff should have an initial health risk assessment for the region and may have a published operations plan with a health services support annex. Other COCOM or JTF resources may include published medical reporting requirements and theater treatment protocols, depending on the maturity of the theater. Nonmedical JTF staff are also valuable sources of information for the medical officer, as shown in Exhibit 16-1. If, however, the medical officer is on the command or JTF surgeon’s preventive medicine staff, is building the health services support annex, or guidance is not yet available, the next source of information is the DoD’s National Center for Medical Intelligence (NCMI).[13]

EXHIBIT 16-1

JOINT TASK FORCE STAFF AND SOURCES OF INFORMATION

The NCMI is a closed source of information (requiring DoD credentials to access the website and intelligence products). NCMI is specifically tasked in DoDI 6490.03 to provide a broad range of medical intelligence. Medical intelligence refers to information about foreign military and civilian medical capabilities, disease, environmental and industrial health threats, and biotechnology that can have an impact on military strategy, plans, and operations.[8] Products available to the medical officer include the Infectious Disease Risk Assessment, Infectious Disease Alert, Health Service Assessment, Industrial Facility Health Risk Assessment, and Environmental Health Risk Assessment.[13] Additional DoD sources of health threat information include the Armed Forces Health Surveillance Branch and the MESL; the Armed Services Pest Management Board; the US Army Research Institute of Environmental Medicine; the US Army Public Health Center; the US Air Force School of Aerospace Medicine; and the Navy and Marine Corps Public Health Center. Lastly, the medical officer should obtain background information and important assumptions directly from the JTF or COCOM staff, as summarized in Exhibit 16-2.

EXHIBIT 16-2

LIST OF RESOURCES FOR THE HEALTH RISK ASSESSMENT

Closed Source

- Combatant Command (COCOM):

- Joint Staff (see Exhibit 16-1)

- Operations Plan Annex Q, Health Services Support

- Theater Reporting Requirements

- National Center for Medical Intelligence: https://www.ncmi.detrick.army.mil/

- Armed Forces Pest Management Board: https://health.mil/afhsb

- Armed Forces Health Surveillance Branch: https://health.mil/afhsb

- US Air Force School of Aerospace Medicine: http://www.wpafb.af.mil/afrl/711hpw/USAFSAM.aspx

Open Source

- US Centers for Disease Control and Prevention Traveler’s Health: https://wwwnc.cdc.gov/travel/

- US Central Intelligence Agency World Fact Book: https://www.cia.gov/library/publications/the-worldfactbook/

- World Health Organization: http://www.who.int/countries/en/

Open sources of health threat information are also widely available. The US Centers for Disease Control and Prevention has a well-developed and easily accessible website called Travelers’ Health.[14] This site can be searched by location, disease, or individual factors. The site can be used to develop travel health recommendations based on the characteristics of the individual traveler. The World Health Organization website provides country-specific health profiles that describe demographics, burden of disease, and risk factors.[15] This site also provides up-to-date reports on infectious disease outbreaks, public health emergencies, environmental health conditions, and a wide range of other health-related topics. The Central Intelligence Agency’s World Fact Book[16] gives a wider picture of a country or a region focusing on history, people, government, economy, geography, communications, transportation, military, and transnational issues. The site also contains regional maps based on physical and political features of the region.

Once information has been gathered, it is useful to divide it into categories. One convention to follow is shown in Figure 16-3 and Exhibit 16-3. Health threat categories to consider are food- and water-borne diseases, vector-borne diseases, infectious (person-to-person) diseases, environment, plants and animals (flora and fauna), psychological injuries, noncombat injuries, and combat injuries. Although not included in a formal health risk assessment, the type and scope of preexisting health conditions among deploying service members will also affect unit strength and should be considered by the medical officer. Assessments of combat injury and illness threats should consider the probability of enemy contact, enemy weapons and tactics, and chemical, biological, and radiological weapons capability.

Figure 16-3. Health threat categories to consider as part of the health risk assessment: food- and water-borne diseases, vector-borne diseases, infectious (person-to-person) diseases, environment, plants and animals (flora and fauna), psychological injuries, noncombat injuries, and combat injuries. Although not included in a formal health risk assessment, the type and scope of preexisting health conditions among deploying service members will also affect unit strength and should be considered by the medical officer.
HIV: human immunodeficiency virus
MERS-CoV: Middle East respiratory syndrome-coronavirus
MVA: motor vehicle accident
STI: sexually transmitted illness

EXHIBIT 16-3

HEALTH RISK ASSESSMENT TEMPLATE FOR DISEASE AND NONBATTLE INJURY BY CATEGORY

Step 3. Develop Countermeasures

Each health threat should be evaluated for potential countermeasures. The countermeasures should be further divided into predeployment, deployment, and postdeployment actions (see Exhibit 16-3). Figure 16-4 shows countermeasures that could be considered within each health threat category. Combat injury countermeasures may include personal protective equipment such as body armor, ballistic eye protection, laser eye protection, a Kevlar (Du-Pont, Wilmington, DE) helmet, and mission-oriented protective posture gear; prophylactic medications in the event of chemical, biological, or radiological weapons exposure; and combat stress countermeasures. Combat injury countermeasures may also involve strategic-level changes in vehicle design for blast protection or changes in tactics such as convoy operations.

Countermeasure effectiveness depends on several factors. First, how well does the countermeasure actually prevent the health outcome (eg, vaccine effectiveness)? Next, how well has the health risk been communicated by the medical officer, and how well has inspection and surveillance been conducted throughout the deployment cycle? Countermeasure effectiveness also depends on individual compliance and the level of command support. Finally, changes in the health threat itself (eg, virulence) can alter countermeasure effectiveness.

Figure 16-4. Preventive countermeasures for selected health threat categories.

Step 4. Monitor and Report Disease and Injury

The success of FHP depends on the vigilance of the medical officer in monitoring, reporting, and analyzing disease and injury rates. Combatant commanders are required by DoDI 6490.03 to “ensure theater health surveillance plans and requirements are identified in each operation plan,” and to “provide timely reporting of disease and non-battle injuries (DNBI), battle injuries and other medical information.”6(pp7–8) DNBI rates should be divided into the most common categories such as gastrointestinal, respiratory, dermatologic, febrile illness, mental, musculoskeletal, heat or cold injury, and dental. More specific categories may be developed based on the known health threats in the operations area; for example, disease-specific categories like malaria or leishmaniasis or injury-specific categories like motor vehicle accidents. In addition, reportable medical events should be defined (usually by the COCOM) based on the threat to public health or the threat to the operational mission. Highly contagious or highly fatal diseases will usually be on this list. The medical officer should be aware of the reporting requirements and reporting chain in their theater of operations. As previously mentioned, medical officers must be prepared on the first day in theater to track all medical events and patient encounters and, in the absence of specific theater guidance, they should develop their own system for surveillance until guidance is obtained.

The goal of disease and injury surveillance is to quickly identify new health threats, failure of countermeasures, breakdowns in hygiene or discipline, and disease outbreaks, followed by rapid mitigation of the threat to protect the health of the force. Surveillance, reporting, and mitigation can result in effective changes at the smallest individual unit all the way up to COCOM and DoD levels. In one case (author’s personal experience), tracking of DNBI resulted in the early recognition of increased heat injuries during the first days in theater. Because the teams were small and rotated every 2 weeks, mission accomplishment was adversely affected. Analysis of the events revealed a trend in poor physical fitness, with more than half of the ill members having failed the service fitness assessment prior to the deployment. This information was reported up the chain, resulting in more rigorous screening of individuals selected for the mission, with no additional heat injuries and full team strength for the duration of the time in theater.

Step 5. Health Risk Communication

Once the health risk assessment is complete and countermeasures decided upon, this information must be communicated to all stakeholder groups. Stakeholder groups include individual deployers, the commander, the in-garrison medical team, and the deployed medical team. Family members may also comprise a stakeholder group. The in-garrison medical team should be informed of the health threats for which deployers must be cleared and countermeasures that must be prescribed by the provider. The in-garrison medical team should also be informed of health threats that must be monitored in returning deployers, such as malaria, tuberculosis, and posttraumatic stress disorder.

Health risk communication briefings should occur during predeployment preparation, upon arrival into theater, just prior to departure from theater, upon return to home station, and any time the threats may have changed. Each briefing should focus on the most important health threats and countermeasures for that portion of the deployment cycle. For example, predeployment health threat briefs might focus on personal protective equipment such as treatment of uniforms with permethrin, vaccinations, prophylactic medication prescriptions, and training and certifications for workplace safety. Upon arrival in theater, briefs might focus more on safe food and water sources, vector avoidance, safety and injury prevention, adherence to prophylactic medications, and updates in the health risk assessment. To get the attention of new deployers, diseases and injuries already seen in theater should be emphasized. As previously discussed, the postdeployment health threat brief is a critical opportunity to educate the returning deployer on any health threats they may have encountered, the importance of completing any postexposure prophylactic medications, and the importance of documenting any exposures that occurred during deployment. Also, any individual concerns should be addressed as soon as possible. Returning deployers should be reminded to report their recent deployment and travel history to their medical provider if any medical conditions develop. Finally, returning deployers should complete the postdeployment health assessments at the prescribed times as described in DoDI 6490.03.[7]

Step 6. Command Support

The final and critical piece in FHP is command support. In addition to the need for a resilient and effective fighting force for mission accomplishment, the commander has a legal and ethical responsibility to care for the health and welfare of people under his or her command. The commander must balance operational demands with health threats; some risk may need to be accepted and managed. The commander depends on the medical officer to provide clear and concise health risk communication and guide the content of the commander’s orders and policies in this regard. Through sound advice, the medical officer must strive to gain the trust of the commander. In turn, the medical officer will depend on the authority of the commander for implementation of FHP measures.

Command support of FHP ensures that preventive medicine personnel are well trained, well equipped, and well placed to conduct the health risk and environmental risk assessments that must be accomplished per DoDI 6490.03. Lessons learned from recent conflicts have shown that preventive medicine personnel must be involved in the early phases of mission analysis and planning, and they should be prioritized for early entry into theater. In this way, inadvertent exposure to environmental and industrial threats can be minimized.[11] In his article on FHP during the 2010 Pakistan flood relief,[17] Major RL Burke describes a good example of command support. The health threats during this mission were substantial, involving mosquito vector threats and food- and water-borne threats. Command support for preventive medicine personnel was needed due to the restricted number of military personnel allowed into the response area. In addition, command foresight into the value of training all medical personnel to a basic level in preventive medicine skills was a force multiplier.[17]

SUMMARY

FHP, the prevention of disease and injury to protect the strength and capability of the military force for mission accomplishment, has been a part of US military strategy since the revolutionary era, and was reinvigorated following the Persian Gulf War. FHP spans the lifecycle of the military service member and can be divided into predeployment, deployment, and postdeployment phases; each phase includes required and specific health-related activities. A health surveillance program is a critical component of FHP, whether a unit is deployed or in garrison. Components of a health surveillance program include identification of the population at risk, conducting a health risk assessment, development of countermeasures, monitoring and reporting of disease and injury, health risk communication, and command support.

REFERENCES

1.   Withers BG, Craig SC. The historical impact of preventive medicine in war. In: Kelley PW, ed. Military Preventive Medicine: Mobilization and Deployment, Vol 1. Washington, DC: Borden Institute; 2003: 21–57.

2.   Defense Casualty Analysis System (DCAS 2.1.10). Casualty summary by casualty category. https://www.dmdc.osd.mil/dcas/pages/casualties.xhtml. Accessed November 29, 2016.

3.   Llewellyn CH. Preventive medicine and command authority—Leviticus to Schwarzkopf. In: Kelley PW, ed. Military Preventive Medicine: Mobilization and Deployment, Vol 1. Washington, DC: Borden Institute; 2003: 3–19.

4.   Committee to Review the Health Effects of Vietnam Veterans of Exposure to Herbicides. Veterans and Agent Orange: Update 2010. Washington, DC: National Academies Press; 2012.

5.   Trump DH, Mazzuchi JF, Riddle J, Hyams KC, Balough B. Force health protection: 10 years of lessons learned by the Department of Defense. Mil Med. 2002;167(3):179–185.

6.   US Department of Defense. Comprehensive Health Surveillance. Washington, DC: Office of the Under Secretary of Defense Personnel and Readiness; October 3, 2013. DoD Directive 6490.02E.

7.   US Department of Defense. Deployment Health. Washington, DC: Office of the Under Secretary of Defense Personnel and Readiness; September 30, 2011. DoD Instruction 6490.03.

8.   US Joint Chiefs of Staff. Health Service Support. Washington, DC: JCS; July 26, 2012. Joint Publication 4-02.

9.   US Department of Defense. Medical Standards for Appointment, Enlistment, or Induction in the Military Services. Washington, DC: Office of the Under Secretary of Defense Personnel and Readiness; September 13, 2011. DoD Instruction 6130.03.

10.   US Department of Defense. Deployment Limiting Conditions. Washington, DC: Office of the Under Secretary of Defense Personnel and Readiness; February 5, 2010. DoD Instruction 6490.07.

11.   Mallon TM. Progress in implementing recommendations in the National Academy of Sciences reports: “Protecting Those Who Serve: Strategies to Protect the Health of Deployed U.S. Forces.” Mil Med. 2011;176(7 Suppl):9–16.

12.   US Department of the Army. Force Health Protection. Washington, DC: DA; March 2016. Army Techniques Publication 4-02.8.

13.   National Center for Medical Intelligence website. https://www.ncmi.detrick.army.mil/. Updated April 28, 2017. Accessed June 12, 2017.

14.   US Centers for Disease Control and Prevention. Travelers’ Health website. https://wwwnc.cdc.gov/travel/. Updated June 2, 2017. Accessed June 12, 2017.

15.   World Health Organization. Countries. http://www.who.int/countries/en/. Accessed June 12, 2017.

16.   US Central Intelligence Agency. The World Fact Book. https://www.cia.gov/library/publications/the-world-factbook/. Updated June 12, 2017. Accessed June 12, 2017.

17.   Burke RL. One health and force health protection during foreign humanitarian assistance operations: 2010 Pakistan flood relief. Army Med Dep J. 2013;Jan-Mar:81–85.

Chapter 17

MEDICAL LOGISTICS

DAVID SLONIKER* AND JAMES F. SCHWARTZ†

INTRODUCTION

INTEGRATED MEDICAL LOGISTICS MANAGEMENT

ORGANIZATIONAL ROLES AND MISSIONS

Strategic Role

Service Agencies

Operational Roles

Tactical Roles

Blood Management

Medical Maintenance

Optical Fabrication

Patient Movement Items

MEDICAL LOGISTICS LESSONS LEARNED

Tips for the Provider

Checklist and Planning Considerations

RESOURCES

SUMMARY

*Colonel, Medical Service Corps, US Army; Commander, 6th Medical Logistics Management Center, Fort Detrick, Maryland

†Lieutenant Colonel (Retired), Medical Service Corps, US Army; Assistant Professor and Chief of Staff, Department of Military and Emergency Medicine, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

Few elements of health service support (HSS) are as routinely underappreciated by the medical caregiver as is medical logistics (“MEDLOG”). In a world in which Internet-enabled purchasing of everything from books to clothing to groceries and toiletries has made face-to-face encounters with a salesperson nearly obsolete, where delivery trucks make round-the-clock home deliveries, and even drones are being explored for supplying just-in-time commercial products, the many processes and network of relationships in logistics have become invisible to the customer. In a tribute to the professional success of medical logisticians, these processes are often even less apparent in a clinic or hospital. Drugs are ordered electronically and either unit-dosed to a ward or dispensed promptly in a pharmacy. The surgeon—swaddled in disposable sterile gowns and mask and sheathed in latex gloves—asks for a specific suture, instrument, or device and is almost instantly provided the right tool.

Yet no aspect of medical support for global military operations is more complex or demanding of agility, adaptive processes, specificity, and creativity than MEDLOG. In addition, effective and efficient MEDLOG in the dynamic field of healthcare must be concerned with the entire supply chain, from manufacturer to end-user, and from initial deployment of a device or piece of equipment, through obsolescence, disposal, and replacement with a more current or updated version. Joint Publication 4.02 describes MEDLOG as an integral part of the Military Health System that provides capabilities to organize and provide lifecycle management of the specialty medical products and services required to operate an integrated health system anywhere in the world.[1]

MEDLOG support must be responsive to differences in professional training and specialty requirements. Proactive planning is required to predict materiel requirements and logistics support based on mission requirements and the operational environment. Close rapport, continuous communication, and mutual respect and understanding between the medical logistician and the healthcare provider are all essential for maintaining the health of military personnel, ensuring the lifesaving ability of the medical force, and conserving the fighting force. This chapter provides new medical officers and other healthcare providers with a primer on the Department of Defense (DoD) MEDLOG functional area, on the operational, strategic, and tactical levels. This is by no means a doctrinal document; rather, it is a guide for understanding the roles of medical logisticians in garrison and for developing the MEDLOG support plan in an operational environment. The primary tasks of the MEDLOG function is to provide:

- medical materiel management,

- medical equipment maintenance and repair,

- optical fabrication,

- blood distribution management,

- centralized management of patient movement items,

- health facilities planning and management, and

- medical contracting.

INTEGRATED MEDICAL LOGISTICS MANAGEMENT

The differences among US Army, Navy, Air Force, and Marine Corps medical operations are often contextually specific. MEDLOG support is therefore normally a USC Title 10 service responsibility. However, in joint operations, a single integrated medical logistics manager (SIMLM) and a theater lead agent for medical materiel (TLAMM) are designated. The SIMLM’s mission, assigned to a service component command or joint task force, is to provide MEDLOG support of the joint force and government or multinational partners. The mission assignment is specific and depends on the supported force, complexity of distribution processes, and duration of need. The SIMLM promotes supply chain efficiency and minimizes the theater MEDLOG force.

TLAMMs are units or organizations designated by the Chairman of the Joint Chiefs of Staff, in coordination with the geographic combatant commands and secretaries of the military departments, to serve as the major theater medical distribution point. These units provide the face to the customer for MEDLOG and supply chain management. TLAMMs manage demand-supported medical materiel inventories to support HSS operations and maintain relations with theater customers, national-level suppliers, and theater distribution management activities. TLAMMs are geographically based and assist the geographical combatant commander, SIMLM, and Defense Logistics Agency (DLA) in MEDLOG planning, provide direct medical materiel support to theater medical forces, and ensure operational and tactical units are integrated into the end-to-end medical supply chain. They are resourced through their parent service, operate through the command and control structure of their parent organization, and provide support under the authority of the Chairman of the Joint Chiefs of Staff designation and DoD policy.

Army TLAMMs execute supply operations using DLA’s Defense Working Capital Fund, while the Air Force TLAMMs use the Air Force Working Capital Fund. Core MEDLOG functions required to support medical operations, as defined in Joint Publication 4-02, include medical supply; medical equipment maintenance and repair; assembly and fielding of medical assemblages; and management of vaccines, investigational drugs, special equipment, and any other materiel subject to special interest or control by the joint force surgeon.[1] The joint force surgeon’s office coordinates HSS and force health protection capabilities for the joint force, including MEDLOG. Synchronization of HSS among the joint force and the SIMLM leads to integrated MEDLOG support across the geographic combatant command.

ORGANIZATIONAL ROLES AND MISSIONS

For an enterprise of the magnitude required to provide and maintain medical supplies and equipment for military operations on a global scale to be successful, it must have an orderly approach and a coherent structure from the highest level of DoD acquisition to the smallest unit or the sole provider at the point of use anywhere in the world. Imagine a combination drug store, appliance store, and repair garage serving a small community coupled to an ever-changing research and development and manufacturing consortium capable of staying abreast of the community’s demands for the most effective, safest, and targeted needs. Military MEDLOG performs these functions on a continuous basis with few interruptions or miscues.

Strategic Role

Like any large health maintenance and healthcare organization, the DoD is an enormous consumer of medical supplies, pharmaceuticals, and equipment. At the highest organizational level, the demands of the individual services can be unified into large bulk purchases, resulting in cost advantages, reduced variation in quality and form, and simplified warehousing and distribution. DoD designated the DLA director as the single representative for all of the services—the DoD executive agent for medical materiel (known in DoD parlance as Class VIII)—in 2005.[2] (DLA also serves as the DoD executive agent for several classes of supply besides medical, including food [Class I], uniforms [Class II], and fuel [Class III].) DLA in turn delegated executive responsibility to the commander of DLA-Troop Support (DLA-TS), located in Philadelphia.

DLA-TS provides the overarching contracts for the DoD worldwide. Major multiyear contracts are negotiated with the major suppliers of materiel (“prime vendors”) at great savings for the DoD through economies of scale. DLA-TS procures medical materiel and equipment for the DoD and “sells” them to the military service end-users. DLA-TS establishes contractual arrangements for the acquisition and distribution of surge and sustainment materiel in support of the services’ contingency shortfalls. DLA-TS provides the operational infrastructure enabling high-priority medical materiel to be shipped through a single consolidation hub directly into theater. As a result, medical customers in the Army Central Command (CENTCOM) and European Command (EUCOM) have in-transit visibility, which allows limited transportation resources to be used more efficiently, thereby improving the effectiveness of the DoD MEDLOG supply chain.

Service Agencies

As mentioned above, each of the medical services maintains a service-specific MEDLOG capability to meet the unique demands of their respective end-users. But it should be noted that each of three principal service MEDLOG coordinating centers are collocated at the Defense Medical Logistics Center facility located at Fort Detrick, Maryland—in many regards, the center of MEDLOG for the DoD.

The US Army Medical Materiel Agency (USAMMA), a subordinate command of the Army Medical Research and Materiel Command, acts as the Army surgeon general’s focal point for strategic MEDLOG programs and initiatives. USAMMA’s mission is to develop, acquire, provide, and sustain world-class solutions and capabilities to enable medical readiness globally. Accordingly, the USAMMA’s principal skills and technologies focus on the medical logistician’s role in lifecycle management, sustaining and modernizing the medical force (active, Guard, and reserve), supporting exercises and contingency operations, and promoting MEDLOG information and knowledge.

The Navy Medical Logistics Command (NMLC) is focused on operational/expeditionary MEDLOG support and military treatment facility logistics support, acquisition, and analytics. It also offers commercial law advisors to Navy medicine. NMLC possesses a unique capability by centrally owning the technical, legal, and contracting execution arms for Navy medicine. In addition to the Fort Detrick location, NMLC operates a detachment in Germany; the Naval Expeditionary Support Command in Williamsburg, Virginia; and the Naval Ophthalmic Support and Training Activity in Yorktown, Virginia.

The Air Force Medical Logistics Operations Center (AFMLOC) provides equipment, materiel, services, and information to the Air Force medical mission and MEDLOG activities at the unit level. AFMLOC is the center for Air Force medical supply chain management; it publishes and monitors guidance on supply chain management for Air Force major commands and deployed medical units. Deployed Air Force units use expeditionary MEDLOG and a “reach back” system of support for sustainment of early-deployed platforms until a TLAMM becomes available.

Operational Roles

The link between commercial vendors, military acquisition, and distribution occurs at key MEDLOG oversight and distribution centers. These centers are distributed to optimally serve the geographic combatant commands while exploiting economies of scale whenever possible. In addition, modifications of MEDLOG support of US and coalition partners can be adapted for specific needs to build host nation capacity.3–6 The major centers are listed below.

The 6th Medical Logistics Management Center (6th MLMC) deploys to provide centralized medical materiel lifecycle management to designated forces to sustain worldwide combatant command contingency operations and defense support of civil authorities. The 6th MLMC is a direct reporting unit to US Army Forces Command under the administrative control and training readiness authority of the Army Medical Research and Materiel Command (USAMRMC). (As of October 1, 2018, USAMRMC is a subordinate command of the US Army Materiel Command.[7] The impact of this reorganization on the strategic and operational dimensions of MEDLOG is unclear at the time of this textbook’s publication.)

The US Army Medical Materiel Center–Europe (USAMMC-E), also a subordinate command of the Medical Research and Materiel Command, is the TLAMM for EUCOM, US Africa Command (AFRICOM), and State Department activities. USAMMC-E is located in Pirmasens, Germany, near Landstuhl Regional Medical Center and the major airhead at Ramstein Air Force Base. The core functions of USAMMC-E are lifecycle management and distribution of Class VIII materiel; clinical engineering support; clinical advice and consultation; optical fabrication; and assembly, reconstitution, and disassembly of medical sets, kits, and outfits. USAMMC-E also trains logisticians on supply chain management, including military occupational specialty proficiency training for enlisted MEDLOG specialists, overseas deployment training for Guard and reserve troops, and predeployment training to deploying units.

The US Army Medical Materiel Center–Korea (USAMMC-K), located in Camp Carroll, South Korea, serves at the TLAMM for US Forces Korea and organizations located in the Korean theater. USAMMC-K provides unit-level medical maintenance to outlying health, dental, and veterinary clinics and operational units across the Korean peninsula.

Other centers are listed below.

- The US Army Medical Materiel Center–Southwest Asia (Provisional) serves as the TLAMM for CENTCOM. Its mission is to provide, project, and sustain MEDLOG support across the full spectrum of operations throughout the CENTCOM area of responsibility.

- The Air Force Medical Operations Agency, located in San Antonio, Texas, is the TLAMM for US Southern Command.

- The 18th Medical Group, located on Kadena Air Base, Japan, is the TLAMM for US forces and organizations operating inside the Pacific Command (PACOM) area of responsibility, excluding the Korean theater.

Tactical Roles

Different types of units perform MEDLOG at the tactical level for the services. An Army medical logistics company (MLC) is normally subordinated to a multifunctional medical battalion (MMB). If an MMB is not available, the MLC is aligned to a combat support hospital. The MLC mission is to provide direct support for medical supplies, single and multi-vision optical lens fabrication and repair, and medical equipment maintenance to brigade- and corps-level medical units or to a maximum force of 22,000 soldiers. It can receive and process 11.1 short tons and store up to 51 short tons of Class VIII supplies and equipment, and is capable of deploying forward distribution and contact repair teams.

Unlike the Army MLC, the Marine Corps MLC is organized as a part of a Marine supply battalion, combat logistics regiment, and Marine logistics group. The Marine Corps MLC is not a part of the Marine medical battalion; like the Army MLC, it has materiel management, distribution management, and biomedical maintenance capabilities within the company.

In the Air Force, a medical logistics flight is a part of a medical support squadron in a medical group. Air Force MEDLOG support is not designed to provide area support to other services without augmentation.

An Army brigade medical supply office (BMSO) is located in a medical company with a brigade support battalion. The BMSO mission is to provide direct support for Class VIII supplies and medical equipment maintenance to the brigade, it has limited capacity to provide area support in an operational environment. Another MEDLOG tactical unit is the Army blood support detachment, described below.

Blood Management

The Armed Forces Blood Program Office is responsible for managing the DoD’s blood supply, also known as Class VIII (B). At the strategic level, the geographic combatant command surgeon creates a joint blood program office to jointly manage the blood program and an area joint blood program office (AJBPO) in support of the theater directly. In theater, the Air Force expeditionary blood transshipment center (EBTC) provides initial reception processing from one of the two armed services whole blood processing laboratories based in the continental United States: West for PACOM and East for EUCOM, CENTCOM, and AFRICOM. Upon direction and coordination from the AJBPO, the EBTC ships whole blood or blood products to a blood support detachment in the Army or blood product depot in the Navy.

The Army blood support detachment may be attached or assigned to an MMB. If a unit deploys without the MMB, the detachment will rely on the unit to which it is assigned for command and control and life support. A blood support detachment is generally collocated with an MLC or combat support hospital. The detachment provides flexibility to shift personnel between blood collection and distribution missions, as required. The basis of allocation is one blood support detachment per 100,000 soldiers in theater and one per 150,000 service members for joint operations. The blood support detachment provides refrigerated storage for 4,080 units of packed red blood cells, collecting up to 432 units of whole blood and distributing boxes of packed red blood cells and other blood products to echelon-above-brigade medical treatment facilities through three blood distribution teams (while not collecting or manufacturing blood).

Medical units such as Army combat support hospitals and forward surgical teams, Marine Corps forward surgical groups, and Navy ships at sea or fleet surgical teams submit their requisitions to the supporting blood support detachment or blood product depot for emergency resupply or sustainment. MEDLOG units assist in blood distribution, planning, and delivery depending on the mission and location.

Medical Maintenance

Acquisition and distribution of high-quality, technically sophisticated, accurate, and often delicate medical equipment such as radiograph machines, computed tomography scanners, laboratory equipment, ventilators, and electrocardiogram machines require timely maintenance and repair. Military MEDLOG functions as the lifecycle technology manager for medical devices and systems. MEDLOG responsibilities include financial and budgetary management, service contract management, data processing systems for managing the medical equipment, and coordination of service agreements and in-house operations, acquisitions, property accountability, facilities, and patient safety.

A primary function is to ensure that the medical equipment is safe, effective, and highly reliable for use by surgeons and other clinicians, nurses, and allied health staff members. This responsibility requires participation in the planning process and in the assessment of new technology, assuring regulatory compliance in the medical technology management area, investigation of incidents, and active participation in training and education of technical and medical personnel. The scope of these activities is expanding significantly as medical technology continues to become integrated into systems, and as the lines between medical, communications, and information systems continues to blur. At the operational level, the most readily available biomedical technician is located in the BMSO in the Army. Across the services, biomedical technicians are most often located at the MLC level and theater Role 3 hospitals.

Optical Fabrication

From the MEDLOG perspective, optical fabrication focuses on the production of combat eye protection, protective mask inserts, tinted lens, frames of choice, flight frames, and standard issue (“5A”) frames. At the strategic level, the DoD executive agent for the optical fabrication enterprise is the Navy surgeon general; this authority is designated to the commanding officer of the Naval Ophthalmic Support and Training Activity to act as the program executor’s representative to provide the day-to-day oversight of the optical fabrication enterprise. At the operational level, the optical fabrication enterprise is comprised of 26 Navy and Army medical treatment facilities and TLAMM fabrication laboratories strategically located worldwide to manage fabrication assets and meet requirements for all services. At the tactical level, optical fabrication assets are located within MEDLOG companies, optometry detachments, and some ships at sea.

Patient Movement Items

Patient movement items (PMIs) are specific medical equipment and supplies that are required to support patients during evacuation. PMIs include more expensive equipment requiring accountability at the intra-theater level, as well as less expensive, more numerous items such as litters, blankets, and litter straps, that must be a part of the planning process at the tactical level. The function of the PMI system is to support in-transit patients, exchange in-kind PMIs without degrading medical capabilities, and provide prompt recycling of PMIs. The PMI system provides seamless in-transit visibility for the equipment management process from initial movement to the patient’s final destination. Without accountability and a process of PMI exchange and replenishment, evacuation of patients and associated PMIs would quickly deplete front-line medical units of essential transport items.

The US Transportation Command is the DoD’s single manager for patient movement (with the exception of intra-theater patient movement) and the program manager for the PMI system. The Air Force is responsible for resourcing, maintaining, and recycling PMIs to support contingency operations for patient movement. The Air Force is also responsible for the establishment of theater PMI centers and cells. Medical equipment designated for use as a PMI must be tested and certified for use on the appropriate patient evacuation platform (for example, fixed-wing or rotary-wing aircraft). A joint certification label is required to designate airworthiness certification for all PMI equipment. The label must be affixed to each piece of aeromedical evacuation-certified equipment.

Intra-theater movement of PMIs is the responsibility of the combatant commander. As the theater matures, the combatant commander may establish a TLAMM or SIMLM. If established, the services will coordinate as necessary with the SIMLM for support in the areas of requisitioning, storage, maintenance, and distribution of PMIs. Forward distribution and exchange of PMIs is a SIMLM or service responsibility. Theater medical treatment facilities, MLCs, and surgical teams must coordinate with the theater PMI center for replacement in kind for PMI items.

MEDICAL LOGISTICS LESSONS LEARNED

The medical staff officer and medical provider must work closely with MEDLOG staff at all levels to ensure required MEDLOG support. In every aspect of field medical operations, MEDLOG support requires close coordination with the personnel and systems that provide supplies, equipment, medical equipment repair, and other aspects of MEDLOG for effective mission execution. As described above, MEDLOG operations are a specialized, complex, and interconnected network of manufacturers, vendors, and other suppliers with automated tracking and delivery systems, all intended to meet medical support plan requirements as well as needs that emerge as the mission progresses. This includes sophisticated subsets of the overall process, such as cold chain management, which ensures the maintenance of temperature-controlled shipping and handling for items such as blood, medications, and vaccines. Success depends on clear communications, habitual training, and good working relationships between providers and the MEDLOG support community. The following section lists lessons learned and tips to assist medical staff officers and providers requiring MEDLOG support.

Tips for the Provider

- When coming to a new operational unit, first have the junior leaders describe their section’s capability and review the local standard operating procedures, then find the time to visually inspect the equipment and processes with the leaders you will be working with.

- Look for anything expired, not calibrated, or missing, and ask who performs reconciliations with the supplier and how often. This will give you a sense of your organization’s readiness and operational capability. The budget may not support maintaining sets, kits, and outfits at 100%; however, the unit should maintain a current status of all shortages—even expendable items. Being aware of potential shortages will be key when requesting funds in support of exercises or deployments.

- In general, every operational unit has a group of items designed to perform a specific task that provides basic essential combat casualty care for the military population (eg, medical equipment set in the Army, allowance standard in the Air Force, authorized medical and dental allowance lists in the Navy and Marine Corps). Each of these groups is designed to meet a specific set of treatment or prevention criteria. You must learn these criteria. No group of items will meet 100% of your needs, because the overall intent is to provide basic essential supplies and equipment. Therefore, if your mission requires more than what is available at your location, careful initial outfitting and sustainment planning must be done prior to deployment.

- Know the difference between a request and a requisition. Just because you request something in theater does not necessarily mean the medical logistician has completed all of the necessary steps to translate a request into a requisition, especially when faced with a large number of requests in a high operational tempo environment. Conduct measured follow-up by asking for the document number, and get updated informal status reports.

Checklists and Planning Considerations

The following is a short list of key MEDLOG considerations for the healthcare provider in every mission.

- What is the source of Class VIII materiel? Who provides your tactical and operational level MEDLOG support?

- Do you have a close working or habitual relationship with your MEDLOG support? Have you adequately trained on the information systems and other administrative processes to ensure the outfitting and sustainment of your entire medical plan—from acute care and area medical support; to operative, nonoperative, nursing, and other care; laboratory and imaging; and biomedical equipment?

- What is the funding source for use of military Class VIII materiel?

- Will blood products be required in this mission?

- Will other US government or non-DoD entities need our support?

- What is the flow of patient movement items?

RESOURCES

Policy and practice change over time. Doctrine, that is, published official guidelines and policies, will change in content, but military references will retain their numeric designation. These publications can be monitored over time for key principles and practices.

- Chairman of the Joint Chiefs of Staff. Healthcare Service Support. Washington, DC: JCS; 26 July 2012. Joint Publication 4-02.

- Headquarters, Department of the Army. Medical Logistics. Washington, DC: HQDA; 28 January 2005. Army Regulation 40-61.

- Headquarters, Department of the Army. Army Medical Logistics. Washington, DC: HQDA; December 2009. Field Manual 4.02.1.

- Headquarters, Department of the Army. Operating Guide for MTOE Medical Equipment Maintenance. Washington, DC: HQDA; November 2006. Technical Bulletin Medical 750-2.

- Headquarters, Department of the Air Force. Medical Operations. Washington, DC: USAF; 29 September 2015. Air Force Doctrine Document 4-02.

- Headquarters, Department of the Air Force. Expeditionary Medical Logistics. Washington, DC: USAF; 5 October 2011. Air Force Tactics, Techniques and Procedures 3-42.8.

- Headquarters, Department of the Air Force. Managing Clinical Engineering Programs. Washington, DC: USAF; 26 July 1994. Air Force Instruction 41-201.

- Headquarters, Department of the Air Force. Medical Logistics Support. Washington, DC: USAF; 6 October 2014. Air Force Instruction 41-209.

SUMMARY

MEDLOG is a vital and irreplaceable element of medical support for global military operations. To be effective in contributing to mission success, MEDLOG requires agility, adaptive processes, specificity, and creativity. The primary tasks of the MEDLOG function are to provide medical materiel management; medical equipment maintenance and repair; optical fabrication; blood distribution management; centralized management of patient movement items; health facilities planning and management; and medical contracting. MEDLOG is a dynamic field of both peacetime and operational health services support that is concerned with the entire supply chain, from manufacturer to end-user of supplies, and from initial outfitting of a unit and its deployment of a device or piece of equipment, through obsolescence, disposal, and replacement with a more current or updated version.

The entire system of military MEDLOG involves organizations and units from the level of the DoD, through service-specific agencies, to organic elements of deployed field units. The MEDLOG tasks of acquiring and distributing Class VIII medical supplies and equipment are focused on supplying the combatant command-oriented organizations that manage these materiel needs globally on a regional basis.

The medical staff officer and healthcare provider must have an intimate understanding of MEDLOG, and they must develop key relationships with MEDLOG personnel involved in tactical and operational actions. There is no substitute for careful planning for MEDLOG support, including training whenever possible with those who will provide this support during deployments and contingencies, while in garrison operations or predeployment preparations.

REFERENCES

1.   Chairman of the Joint Chiefs of Staff. Healthcare Service Support. Washington, DC: JCS; 26 July 2012. Joint Publication 4-02.

2.   US Department of Defense. Class VIIIA Medical Materiel Supply Management. Washington, DC: DoD; 29 September 2015. DoD Directive 5101.09E.

3.   Mark B, Sheikh H, Brenner S, Howe S. How militaries can improve medical logistics planning. Pricewaterhouse Coopers Strategy& website. http://www.strategyand.pwc.com/global/home/what-we-think/reports-white-papers/article-display/militaries-improve-medical-logistics-planning. Published December 9, 2013. Accessed July 1, 2018.

4.   Frise MM. Medical logistics in Regional Command North. Army Sustainment. 2012;44(5). http://www.alu.army.mil/alog/issues/SepOct12/medical_logistics_regional_command_north.html. Accessed July 1, 2018.

5.   Tudor W, Schubert S. Medical logistics operations on the Korean peninsula during Key Resolve 2010. Army Sustainment. 2011:43(3). http://www.alu.army.mil/alog/issues/mayjun11/med_log_korean.html. Accessed October 10, 2018.

6.   Rodriquez EH. Crafting a sustainable medical logistics infrastructure for the Iraqi Ministry of Defense. Army Sustainment. 2012:44(1). http://www.alu.army.mil/alog/issues/JanFeb12/crafting_sustainable.html. Accessed July 1, 2018.

7.   US Department of the Army. Assignment of US Army Medical Research and Materiel Command (USAMRMC) from US Army Medical Command to US Army Materiel Command (AMC). Washington, DC: HQDA; 3 October 2018. Executive Order 013-19.

Chapter 18

JOINT HEALTH SERVICES SUPPORT: OPERATIONAL PLANNING

JAMES F. SCHWARTZ,* MEGAN C. MULLER,† AND CONRAD R. WILMOSKI‡

INTRODUCTION

THE PLANNING PROCESS

PLANNING INITIATION

MISSION ANALYSIS

Overview

Define the Operational Environment

Determine Specified, Implied, and Essential Tasks

Identify Available Resources and Shortfalls

COURSE OF ACTION DEVELOPMENT, ANALYSIS, COMPARISON, AND APPROVAL

Course of Action Development

Course of Action Analysis (War-Gaming)

Course of Action Comparison and Approval

RESOURCES

SUMMARY

*Lieutenant Colonel (Retired), Medical Service Corps, US Army; Assistant Professor and Chief of Staff, Department of Military & Emergency Medicine, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Major, Medical Service Corps, US Army; Executive Officer, 264th Medical Battalion, 32nd Medical Brigade, Joint Base San Antonio-Fort Sam Houston, Texas

‡Major, Medical Service Corps, US Army; Sustainment Branch, Concepts and Capabilities Division, Health Readiness Center of Excellence, Capability Development Integration Directorate, Joint Base San Antonio-Fort Sam Houston, Texas

INTRODUCTION

Scenario: You are the unit surgeon of a 1,000-person ground combat unit. Your unit has been deployed to Country X for 8 months. Morale is high with the anticipation of going home in 4 months. The unit has had adequate rest and has not conducted a combat operation in the last 7 days. Your commander has just alerted the staff of an impending mission within the next 3 days to conduct a raid on a suspected enemy weapons cache located in a mid-size town in the mountainous region of the country. The road system near the town is primarily comprised of two major paved roads leading to the town with multiple secondary and tertiary unimproved gravel and dirt roads. The town is described as rectangular, blocked with numerous multilevel buildings, alleys, and courtyard; there are limited open spaces, lots, or fields within the town (Figure 18-1). The town road structure is accompanied by electric power poles and lines; road barricades and obstacles have been observed at various locations throughout the town. Population is less than 3,000. The enemy uses guerilla tactics, improvised explosive devices (IEDs), rocket-propelled grenades, and small arms. The enemy force is estimated to be 30 to 50 fighters. Intelligence suggests the enemy will provide heavy resistance to defend the town as a strategic location for weapons smuggling and cache operations. The mission is expected to be conducted during darkness, with limited moon illumination; temperatures will range between 60°F and 85°F; there will be light winds, a 10% chance of rain, with ceilings expected to be at greater than 10,000 ft, and visibility greater than 7 miles. The executive officer has called together the staff to begin the planning process.

Figure 18-1. Notional town.

Planning is a team sport. A medical staff officer (MSO) is a member of a larger staff that will come together to develop a comprehensive operational plan for joint health services support (HSS). As a special staff officer to the commander, the medical officer is expected to be involved in the planning process as an expert in all things medical. Joint Publication 5-0, Joint Operations Planning, defines the joint operation planning process (JOPP) as “an orderly, analytical process, which consists of a set of logical steps to examine a mission; develop, analyze, and compare alternative Courses of Action (COAs); select the best COA; and produce a plan or order.”[1] Each service component has its own planning process that closely mirrors the JOPP; the Army uses the military decision-making process, while the Marine Corps uses the Marine Corps planning process (see Resources, below).

Although this chapter focuses primarily on tactical-level planning, the principles and processes are very much the same at the tactical, operational, and strategic levels—just from a different perspective. Strategic-level planning focuses on national policy and theater strategy, while the operational level links strategy and tactics by establishing operational objectives needed to achieve military end-states and strategic objectives.[2] Tactical planning involves the employment of tactics, techniques, and procedures and the arrangement of forces to achieve a military objective. At all three levels, MSOs are focused on many of the same key aspects, such as the mission, the operational area, the threats, the number and type of personnel involved in the mission, and the operational timeline. The major difference among these levels when planning HSS is the breadth and width of the plan. At the strategic level, the MSO focuses on determining the types and quantities of medical assets required to deploy in support of a theater strategy; at the tactical level, the MSO focuses on how best to employ medical assets on the ground to support a battle, engagement, or small-unit action in support of a specific military objective. The operational level ties tactical actions to strategic goals.

MSOs must have a solid grasp of their service’s planning process. Although each service may label specific steps of their planning process differently, the processes are essentially the same (Table 18-1 compares the JOPP and services’ planning processes). This chapter will provide a general overview of the key steps in the planning process and the accompanying medical actions.[3] It is important to recognize that each step of the planning process has multiple sub-steps; for example the Army’s military decision-making process mission analysis step consists of 18 sub-steps. This chapter will not necessarily go into detail for each step, but leaves it to the reader to research their specific service’s planning doctrine for additional information and guidance.

This chapter is not intended to replace Department of Defense or service doctrine, but rather to provide a brief overview of the process and applicable resources. It is important to keep in mind that the planning process can be extremely time consuming; the reader should not assume from this brief introduction that the planning can be done quickly (although the services do have a process for planning in time-constrained environments). Lastly, to truly become comfortable with the planning process takes more than reading about it—it requires experience. Take advantage of opportunities to be involved in the process; the more you practice, the better you will become.

TABLE 18-1

SERVICE-SPECIFIC OPERATIONAL PLANNING

AFPP: Air Force planning process; COA: course of action; JOPPA: joint operation planning process for air; MCPP: Marine Corps planning process; MDMP: military decision-making process; NPP: Navy planning process

1. Chairman of the Joint Chiefs of Staff. Joint Operations Planning. Washington, DC: JCS; 11 August 2011. Joint Publication 5-0.

2. Headquarters, Department of the Army. Commander and Staff Organization and Operations. Washington, DC: HQDA; May 2014. Field Manual 6-0.

3. Department of the Navy, Office of the Chief of Naval Operations. Navy Planning. Washington, DC: CNO; December 2013. Navy Warfare Publication 5-01.

4. Headquarters, Department of the Navy, US Marine Corps. Marine Corps Planning Process. Washington, DC: USMC; 24 August 2010. Marine Corps Warfighting Publication 5-1.

5. Headquarters, Department of the Air Force. Operations and Planning. Washington, DC: USAF; 4 November 2016. Doctrinal Annex 3-0.

THE PLANNING PROCESS

HSS planning is tethered to operational planning. Upon receipt of the mission, planning begins with a detailed analysis of mission variables; continues through the development, analysis, and selection of a course of action (COA); and proceeds to the production of orders. The approach to HSS planning and tactical planning is analogous to a method all healthcare providers are familiar with: the scientific method. The six steps of the scientific method—purpose/question, research, hypothesis, experiment, data/analysis, and conclusion—correlate to the MSO’s approach to a mission or problem and plan development. Still another way to think about HSS planning is comparing it to a treatment plan for a patient. Most healthcare providers are familiar with the use of the “SOAP note”—Subjective, Objective, Assessment, Plan (Figure 18-2). The SOAP note provides the healthcare provider a methodical, standardized process for analyzing signs, symptoms, lab results, and imaging; assessing alternative diagnoses; and developing a patient treatment plan, including COAs that must weigh the patient’s preferences, the outcomes of earlier steps, and the inherent risks of each COA. The military planning process provides the MSO that same orderly, analytical process to examine a mission and produce a plan or order.

A word about communicating: throughout the planning process, the MSO must actively communicate—with higher headquarters, with fellow staff officers, with adjacent units and organizations, and lastly, with subordinate units and organizations. Often, parallel planning is being conducted by higher, adjacent, and subordinate units. As more information becomes available and plans begin to form, information is shared. As the MSO progresses through the planning process, information is shared in an effort to provide the unit that will execute the mission the greatest opportunity for success. Bottom line: communicate, communicate, and communicate.

PLANNING INITIATION

Planning begins when a mission is directed (Exhibit 18-1). Upon receipt of the mission, the commander issues planning guidance, and the staff gathers planning resources: orders, current estimates or evaluations, maps, overlays, and graphics. The MSO must be involved early in the planning process. Failure to get involved early in the process could result in an incomplete plan; an unsynchronized plan; a plan that places the unit at an exceeding high risk, a risk that could have been mitigated if known earlier; or a plan that is directed rather than developed in partnership with the staff. The importance of establishing trust and credibility as a member of the commander’s special staff is discussed more fully in Chapter 14, Introduction to Health Service Support; these efforts are essential to the MSO’s early and ongoing involvement in mission planning. Once guidance is received and resources are collected, the staff begins the most important step of the process: mission analysis. It must be emphasized, however, that HSS planning is an iterative process. New information, as well as further guidance from the commander, may cause the staff to revisit any step of the planning process. Additionally, at each step in the process, the staff should attempt to convert planning assumptions into facts.

MISSION ANALYSIS

Overview

The next step in developing the plan, at the strategic through tactical levels, is to conduct a thorough mission analysis. Mission analysis is the most important step of the planning process. For the healthcare provider, this can be equated to doing a total “work-up” on the patient, including a thorough history, physical examination, records review to find previous diagnoses and treatments, laboratory tests, and x-rays. Mission analysis begins with a thorough study of the higher headquarters’ plan or order. Answers to following questions are critical to understanding the mission:

What is the higher commander’s intent?

What is the concept of the operation?

What assets are available?

What is the timeline?

What is the area of operations?

The commander and staff conduct a mission analysis to better understand the situation and problem, and identify what the command must accomplish, when and where it must be done, and most importantly why—the purpose of the operation.[4] Staff must then compile what is known about the situation, that is, what relevant facts have impact on the mission and what valid planning assumptions can be made about the situation. What does the operational environment look like, including the enemy situation? What constraints, if any, are placed on the command? What resources are required to complete the mission, and what resources are available? How much time is allotted for planning? What is the duration of the mission? And finally, what tasks are required for success? Variables such as these—mission, threat, resources, and time, along with a thorough understanding of the problem and situation—provide the foundation for follow-on planning and are critical to the success of the mission. The Army and Marine Corps categorize mission variables for tactical planning as Mission, Enemy, Terrain and weather, Troops and support available, Time available, and Civilian considerations (METT-TC). Every mission must be adjusted for the realities of METT-TC.

Figure 18-2. The medical “SOAP note” format.

EXHIBIT 18-1

PLANNING INITIATION

1. Alert the staff.

2. Gather resources.

3. Issue commander’s guidance.

Define the Operational Environment

This step requires the MSO to conduct a detailed analysis of the operational environment. The analysis of the operational environment includes evaluating the METT-TC variables enemy, terrain and weather, and civilian considerations. Depending on the mission and scope of the operation, it might also include evaluating variables such as political, military, economic, social, information, and infrastructure strengths and weaknesses. Each staff section assesses the operational environment from their perspective and develops what is referred to as “a staff estimate.” The MSO must assess the operational environment for those variables that can impact both the success of the operational mission (ie, what can impact the commander’s ability to accomplish the mission) as well as the medical mission (ie, what can impact the health of the troops and the healthcare team’s ability to accomplish their HSS mission).

Defining the many variables that frame the operational area is commonly referred to as intelligence preparation of the battlefield, or IPB. The medical equivalency is commonly referred to as medical intelligence preparation of the operational environment (MIPOE), or the medical intelligence preparation of the battlefield. It is through MIPOE that threats become known, and the MSO can begin to visualize their impact on the operational and medical mission. Depending on the level of consideration (tactical, operational, or strategic), intelligence used to identify the threat will probably originate from different sources; the strategic planning level will likely include national and geographic intelligence resources, whereas at the tactical level, local intelligence will most likely be heavily relied on to identify the immediate threat to the mission. The unit intelligence officer (S-2 or G-2) is a valuable resource for helping to define the operational environment. All available intelligence resources, including fellow staff officers and even units and personnel who have previously operated in the area, should be consulted to accurately describe the operational environment and identify the threats.

Enemy considerations include analyzing the type of enemy units involved (eg, mechanized, armor, light infantry, special operations, maritime, aviation); types and capabilities of equipment and weapon systems; and the enemy’s strength, location, and probable COAs. These considerations should give the MSO insight into probable mechanisms of injury, and possibly when and how these injuries may occur. Furthermore, evaluating the enemy can provide insight into the threat and risk to medical assets, specifically medical personnel, ground and air ambulances, and treatment facilities.

Terrain considerations include assessing the operational environment for key terrain, avenues of approach, points of observations and fields of fire, obstacles, and areas that afford cover and concealment. A detailed analysis of the terrain should give the MSO insight into where casualties may occur, for example, near key terrain such as beachheads, river crossings, or choke points; on avenues of approach; or at obstacles. It should also highlight potential mobility corridors, evacuation routes, landing zones, and areas to establish treatment, in addition to possible hazards to personnel, equipment, and operations. The terrain analysis can also provide insight into the types of potential injuries (eg, urban terrain may yield more crushing injuries, electrocutions, or upper body gunshot injuries due to snipers, while mountainous terrain may yield more musculoskeletal injuries, cold injuries, and altitude sickness). Weather considerations include visibility, winds, precipitation, cloud cover, temperature, and humidity. These conditions can impact aviation and ground operations (Figure 18-3), the navigability of roads, and again, the types of potential injuries (eg, heat, cold, hypothermia). These three variables, enemy, terrain, and weather, provide extremely valuable pieces of the puzzle. When pieced together, they provide a fairly comprehensive picture of the operational environment and its impact on the operational and medical mission.

Figure 18-3. An MV-22 Osprey with Marine Medium Tiltrotor Squadron 161 prepares to land in southern Helmand province, Afghanistan, December 9, 2012. The Osprey was picking up coalition and Afghan government officials following a visit to a remote area. The officials were checking the status of a 6th Zone Afghan Border Police clearing operation. Photo by Sgt. John Jackson.
Reproduced from: https://www.dvidshub.net/image/797378/afghan-border-police-conduct-independent-clearingoperation-southern-helmand.

Although this example is very simple, in the opening scenario of this chapter the enemy may be described as a well-armed enemy force of 30 to 50 fighters who predominantly use small-arms weapons and IEDs, and who employ guerilla-type techniques. The geographical environment is urban with a population of less than 3,000; it is rectangular blocked with numerous multilevel buildings, alleys, and courtyards; it has limited open spaces, lots, or fields; there are road barricades and obstacles; and power lines are strung throughout the area. Mountain ranges are to the north and east; open flat terrain to the south and west. Major improved roads run west to east and north and south through the town. A river runs from north to south through the town. The staff will analyze an actual operational environment in much greater detail in order to develop a comprehensive picture; this “picture” will be used for follow-on COA development, analysis, and comparison (Figure 18-4).

Figure 18-4. Notional town with the addition of major geographic terrain features.

Vignette 18-1. Air Force Captain Matthew Miller wrote about the challenges of flying in Afghanistan after returning from a four-month deployment there in 2007. His medevac unit, from Georgia’s Moody Air Force Base, had lost three helicopters and seven crew members in the two wars. Enemy fire had been a factor in none of the Afghan crashes. “In Iraq, helicopter pilots face a greater prospect of being shot at by ground fire,” Miller wrote. “In Afghanistan, the greatest threat is the terrain.” He described flying in Afghanistan as “graduate level” piloting more challenging than cruising over the flatlands of Iraq. “It didn’t take long to feel the perils of mountainous flying in Afghanistan,” he added. “Between Iraq and Afghanistan, most helicopter pilots I’ve spoken to consider Afghanistan the more dangerous place to fly.”[5]

Key to mission analysis is not only accurately defining the operational environment, but also interpreting how the environment impacts the mission. For example, the MSO may discover that the road structure near the objective is narrow, with multiple choke points. From this data point, the MSO may deduce that casualty evacuation will be slowed, or some areas may be impassable, and therefore alternative evacuation routes will be needed. Again, it is important that the MSO not only accurately defines the operational environment, but just as importantly, translates that data into useful and meaningful information. An inaccurate or incomplete mission analysis will sabotage the planning process and could very well lead to catastrophic results.

Determine Specified, Implied, and Essential Tasks

A mission statement always consists of five parts: the who (organization to act), what (the task to be accomplished and actions to be taken), when (time to accomplish the task), where (the location to accomplish the task), and why (the purpose the task is to support).[1] Notice that the how is not addressed at this time. During the planning process, how the unit will accomplish the mission is conceptualized and analyzed after the staff has developed a full understanding of the tasks that must be accomplished, that is, the mission, the state of the operational environment, and the resources available. It is important for the MSO to have a thorough understanding of the tasks required for both medical and operational success.

A task is a clearly defined action or activity assigned to an individual or organization.[1] Tasks fall into three categories: specified, implied, and essential. A specified task is a task specifically assigned to a unit by its higher headquarters. An implied task is one that must be performed to accomplish a specified goal or mission, but is not stated in the higher headquarters’ order. Implied tasks are typically derived from a detailed analysis of the operations order or plan, the operational environment, civil considerations, and other factors. An essential task, which can be either specified or implied, must be executed to accomplish the mission. Essential tasks are always included in the unit’s mission statement.

In the introductory scenario example, due to the expected intensity of the fight, the commander of the ground combat unit has instructed his medical platoon leader to deploy a medical team to a forward position in proximity to the objective to provide responsive casualty care during the battalion raid. In this scenario, the specified, implied, and essential tasks are as follows:

- Specified task: “Provide treatment and evacuation in support of the battalion mission.” This task is essential to mission success.

- Implied task: Conduct reconnaissance to determine the best location for the medical team in proximity to the objective. This task, although not specifically stated, is implied by the commander and should be inferred by the medical platoon leader to accomplish the above specified task.

- Essential task: “Provide treatment and evacuation in support of the battalion mission.” This task is both specified and essential to mission success.

It is critical for the MSO to understand the mission tasked to their unit, to thoroughly review the operation order or plan to identify all specified medical tasks, as well as related implied tasks, and finally to be sure of the essential medical tasks. Many HSS tasks are found in the operation order or plan’s paragraph 4 (administration and logistics) and the HSS annex (Exhibit 18-2). It is critical to remember that the mission is the task, together with the purpose, that clearly indicates the action to be taken and the reason.

During the mission analysis, the personnel officer and MSO begin to formulate an approximate casualty estimate. Although determining the casualty rate is the responsibility of the personnel officer; the MSO is responsible for patient estimates, which include only the medical casualties (patients) included in the overall casualty rate.[6] According to Army Techniques Publication 4-02.55, Army Health System Support Planning, “patient” is the generic term applied to a sick, injured, or wounded person who receives medical care or treatment from medically trained personnel. Once a casualty is treated by the first medically trained person (normally the combat medic, corpsman, or independent duty medical technician), he or she is no longer referred to as a casualty and is subsequently referred to as a patient. The casualty estimate is based on information derived from an analysis of the operational environment, specifically, from the enemy’s capabilities, strength, and morale; the terrain and weather; and the unit’s mission. The casualty estimate will be further refined during COA development and analysis, when specific operational plans with more defined troop employments and movements on the battlefield will be developed.6,7

Vignette 18-2. The Naval Health Research Center (NHRC) developed the Joint Medical Planning Tool (JMPT), a computer-based simulation tool that models patient flow from the point of injury through more definitive care. It supports research, medical systems analysis, operational risk assessment, and field medical services planning. NHRC also developed the Medical Planners’ Toolkit (MPTk), which consists of the Patient Condition Occurrence Frequency (PCOF) tool, the Casualty Rate Estimation Tool (CREstT), the Expeditionary Medicine Requirements Estimator (EMRE), and the Estimating Supplies Program (ESP). The PCOF tool provides baseline probability distributions for illnesses and injuries across a range of 33 military operations. The CREstT provides the capability to emulate the operational plan using a 180-day scenario to calculate battle and nonbattle injuries and illnesses that are expected during ground military operations. The EMRE estimates operating room, intensive care unit, ward and bed, evacuation, and blood product requirements for in-theater hospitalization, based on a given patient load. The ESP uses scenario-specific patient streams created by CREstT and known medical supply inventories to estimate the total supply requirement for treating those patients.[8]

EXHIBIT 18-2

FIVE-PARAGRAPH OPERATION ORDER FORMAT

1. Situation

2. Mission

3. Execution

4. Administration and logistics

5. Command and signal

Identify Available Resources and Shortfalls

Once the MSO has defined the operational environment, identified the mission and tasks, and begun to develop a preliminary casualty estimate, they can begin considering the capabilities needed to support the mission. At the tactical level, this variable is sometimes referred to as troops and support available. When analyzing resources, the MSO should consider both medical and nonmedical personnel, equipment, supplies, and organizations available to support the medical mission. The MSO should also note the total number of personnel or troops involved in the mission, sometimes referred to as the population at risk (PAR). The PAR data point is important for determining the number of medical resources required and the positioning of these resources in support of the operation. Along with determining the number of personnel involved in the operation, the MSO analyzes the type of personnel involved in the mission, as well as their operational and medical readiness, training readiness, morale, psychological state, nutrition, rest, and clothing and equipment.

Figure 18-5. Blackhawk helicopter for medical aero evacuation. The Task Force Marauder medical evacuation (medevac) company participated in a mass casualty exercise with the Role 3 hospital, December 23, 2017, in Afghanistan to practice and refine procedures in the event of a real-world emergency. Detachment 1, Charlie Company, 2-211th General Support Aviation Battalion (GSAB), MEDEVAC, Iowa National Guard, with Task Force Marauder partnered with the hospital, base emergency medical services, Polish special forces, US Air Force security forces, and US Army 82nd Airborne service members for the exercise. C Co, 2-211th GSAB (MEDEVAC) provided aerial transportation and en route medical care for simulated casualties before transporting the patients to the hospital for follow-on care. The purpose of the exercise was to test current practices and communication in a controlled environment. Task Force Marauder consists of soldiers from South Carolina National Guard, Illinois National Guard, and Iowa National Guard, as well as an active duty component, and provides aviation capabilities with AH64 Apaches, UH60 Black Hawks, CH47 Chinooks, and medevac assets in Afghanistan under the 3rd Combat Aviation Brigade while deployed. (US Army National Guard photo by Capt. Jessica Donnelly, Task Force Marauder.)
Reproduced from: https://www.dvidshub.net/image/4050146/task-force-marauder-participates-masscasualty-exercise.

The level of planning being conducted (strategic, operational, or tactical) will dictate the level of detail need in resource assessment. For example, tactical MSOs focus on the number of medics, ground ambulances, and tactical aeromedical evacuation in support of a specific operation, whereas strategic-level MSOs look at the number of hospital beds, surgical suites (operating room hours and intensive care beds), strategic aeromedical evacuation, and medical specialties available to support a theater strategy (Figure 18-5). HSS planning considerations (Exhibit 18-3) should be kept in mind during mission analysis. These considerations provide an excellent checklist regardless of the level of planning; however, not every consideration is applicable to every mission. For example, planning for support of a tactical mission such as a small unit raid probably does not require the MSO to plan specifically for pharmacy services, but an MSO at the operational level planning for a campaign must consider and plan for these services.

EXHIBIT 18-3

HEALTH SERVICES SUPPORT PLANNING CONSIDERATIONS

- Threat identification

- Clinical capabilities

- Host nation support

- Medical intelligence

- Dental services

- Health services support (HSS) for returned US prisoners of war and detained persons

- HSS for detainees

- Preventive medicine and health surveillance

- Pharmacy services

- Prevention of stress casualties

- Medical logistics (MEDLOG)

- Patient movement

- Patient movement items

- Veterinary services

- Mass casualty situations

- Additional HSS considerations

Medical Resources

When assessing the medical resources available to support the operational mission, both medical assets that are organic to nonmedical organizations (eg, a medical platoon assigned to an infantry battalion), and specifically missioned medical organizations (eg, medical company, surgical company), must be considered. The full continuum of available resources to consider includes all personnel, medical organizations and their current capabilities, medical logistics, patient movement assets (both medical and nonmedical), patient movement items, and host nation assets. One method for this step is to take an inventory of HSS assets available and their capability across the continuum of care; eventually the MSO will compare this inventory with the capabilities needed to successfully support the mission to determine medical support gaps. The MSO must then communicate any known shortfalls, and the risks associated with these gaps, to higher headquarters.

During mission analysis in the introductory scenario, staff may have determined that due to the enemy’s capability and tactics, there is a high probability the mission will generate trauma surgical casualties (remember, translate what is discovered during mission analysis into useful and meaningful information). For this mission, the healthcare provider would want to ensure that internal assets are available, equipped, trained, and positioned to support surgical casualties. Questions for the MSO to consider are: Do both medical and nonmedical personnel have the required medical supplies for the types of injuries they may encounter at the point of wounding (tourniquets, clotting agents, and compressed gauze)? Are personnel properly trained to treat these injuries? Additionally, the healthcare provider should ensure surgical assets are in a position to support the operation, both from a time/distance factor and the ability to readily accept casualties.

Conducting the analysis of support available provides the MSO with the information needed to support COA development, analysis, and eventual recommendation to the commander. If surgical assets are not in a position to provide timely support, the provider has identified a capability gap that must be mitigated. In this case a surgical asset might be temporarily relocated to provide timely support, or an evacuation asset could be relocated closer to the fight to provide a faster time from wounding to forward resuscitative surgery capability. A good technique is to trace the continuity of care from the unit to the next higher role of care. For example, a provider at a Role 1 aid station should trace a casualty from the point of injury to Role 2 and a forward resuscitative surgical capability. This would entail identifying who will provide care from the point of injury to Role 2; evacuation methods from the point of injury to Role 2; the means to provide medical resupply; and the means to communicate throughout the medical continuity chain.

Vignette 18-3. During mission analysis for each of our operations [1st Battalion/505th Parachute Infantry Regiment in Fallujah, Iraq], the principles that we have detailed [prevention, proportion, preparation, portability, proximity, protection, and projection] … were taken into account. These principles were developed through our close interaction with our line commanders and battalion staff (in regular daily briefings, informal discussions during the planning process, and even over conversations at meal time). We were able to use their knowledge and experience in infantry operations and combine it with our medical knowledge and experience to develop medical coverage for the task force upon which both command and medical providers agreed.[9]

Time

Another critical resource to consider is time available. For most planning, time is not infinite. The MSO must consider, especially at the tactical and operational level, the amount of time required to prepare for mission execution. The MSO must ensure that those who will execute the mission are provided ample time to prepare. The typical rule of thumb at the tactical level is a 1:2 ratio of leaders to staff (ie, the MSO utilizes one-third of the time, leaving two-thirds of the time for subordinates to plan and prepare to execute the mission). Time, obviously, is the one resource that is nonrenewable; it must be used wisely.

Risk Management

Risk management is the process of identifying, assessing, and controlling risks arising from operational factors and making decisions that balance risk cost with mission benefits.[2] The medical planner should address the hazards associated with the operational environment, such as food- and water-borne illnesses, disease vectors, person-to-person transmission of disease, harmful animals and toxic plants, environmental risks, and likely battle and nonbattle injuries. The planner should also identify control measures that can be implemented to mitigate these hazards. Although the risk management process is fairly consistent among the services, each service has doctrinal publications that outline their specific process.6,10–13

The mission analysis is completed with the commander issuing their initial intent, planning guidance, and evaluation criteria that will be used during COA selection. Mission analysis will begin to bring HSS requirements into focus; while COA development and analysis (war-gaming) will bring refinement to the HSS requirements. Joint Publication 4-02, Healthcare Service Support, fully discusses HSS considerations.[3]

COURSE OF ACTION DEVELOPMENT, ANALYSIS, COMPARISON, AND APPROVAL

Course of Action Development

Following mission analysis, staff begin developing COAs that meet the commander’s intent and the stated mission. A COA is a potential how (proposed solution or method) to accomplish the assigned mission.[1] All COAs, along with supporting medical plans, must adhere to specific screening criteria to ensure validity: each COA must be adequate, feasible, acceptable, distinguishable, and complete.[1] A healthcare provider might equate this step to the treatment plan to cure or manage a patient’s illness. COA development entails assessing the friendly versus enemy forces, generating options, arraying the forces, developing a broad concept, and finally, developing COA statements and sketches.

During COA development, the MSO applies the information learned from the mission analysis coupled with the operational COA to develop a synchronized medical support plan. It is important to understand that the mission analysis, to a great extent, determines the medical capability requirements. The operational COA further defines requirements, as well as driving the employment of the medical capability requirements in the form a medical support plan. At this point the MSO should reflect back on the principles of HSS (conformity, control, continuity, proximity, mobility, and flexibility; see Chapter 14), and the medical and HSS planning considerations, whether the plan is strategic or tactical. The MSO should begin overlaying medical support capabilities onto the operational plan and sketching out a medical support plan specific to each operational COA.

Furthermore, casualty estimates can become more refined during COA development. Lastly, the MSO has the responsibility to communicate any known medical support risks to the operational plan. The commander must know the risks a specific operational plan may pose to medical support capabilities, and the staff has the responsibility to mitigate risks as much as possible. The commander makes the final decision on whether to accept the risk or not for each COA as the final operational plan is selected.

Course of Action Analysis (War-Gaming)

Following COA development, the next planning phase is COA analysis. During this phase, the staff methodically examines each COA to determine more precisely its advantages and disadvantages and the likelihood that it will achieve the mission. COA analysis is conducted through “war-gaming,” in which the commander and staff visualize the plan set against the operational environment and enemy forces. War-gaming helps identify advantages and disadvantages, execution and coordination problems, operational gaps, points of decision-making, and contingencies. COA war-gaming can be conducted in various ways; the easiest and most basic is to war-game the plan by critical event or phase through a table-top method using the action, reaction, and counteraction moves of friendly and enemy forces. For the MSO, war-gaming is also an opportunity to analyze the COA for casualty-producing events and required HSS support.

Course of Action Comparison and Approval

Following COA analysis, the commander and staff conduct a COA comparison. Using the evaluation criteria identified during mission analysis and refined during COA development and analysis, they identify strengths and weakness and determine the best COA. Common methods for evaluating COAs include non-weighted, weighted, advantages/disadvantages, and pluses/minuses/neutral comparison matrices. COAs of friendly forces are not compared against each other; rather, they are independently compared against predicted enemy COAs, using agreed-upon evaluation criteria. The COA with the superior rating typically becomes the COA recommended to the commander.

Functional staff officers, including the MSO, conduct a COA comparison based on their respective functional areas and provide their recommendation as part of the overall COA comparison. Just as the operational staff compares COAs to identify the strongest one for a successful mission, the MSO compares them to identify the strongest in terms of medical support. It may be possible to use the same evaluation criteria for the operational and medical COAs, or they might require different criteria. The medical COA might use evaluation criteria such as proximity to the operational forces, casualty estimate, or ground evacuation routes. It is incumbent upon the MSO to honestly evaluate the medical support COAs and provide the commander with the best recommendation.

Once the commander approves an operational COA, the staff begin developing the orders or plan. The MSO’s role in the orders development process is to ensure the medical support plan is written into the operational plan, whether located in the operations order, plan, or supporting annex. Templates for orders, plans, and annexes can be found in joint and service component planning documents (see Resources). An operation planning process reference guide is provided in Figure 18-6, and key points for the MSO are list in Exhibit 18-4.

Figure 18-6. Operation planning process reference guide.

Figure 18-7. Uniformed Services University of the Health Sciences students in planning exercise.
Photograph by Thomas C. Balfour, Uniformed Services University.

EXHIBIT 18-4

KEY POINTS FOR THE MEDICAL STAFF OFFICER

- Joint Publication 5-0 defines the joint operation planning process (JOPP) as “an orderly, analytical process, which consists of a set of logical steps to examine a mission; develop, analyze, and compare alternative COAs; select the best COA; and produce a plan or order.”[1]

- The services have a planning process (MDMP, NPP, MCPP, JOPPA) that closely mirrors the joint operation planning process.

- It is important to have a solid grasp of your service’s planning process.

- The MSO must be involved early in the planning process.

- Mission analysis is the most important step of the planning process. An inaccurate or incomplete mission analysis will sabotage the planning process and very well could lead to catastrophic results.

- Mission analysis assists with identifying support gaps and drives HSS capability requirements.

- HSS planning considerations provide a “checklist” that the MSO can use during mission analysis and COA development.

- It is critical to reflect on the principles of HSS and HSS planning considerations when developing support plans, whether strategic, operational, or tactical.

- The MSP must be synchronized with the operational plan.

- It is important to use all available intelligence resources, including fellow staff officers, units, and personnel that have previously operated in the area, to accurately identify the operational environment and the threat.

- It is important for the MSO to have a thorough understanding of the tasks that are required for success and where and how medical assets can support the mission.

- The MSO must communicate vertically and horizontally throughout the planning process.

- Time is not infinite; remember the one-third to two-thirds rule.

- HSS planning is an iterative process. The MSO must be prepared to revisit any step of the planning process based on new information as well as guidance from the commander.

- The MSO has the responsibility to communicate any known medical support risks to the operational plan.

- Seek opportunities to be involved in the planning process. The more you practice, the better you will become.

____________

COA: course of action; HSS: health services support; JOPPA: joint operation planning process for air; MCPP: Marine Corps planning process; MDMP: military decision-making process; MSO: medical staff officer; MSP: medical support plan: NPP: Navy planning process 1. Chairman of the Joint Chiefs of Staff. Joint Operations Planning. Washington, DC: JCS; 11 August 2011. Joint Publication 5-0.

The processes and steps described above should be very familiar to students (Figure 18-7) and practitioners of the healing professions. As discussed earlier, clinicians will recognize the process of mission analysis, COA development, COA comparison, and selection of an operational plan as parallel to what ideally occurs in caring for patients. In partnership with the patient, the clinician seeks to understand the health challenges facing the patient, to appreciate the patient’s desires in achieving optimal health, to use current scientific insights and best practices to develop potentially competing COAs in managing the illness (diagnosing and treating), and ultimately arriving at the optimal approach, tailored to the individual patient and clinical situation. Because of these parallels, medical professionals are well positioned to adapt their skills in critical thinking to the demands of battlefield operational planning.

RESOURCES

Policy and practice change over time. Doctrine, that is, published official guidelines and policies, will change in content, but military references will retain their numeric designation. Listed below are the services’ primary planning documents and corresponding HSS or medical operations planning documents. They should be monitored over time for key principles and practices. In addition to doctrinal publications, MSOs should review after-action reports, lessons learned, and scholarly articles to hone planning skills.[14]

Joint

- Chairman of the Joint Chiefs of Staff. Joint Operations Planning. Washington, DC: JCS; 11 August 2011. Joint Publication 5-0.

- Chairman of the Joint Chiefs of Staff. Joint Health Services. Washington, DC: JCS; 11 December 2017. Joint Publication 4-02.

Army

- Headquarters, Department of the Army. Commander and Staff Organization and Operations. Washington, DC: HQDA; May 2014. Field Manual 6-0.

- Headquarters, Department of the Army. Army Health System Support Planning. Washington, DC: HQDA; September 2015. Army Techniques Publication (ATP) 4-02.55.

- Headquarters, Department of the Army. Risk Management. Washington, DC: HQDA; April 2014. ATP 5-19.

Navy

- Department of the Navy, Office of the Chief of Naval Operations. Navy Planning. Washington, DC: CNO; December 2013. Navy Warfare Publication (NWP) 5-01.

- Department of the Navy, Office of the Chief of Naval Operations. Naval Expeditionary Health Service Support Afloat and Ashore. Washington, DC: CNO; January 2008. NWP 4-02.

- Department of the Navy, Office of the Chief of Naval Operations. Operational Risk Management. Washington, DC: CNO; 2 July 2010. Operational Navy Instruction 3500.39C.

Marine Corps

- Headquarters, Department of the Navy, US Marine Corps. Marine Corps Planning Process. Washington, DC: USMC; 24 August 2010. Marine Corps Warfighting Publication (MCWP) 5-1.

- Headquarters, Department of the Navy, US Marine Corps. Health Service Support Operations. Washington, DC: USMC; 10 December 2012. MCWP 4-11.1.

- Headquarters, Department of the Navy, US Marine Corps. Risk Management. Washington, DC: USMC; 26 November 2014. Marine Corps Order 3500.27C.

Air Force

- Headquarters, Department of the Air Force. Operations and Planning. Washington, DC: USAF; 4 November 2016. Doctrinal Annex 3-0.

- Headquarters, Department of the Air Force. Medical Operations. Washington, DC: USAF; 29 September 2015. Air Force Doctrine Document 4-02.

- Headquarters, Department of the Air Force. Risk Management (RM) Guidelines and Tools. Washington, DC: USAF; 27 July 2018. Air Force Pamphlet 90-803.

SUMMARY

This chapter provides only an introductory exposure to the planning process and the accompanying HSS planning considerations. The best way to learn and to master the planning process is to actively engage in actual operational planning, but planners should first have a general understanding of their service’s process—the steps, considerations, and functional (eg, medical) points of interaction with the warfighter. It is incumbent upon the MSO to acquire proficiency in planning. The documents listed in the Resources section should be a part of every healthcare provider’s library, or accessible through the Internet; they should routinely be referred to when engaged in planning.

Additionally, healthcare providers must actively seek out opportunities to engage in planning, no matter the scope of the mission or size of the operation. Such opportunities include table-top exercises, mission rehearsal exercises, local field training exercises or events, mass casualty exercises, and deployments to national training centers. Another opportunity is participating in war-game scenarios with fellow staff officers; these interactions can be conducted over a cup of coffee and demonstrate that MSOs are a member of the team. Experienced personnel should be sought out for advice and mentoring. Finally, remember that no one should be “married to the plan”; once mastered, planning can be conducted slowly and deliberately or quickly and adeptly. Experience and proficiency in effective planning enhances adaptability in real-world events and is a key element to an MSO’s success in protecting and caring for those in uniform.

REFERENCES

1.   Chairman of the Joint Chiefs of Staff. Joint Operations Planning. Washington, DC: JCS; 11 August 2011. Joint Publication 5-0.

2.   Chairman of the Joint Chiefs of Staff. Joint Operations, Washington, DC: JCS; 17 January 2017. Joint Publication 3-0:I-12–I-14.

3.   Chairman of the Joint Chiefs of Staff. Healthcare Service Support. Washington, DC: JCS; 26 July 2012. Joint Publication 4-02.

4.   Headquarters, Department of the Army. Commander and Staff Organization and Operations. Washington, DC: HQDA; May 2014. Field Manual 6-0.

5.   Thompson M. Why flying choppers in Afghanistan is so deadly. Time. http://content.time.com/time/nation/article/0,8599,1932386,00.html. Published October 27, 2009. Accessed August 3, 2017.

6.   Headquarters, Department of the Army. Army Health System Support Planning. Washington, DC: HQDA; September 2015. Army Techniques Publication 4-02.55.

7.   Bricknell MC, Jones F, Hatzfeld J. Casualty estimation and medical resource planning. J Royal Army Med Corps. 2011;157(Suppl 4). doi:10.1136/jramc-157-4s-06.

8.   Naval Health Research Center. Modeling and simulation. https://www.med.navy.mil/sites/nhrc/research/orh/Pages/Modeling-and-Sim.aspx. Accessed September 20, 2018.

9.   Earwood JS, Brooks DE. The seven Ps in battalion level combat health support in the military operations in urban terrain environment: the Fallujah experience, summer 2003 to spring 2004. Mil Med. 2006;171(4):273–277. doi:10.7205/milmed.171.4.273.

10.   Department of the Navy, Office of the Chief of Naval Operations. Navy Planning. Washington, DC: CNO; December 2013. Navy Warfare Publication 5-01.

11.   Department of the Navy, Office of the Chief of Naval Operations. Naval Expeditionary Health Service Support Afloat and Ashore. Washington, DC: CNO; January 2008. Navy Warfare Publication 4-02.

12.   Headquarters, Department of the Navy, US Marine Corps. Marine Corps Planning Process. Washington, DC: USMC; 24 August 2010. Marine Corps Warfighting Publication 5-1.

13.   Headquarters, Department of the Navy, US Marine Corps. Health Service Support Operations. Washington, DC: USMC; 10 December 2012. Marine Corps Warfighting Publication 4-11.1.

14.   Clay JD. The medical platoon leader and parallel planning. Army Logistician. Nov-Dec 2004. http://www.alu.army.mil/alog/issues/novdec04/medical.html. Accessed September 20, 2018.

Section III

HUMAN PERFORMANCE OPTIMIZATION

Section Editors:

PATRICIA A. DEUSTER, PHD, MPH, AND JONATHAN M. SCOTT, PHD

Army astronauts COL Andrew “Drew” Morgan and LTC Anne McClain, both from the astronaut class of 2013, prepare to be promoted while underwater following required training in the Neutral Buoyancy Laboratory at the Sonny Carter Training Facility in Houston, Texas, September 27, 2018. (NASA Neutral Buoyancy Laboratory photo)
Reproduced from: https://www.dvidshub.net/image/4808055/army-astronauts.

Chapter 19

THE EVOLUTION OF HUMAN PERFORMANCE OPTIMIZATION AND TOTAL FORCE FITNESS

PATRICIA A. DEUSTER, PHD, MPH*; FRANCIS G. O’CONNOR, MD, MPH†; AND TRAVIS K. LUNASCO, PSYD‡

INTRODUCTION

DEFINITIONS

BACKGROUND

Historical Context

Total Force Fitness Model

Role of Total Force Fitness in Force Health Protection and Readiness

Proposed Human Performance Optimization Model

Human Performance Optimization/Total Force Fitness: A Paradigm Shift

HUMAN PERFORMANCE OPTIMIZATION AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer

Guidance to the Commanding Officer

SUMMARY

*Professor and Director, Consortium for Health and Military Performance (CHAMP), Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Colonel (Retired), Medical Corps, US Army; Professor and former Department Chairman, Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

‡Senior Operational Psychologist, Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

Service members and their families are the most valuable assets to accomplish the mission of defending the country. This complex mission has resulted in unparalleled operational demands with multiple deployments and strains on the US armed forces. While extensive resources have always been expended to ensure equipment and materials are both state-of-the-art and in good repair, resources for maintaining and improving human performance, health, and resilience have been more limited. By 2006, it had become clear that operational demands were degrading the capabilities, health, and resiliency of military communities.

To address this problem, the terms “human performance optimization” (HPO) and “total force fitness” (TFF) emerged as conceptual frameworks within the Department of Defense (DoD) to preserve the capabilities, health, and well-being of service members and their families. The performance, health, and well-being of the whole person, the family, and the community were viewed as fundamental to accomplishing the mission. Since that time, HPO and TFF have become recognized as cornerstones of an effective and efficient military, and the terms have become ingrained throughout the DoD. This chapter will define terms, provide a brief historical background, describe the holistic framework of TFF and the underpinnings of HPO, relate the terms to the role of a military medical officer (MMO), and then provide resources for the MMO relating to both HPO and TFF.

DEFINITIONS

- Human performance optimization. The process of applying knowledge, skills, and emerging technologies to improve and preserve the capabilities of military personnel to execute essential tasks. A number of related terms have been used to describe various aspect of HPO, for example, performance enhancement, performance sustainment, performance restoration, and human performance modification. The terms “enhancement,” “sustainment,” and “restoration” are aligned with phases of military missions.

- Performance enhancement. Optimizing and enhancing every system to the fullest degree possible before deployment.

- Performance sustainment. Sustaining performance at predeployment levels during deployment.

- Performance restoration. Restoring or returning performance to predeployment levels postdeployment.

- Human performance modification. “Encompasses actions ranging from the use of “natural” materials such as caffeine or khat as stimulants, to the application of nanotechnology as a drug delivery mechanism or an invasive brain implant.[1] Although the literature on human performance modification typically addresses methods that enhance performance, another possible focus is methods that degrade performance or negatively affect a military force’s ability to fight.”1(p1) HPO is the preferred term because it is all encompassing—optimal is the end result—either through enhancement, modification, sustainment, or restoration. Human performance should be optimized whenever possible.

- Total force fitness. A holistic conceptual framework for understanding, assessing, and maintaining the fitness of the armed forces. The TFF framework starts with eight domains (medical/dental, nutritional, social, behavioral, environmental, psychological, spiritual, and physical) that can be tailored to the unique cultural framework of each military community. The interrelated functionality of TFF is informed by five overarching tenets as shown in Exhibit 19-1.

BACKGROUND

Historical Context

The concept of HPO, and its critical role for military success on the battlefield, has been appreciated for a long time. During the Civil War, Dr Jonathan Letterman, considered by many to be the “father of battlefield medicine,” recognized the importance of HPO, stating that “the leading idea [for the medical corps], which should be constantly kept in view, is to strengthen the hands of the Commanding General by keeping his Army in the most vigorous health, thus rendering it, in the highest degree, efficient for enduring fatigue and privation, and for fighting.”[2] In 1933 US Army General (then Colonel) George S. Patton wrote, “Wars may be fought with weapons, but they are won by men. It is the spirit of the men who follow and of the man who leads that gains the victory.”[3] After World War II, General Dwight D. Eisenhower said, “Guns and tanks and planes are nothing unless there is a solid spirit, a solid heart, and great productiveness behind it.”[4] In 1987 US Army Special Forces Colonel John Collins emphasized that “hardware” is only a tool and that it is the person who determines success or failure. He is credited with developing the Special Operations Forces five truths, of which is “Humans are more important than hardware and their quality is more important than quantities.”[5]

EXHIBIT 19-1

THE TENETS OF TOTAL FORCE FITNESS

- Total fitness extends beyond the service member. Total fitness should enhance performance and preserve capabilities, improve health, and strengthen resilience in families, communities, and organizations.

- A service member’s family’s health plays a key role in sustained success and must be incorporated into any definition of total fitness.

- Total fitness metrics must measure positive and negative outcomes, and must show movement toward total fitness.

- Total fitness is linked to the fitness of the society from which the service members are drawn and to which they will return.

- Leadership is essential in achieving total fitness.

It was not until 2006 that the term HPO actually emerged with energy within the DoD. An Office of Net Assessment report came out in 2005 challenging the DoD to take a look at how the most important resource—the service members—were being looked after.[6] In June 2006, the Consortium for Health and Military Performance (CHAMP) at the Uniformed Services University of the Health Sciences hosted a workshop called Human Performance Optimization: An Evolving Charge to the Department of Defense, with the findings published in Military Medicine.[7] This workshop changed the course of HPO in the DoD, and resulted in the development of the Human Performance Resource Center (HPRC), a DoD website for all information relating to the improvement and preservation of human performance (hprc-online.org).

Total Force Fitness Model

In December 2009, CHAMP hosted a workshop on TFF that resulted in an instruction from the chairman of the Joint Chiefs of Staff, which can be found on the HPRC website.[8] This guidance extended the concept of “physical fitness” to include body, mind, social, and spiritual domains; it created a more comprehensive and holistic framework to support and integrate joint and service-specific efforts that seek to promote health, enhance the resilience of service personnel, and improve effectiveness and efficiency of the force.9–22 TFF integrates all aspects of health, well-being, and performance—and recognizes the important contributions of families, friends, communities, and units. In its application, the TFF framework and its tenets are designed to keep service members and their families performing at an optimal level: healthy, resilient, and flourishing in the environment of sustained deployment and combat operations. Thus, TFF and HPO are synergistic and complementary. They go together and must be considered as a unit. Figure 19-1 presents the eight original domains of TFF.

Any evaluation of TFF must be context specific because teams, units, families, and communities may be very effective at particular tasks, and less effective at others. For example, a combat unit may be very successful with mission efforts, but encounter problems when it returns from a deployment or during reintegration. Although the TFF framework identifies eight mind–body domains, social fitness has been highlighted as particularly critical for unit fitness because it is a robust resilience factor.[23] A 2013 Rand report[24] identified social support as a key factor that can affect an individual’s resilience. Social fitness also is very important for unit, family, peer, and community fitness. These are key signatures of military culture and operational success because people are primary drivers for effectiveness. Overall TFF is conceptualized in terms of healthy relationships among people and teams that contribute to optimal unit, family, and community well-being, resilience, and performance.

Figure 19-1. The total force fitness (TFF) framework identifying the critical influence of the family, community, organization, and the eight overarching domains of TFF.

Role of Total Force Fitness in Force Health Protection and Readiness

All eight TFF domains are important and require attention from leaders at multiple levels to ensure TFF of all units, an essential factor in force health protection, readiness, and preservation. The TFF conceptual framework places the service member at the center of the eight interrelated TFF domains and identifies the critical influence of the family, organization, and community (see Figure 19-1). This framework assumes that family, organizational, and community factors have a significant impact on individual fitness. The model also assumes that individual fitness has an important reciprocal relationship with fitness of larger social structures (eg, family, unit, community, and enterprise).[25] This is not surprising or unexpected, given that military culture emphasizes teamwork and group cohesion rather than individuals.[26]

Proposed Human Performance Optimization Model

HPO builds on the framework of TFF with an orientation on performance. Figure 19-2 provides an understanding of HPO in comparison with traditionally offered healthcare delivery. The spectrum begins at left and movement to the right indicates degradation of capabilities, health, and resiliency. Traditional healthcare is considered “right-sided”: the driving force for engagement is centered on illness/pathology. Sustained HPO requires a holistic “left of the bang” engagement and orientation. Leveraging HPO sustainment and improvements should be directed by the primary groups noted in the lower section of the figure. The MMO’s role and function in this process (“left” sided) will be different in comparison to that of working in a clinical/hospital setting (“right”-sided care). A deeper understanding of the need for a paradigm shift and community involvement is offered later in this chapter.

HPO requires military cultural competency and a greater appreciation for the complexities of diverse service member communities and their missions. The demands/resources model (Figure 19-3) is an ideal tool to compliment the HPO-oriented framework and TFF model because it was developed to evaluate work performance.27–29 The model proposed in Figure 19-3 allows for performance metrics in multiple venues: family, relationships, and work. This model also includes multiple resources (individual, family, and external environment) and well-established demands (eg, work, family, financial, social). Overall, the concept is that optimal performance will be sustained when resources (individual, family, and external) match or exceed demands. HPO is resource focused.

Figure 19-4 presents an overview of the multiple and competing individual, family, and other resources by various categories that contribute to performance in diverse venues. Although not complete, these various factors and environmental issues demonstrate the holistic approach: from cognitive to genetic and physiologic, from behavioral and individual skills and practices to social and physical environmental factors. Some of the contributors are inherent, whereas others may be state- or situation-dependent. As new evidence and information becomes available, it can be inserted into the model. In addition to the resources indicated in Figure 19-4, other social support networks may be available to operational communities and commands. The intricacies, interactions, and intersections of how and what impacts performance are numerous.

Figure 19-2. The human performance optimization (HPO) demands/resources model. From top to bottom: (1) An orientation that focuses on the needs of each operator community and their mission essential tasks. (2) The rainbow spectrum begins at left (performance = purple), and movement to the right indicates degradation of capabilities, health, and resiliency. Traditional healthcare is considered “right of bang,” with its driving force for engagement centered on illness/pathology. Sustained HPO requires a holistic “left of bang” engagement and orientation. (3) Leveraging HPO sustainment and improvements should be directed by the primary agents with corresponding service types. (4) An orientation that moves beyond medical readiness toward mission readiness. (5) The holistic and integrative total force fitness framework is key to targeting resources and efforts and the delivery of precision care.
RTD: return to duty

Figure 19-3. The human performance optimization demands/resources model.

Human Performance Optimization/Total Force Fitness: A Paradigm Shift

The traditional model of care delivery is fragmented and illness centered. Think back to your medical training. How many courses offered allowed you to work with a healthy individual? What about a high-performing athlete where your job was to keep them performing at the top of their game and prevent performance degradation? The complexities and evolving operational needs of the battlefront require an approach that aids combatant commanders in sustaining the health, performance, and resiliency of their unit so performance degradation is minimized. In addition, each military community requires a tailored framework given their diverse mission, skill sets, and operational risks. TFF and the capability-focused orientation provided by HPO offer this conceptual framework. The instruments described above are powerful tools to aid in the MMO’s ability to deliver soldier-centric care.

Figure 19-4. An overview of the multiple and competing individual, family, and other resources by various categories.

HUMAN PERFORMANCE OPTIMIZATION AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer

The MMO is key to the successful employment of HPO and TFF and maximizing the health, well-being, and performance of the military community in which they serve. HPO and TFF require the MMO to assume a number of roles (eg, consultant, student, expert, coach, liaison) with a relationship built on trust and credibility. If an MMO can relate to the operational community on key topics and learn to see the mission through the service member’s eyes, they will be welcomed “into the fold.” Keeping service members fit and performing at their best is a high priority; thus, the following characteristics of the MMO are key:

- being able to modulate between expert and student; military community cultural competency;

- establishing presence and role modeling;

- being well versed in the language of HPO;

- having a “holistic” orientation;

- being skilled in adapting the TFF domains to fit the unique needs of each military community; and

- being up to date on the latest available technologies for enhancing performance.

Perhaps one of the most important issues is being a responsible leader. This demands both setting an example and mentoring in a team-like way. To engage operational service members, MMOs must be a learner first to understand their unique unit culture. MMOs must be able to listen and hear what the unit members see as their most critical needs. MMOs must also be a role model, which includes maintaining physical fitness, nutritional fitness, medical/dental fitness, and fitness for the other domains, as well as being versed in all other aspects of TFF and HPO. MMOs should not tell service members what to do; rather, they must live the role and know where to get the information they seek.

EXHIBIT 19-2

ONLINE RESOURCES FOR HUMAN PERFORMANCE OPTIMIZATION AND TOTAL FORCE FITNESS

The websites listed below are Department of Defense (DoD) human performance optimization resources for service members and providers. The first two are hosted by the Consortium for Health and Military Performance (CHAMP), the DoD Center of Excellence for Human Performance. The third site, Military OneSource, complements CHAMP resources.

- Human Performance Resource Center (http://hprc-online.org/)

- Operation Supplement Safety (http:/opss.org)

- Military OneSource (http://www.militaryonesource.mil/)

An MMO’s behaviors, attitudes, and overt actions must demonstrate the value of health, well-being and HPO, but MMOs must also be able to speak and hear the language of the operational communities. One important aspect of HPO for the MMO is being able to listen. HPO is the end result of being proactive in achieving, embracing, supporting, and living the tenets and goals of TFF. The behavior and actions of an MMO make a statement, and that statement must be positive: it must resonate as: “I believe in health and HPO. I embrace HPO and support the TFF and HPO frameworks and expectations.”

However, each unit or operational community may have very concrete strengths and vulnerabilities, and the MMO must help them identify gaps through listening and observing, not just telling. An MMO must assist the DoD in achieving the goal of being an enterprise that welcomes, supports, and promotes the framework that all service members and family members, retirees, and civilians can live and embrace the concepts and behaviors of TFF—a holistic framework that supports the culture of each unit, group, and community.

Guidance to Commanding Officer

The MMO, when in direct support of the line, functions as a special staff officer to the commander. In this function, the MMO serves as a subject matter expert in many arenas, including physical fitness, as Letterman put forth in his original mandate for the Medical Corps. Although the commander has the ultimate responsibility for what their unit does and fails to do, the MMO has the requirement and obligation to assist the commander with the execution of current relevant guidance. TFF is currently written into joint doctrine as a CJCSI 3405.01, published on September 1, 2011.[8] This doctrine is authoritative and should be the principal resource utilized to guide the commander in assuring their service members are totally fit and resilient for combat and all other operations. Other resources can be found online (Exhibit 19-2).

SUMMARY

Leaders recognized that sustained combat operations for over a decade generated the need for a new paradigm for understanding, developing, and assessing fitness. HPO and TFF emerged from thoughtful discussions and innovative actions; they reflect the vision and reality that people represent the military’s most valuable resource. Therefore, a holistic approach to fitness and performance must be and is the foundation for such a vision. TFF is now published in joint military doctrine and represents a desired end state for current service members and their families. HPO is the process whereby TFF can be achieved as knowledge, skills, and emerging technologies are leveraged to improve and preserve the capabilities of military personnel to execute essential tasks. In the execution of any HPO program to achieve TFF, the demands/resources model specifically provides a framework with the principal concept that performance will be optimized when resources (individual, family, and external) match or exceed demands. The MMO is uniquely, and importantly, postured in the military chain of command to directly influence the shaping of a fit and ready force. The ultimate goal of TFF and HPO is not only to enhance individual and unit performance and wellness, but also to ensure a ready force to win the nation’s present and future battles. The remaining chapters in this section should build upon the concepts described here.

REFERENCES

1.   Human Performance Modification: Review of Worldwide Research with a View to the Future. Washington, DC: The National Academies Press; 2012.

2.   Clements BA. Medical Recollections of the Army of the Potomac by Jonathan Letterman, MD, and Memoir of Jonathan Letterman, MD. Knoxville, TN: Bohemian Brigade Publishers; 1994: 100.

3.   Patton GS. Mechanized forces. Cavalry J. 1933;42:5-8.

4.   Eisenhower DD. Speech to the Economic Club of New York; New York, NY; November 20, 1946. Ike Eisenhower Foundation. Quotes, war and defense. https://www.dwightdeisenhower.com/195/War-Defense. Accessed February 5, 2018.

5.   Collins JM. US Special Operations: personal opinions. Small Wars J. 2008(Dec 13).

6.   Russell A, Bulkley B, Grafton C. Human Performance Optimization and Military Missions: Final Report, GS-10F-0297K. Washington, DC: US Department of Defense, Office of Net Assessment; May 2005.

7.   Deuster PA, O’Connor FG, Henry KA, et al. Human performance optimization: an evolving charge to the Department of Defense. Mil Med. 2007;172(11):1133–1137.

8.   Chairman of the Joint Chiefs of Staff. Chairman’s Total Force Fitness Framework. Washington, DC: JCS; 2011. CJCS Instruction 3405.01. https://www.hprc-online.org/resources/chairman-of-the-joint-chiefs-of-staff-instruction-cjcsi. Accessed February 5, 2018.

9.   Land BC. Current Department of Defense guidance for total force fitness. Mil Med. 2010;175(8S):3–5.

10.   Roy TC, Springer BA, McNulty Vl, Butler NL. Physical fitness. Mil Med. 2010;175(8S):14–20.

11.   Coulter I, Lester P, Yarvis J. Social fitness. Mil Med. 2010;175(8S):88–96.

12.   O’Connor FG, Deuster PA, DeGroot DW, White DW. Medical and environmental fitness. Mil Med. 2010;175(8S):57–64.

13.   Bates MJ, Bowles S, Hammermeister J, et al. Psychological fitness. Mil Med. 2010;175(8S):21–38.

14.   Hufford DJ, Fritts MJ, Rhodes JE. Spiritual fitness. Mil Med. 2010;175(8S):73–87.

15.   Montain SJ, Carvey CE, Stephens MB. Nutritional fitness. Mil Med. 2010;175(8S):65–72.

16.   Westphal RJ, Woodward KR. Family fitness. Mil Med. 2010;175(8S):97–102.

17.   Jonas WB, O’Connor FG, Deuster PA, Peck J, Shake C, Frost SS. Why total force fitness? Mil Med. 2010;175(8S):6–13.

18.   Bray RM, Spira JL, Olmsted KR, Hout JJ. Behavioral and occupational fitness. Mil Med. 2010;175(8S):39–56.

19.   Firth KM, Smith K. A survey of multidimensional health and fitness indexes. Mil Med. 2010;175(8S):110–117.

20.   Mullen M. On total force fitness in war and peace. Mil Med. 2010;175(8S):1–2.

21.   Rounds M. The principal challenge of realizing total force fitness: changing our readiness culture. Mil Med. 2010;175(8S):124–126.

22.   Walter JA, Coulter I, Hilton L, Adler AB, Bliese PD, Nicholas RA. Program Evaluation of total force fitness programs in the military. Mil Med. 2010;175(8S):103–109.

23.   Coulter I, Lester P, Yarvis J. Social fitness. Mil Med. 2010;175:88–96.

24.   McGene J. Social Fitness and Resilience: A Review of Relevant Constructs, Measures, and Links to Well-Being. RAND Project Air Force Series on Resiliency. Santa Monica, CA: RAND Corporation; 2013. https://www.rand.org/content/dam/rand/pubs/research_reports/RR100/RR108/RAND_RR108.sum.pdf. Accessed February 5, 2018.

25.   Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Appl Psychol. 2001;86(3):499–512.

26.   Bates MJ, Fallesen JJ, Huey WS, et al. Total force fitness in units, part 1: military demand-resource model. Mil Med. 2013;178(11):1164–1182.

27.   Bakker AB, Van Emmerik H, Van Riet P. How job demands, resources, and burnout predict objective performance: a constructive replication. Anxiety Stress Coping. 2008;21(3):309–324.

28.   Bakker AB, Demerouti E, Euwema MC. Job resources buffer the impact of job demands on burnout. J Occup Health Psychol. 2005;10(2):170–180.

29.   Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Appl Psychol. 2001;86(3):499–512.

Chapter 20

PHYSICAL FITNESS: THE NECESSARY FOUNDATION

BRIAN R. KUPCHAK, PHD*; DANA R. NGUYEN, MD†; AND MARK B. STEPHENS, MD‡

INTRODUCTION

DEFINITIONS

HISTORY OF MILITARY PHYSICAL FITNESS

BENEFITS OF PHYSICAL FITNESS

KEY CONCEPTS

Components of Physical Fitness

Plyometrics

Physical Readiness/Fitness Tests

Overtraining

SPECIAL POPULATIONS

Pregnancy and Postpartum Physical Fitness

Aging

Wounded, Injured, and Ill Service Members

PHYSICAL FITNESS AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer

Guidance to the Commanding Officer

RESOURCES

SUMMARY

*Lieutenant, Medical Service Corps, US Navy; Assistant Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Lieutenant Colonel, Medical Corps, US Army; Assistant Professor, Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

‡Captain (Retired), US Navy; Professor of Family and Community Medicine, Penn State University, State College, Pennsylvania

“Physical fitness is the basis for all other forms of excellence.”[1]

—President John F. Kennedy

INTRODUCTION

Operating in today’s services requires exceptional stamina and physical readiness. Service members must be prepared to travel to a variety of environments on short notice and immediately conduct high-tempo and high-intensity operations. Success in this arena requires constant vigilance among individual units and commands to maintain the highest levels of physical fitness among service members to successfully execute missions. Current military directives emphasize total force fitness (TFF), a holistic approach encompassing all domains of the individual, as defined in the 2011 guidance issued by the chairman of the Joint Chiefs of Staff (CJCSI 3405.01).[2] The TFF instruction directs the services to approach readiness and force preservation through eight domains (discussed in Chapter 19, The Evolution of Human Performance Optimization and Total Force Fitness)—physical, nutritional, medical, environmental, spiritual, psychological, social, and behavioral—all of which are critical for ensuring service members have the requisite knowledge, skills, and abilities to perform optimally with maximal resilience.[3] This chapter will examine the physical domain by presenting definitions and a historical background, followed by the physiologic principles and benefits of exercise, the foundational elements of physical fitness, and the vulnerabilities faced in efforts to maintain a fit fighting force.

DEFINITIONS

- Balance. Ability to control or stabilize the body when standing still or moving.

- Cardiorespiratory fitness. Efficiency with which the body delivers oxygen and nutrients needed for muscular activity and transports waste products from the cells.
Activities to build aerobic capacity: Jogging/running, cycling, climbing, rowing, using the lateral trainer, using the upper-body ergometer, vigorous dance, kickboxing, aerobics, jumping rope, swimming, cross country skiing, inline skating.

- Coordination. Ability to move two or more body parts under control, smoothly and efficiently, to achieve a designated purpose.

- Exercise prescription. Specific plans of fitness-related activities designed for a specified purpose.

- Flexibility. Ability to move the joints (eg, elbow, knee) or any group of joints through an entire normal range of motion.
Activities to build flexibility and mobility: stretching machines, freestyle stretches (or with straps), yoga and Pilates.

- Functional fitness. Exercises that train muscles to work together and prepare them for daily tasks by simulating common movements done at home, at work, or during combat.

- Intensity. Level of effort during exercise, from low to high. Increasing intensity allows one to improve a particular component of training.

- Maximal aerobic power. The highest level of oxygen that a person can utilize, called the Vo2max, and reported as mL/kg/min. With improved levels of aerobic fitness, individuals can improve both their sustainable maximum heart rate and their Vo2max.

- Overload. Setting the intensity of the exercise higher than normal to produce physiological adaptations.

- Periodization. Systematic planning of training to maximize/optimize performance of a mission or competition at a known point in the future.

- Progression. Gradually and consistently escalating a training stimulus to build aerobic capacity, strength, endurance, and mobility.

- Recovery. Providing adequate rest period between exercise sessions to achieve optimal performance, particularly when working on strength or endurance. Usually accomplished by alternating fitness components or muscle groups from one day to the next.

- Specificity. Tailoring the training stimulus to achieve a desired outcome, such as training and practice for physical tasks that service members will be required to perform as part of their duties.

- Strength training. Incorporates muscular strength and muscular endurance.

- Muscular strength. Amount of force a muscle or muscle group can exert in a single effort.

- Muscular endurance. Ability of a muscle or muscle group to perform repeated movements with a submaximal force for extended periods of time.
Activities to build strength and endurance: working out with free weights, plate-loaded machines, kettle bells, medicine balls, resistance bands/tubing, or suspension straps; doing calisthenics with body weight resistance.

- Volume. Combination of the number of sets and repetitions performed in a workout.

HISTORY OF MILITARY PHYSICAL FITNESS

“Nations have passed away and left no trace, and history gives the naked cause of it—one single simple reason in all cases; they fell because their people were not fit.”[4]

—Rudyard Kipling

Throughout the course of human history, leaders have recognized that physical fitness has paralleled the rise and fall of empires. From individuals to societies, physical fitness is a key predictor of the success of nations. The Greeks (2,500–200 BCE) embraced physical perfection as an outward expression of health and fitness. The Romans (200 BCE–476 CE) required men to participate in running, marching, jumping, and throwing. In contrast, during the Middle Ages a relative return to the agrarian lifestyle ensued. Physical work in the field was associated with general gains in fitness on a societal level, whereas traditional knightly acts included shooting (bows), swimming, climbing, horsemanship, fighting (mounted and dismounted), and socializing. From then on, a cyclical history of physical fitness and military success began—an onset of war inspired increased physical fitness efforts, which lapsed after the war ended.

The role of physical fitness in the US military follows an annual course cycle, with tests in the spring and fall. Early colonial militias were typically selected based on their enthusiasm, strength, and reliability. In general, colonial Americans were a largely agrarian society with an active physical lifestyle and commensurate levels of fitness. However, by the early 20th century, the urbanization of American society had shifted work from agriculture to factories and offices, resulting in a population that had become significantly less active. In 1912, Woodrow Wilson recognized the value of physical fitness in military performance, and during his tenure as president, the US Army Manual of Physical Training was developed.[5] The principles of this first edition were to (a) develop general health and vigor; (b) promote muscular strength and endurance; (c) enhance self-reliance; and (d) improve intellect, activity, and precision.

In 1917, when the United States enacted the Selective Service Act, roughly one-third of all recruits were found to be unfit to fight. Therefore, governmental legislation was enacted to improve physical education within public schools in an effort to improve “readiness” for the US military. During World War I, the United States undertook physical assessment of recruits using the standards of modern medicine for the first time. However, one-third of the men continued to be rejected for service due to being physically unfit throughout the war.[6]

As the United States prepared to enter World War II, fitness standards intended to enhance screening for military service were introduced. The standards were used to identify individuals who needed remedial fitness work. About half of the first 2 million service members conscripted through the Selective Service were deemed physically unfit. Over the course of the war, 30% percent of draftees were rejected, most for medical issues related to poor physical fitness. Performance requirements and standards were established both for the individual services and for many military operational specialties, including aviation programs (US Army Field Manual [FM] 21-20, Basic Field Manual, Physical Training [1941]; US Marine Combat Conditioning [1942]; Physical Fitness Manual for the US Navy [1943]).7–9

Attention to civilian fitness levels also increased over the course of the war. The National Committee on Physical Fitness was created in 1943, and the US “Victory Corps,” featuring a series of exercises specifically designed to promote strength, stamina, endurance, and physical skills, was incorporated into high-school curricula. The War Department pamphlet Physical Conditioning (PAM 21-9), published in 1944, defined total military fitness as a composite of:

1. Technical fitness, evidenced by tactical training and a knowledge and skill in the use of arms and equipment.

2. Mental and emotional fitness (more commonly known as morale), characterized by:

a. Habits of thinking and feeling which will permit alertness with an economy of energy and rapid relaxation when opportunity is afforded to do so;

b. A sense of mission, or identification with a cause of great significance shared with others; and

c. A will to fight.

3. Physical fitness, evidenced by a body which can retain normal responses to stimuli in the face of fatigue and exhaustion, and continue to function effectively under the physical stresses placed upon it by the routine and emergency tasks of war.[10]

Colonel Leonard G. Rowntree, medical director of the Selective Service during World War II, defined combat-related fitness as the ability to combine power and efficiency with minimal recovery periods in activities that required strength, stamina, agility, endurance, emotional stability, leadership, and a refusal to lose.[11]

In 1946, War Department PAM 21-9[10] was revised and became Army FM 21-20.[12] It defined the principles of exercise training in terms of progression and overload, and also identified functional exercises to develop strength, muscular endurance, anaerobic and aerobic capacity, agility, and coordination (Exhibit 20-1), as well as attainment of “proficiency in certain military physical skills which are essential to personal safety and effective combat performance.”[13] The Army generally enacted these official fitness initiatives. Although the other services often followed suit, they tended to make duty-specific modifications and only rarely formulated written policies for the entire service.

The entry of the United States into the wars in Korea and Vietnam shifted the focus of military fitness requirements yet again. In 1958 the Army Physical Fitness Service opened at Fort Benning, Georgia, to give physical fitness the same level of importance as technical skill development. In 1962, the principles of balance, variety, and regularity were introduced into military physical training. A 1970 physical fitness symposium at Fort Benning added aerobic activity as a central component and recommended that trained fitness personnel implement physical training programs.[14] FM 21-20 was revised again in 1973 to define fitness as a “healthy body with the capacity for skillful, sustained performance, ability to recover quickly after exertion, a desire to complete the mission, and confidence to face any eventuality.”[15]

FM 21-20 was again revised again in the 1980s to introduce the three-activity physical fitness test: a 2-mile run (aerobic endurance), plus sit-ups and push-ups (muscular endurance).[16] In 1981, Department of Defense (DoD) Directive 1308.1 was published,[17] stipulating further that physical fitness training activities should enhance both combat readiness and unit cohesion, and that personnel trained in fitness methods must plan and supervise the programs according to uniform methods and standards for performance and weight control. As the United States shifted to an all-volunteer force after the end of the Vietnam War, civilian fitness experts began to take military metrics as their model. In 1998, an American College of Sports Medicine position statement used military readiness standards to establish exercise minimums for health and fitness in the civilian population.[18]

The eighth revision of FM 21-20 (1985) had shifted focus from combat readiness to health-related fitness, and troops began to focus on fitness test scores rather than combat performance.[16] However, once active military engagement increased in the early 1990s, Army Regulation 350-41, published in 1993, shifted the focus back to combat readiness, emphasizing nine elements of fitness: (1) cardiorespiratory endurance, (2) muscular strength and endurance, (3) anaerobic conditioning, (4) flexibility, (5) body composition, (6) competitive spirit, (7) self-discipline, (8) ability to cope with psychological stressors, and (9) healthy lifestyle choices.[19] In summary, although the components of military physical fitness have changed over time, battlefield conditions have always imposed strenuous demands even on physically fit, resilient combatants. As conditions of future engagements unfold, physical fitness will remain a significant factor in individual, unit, and force readiness.

BENEFITS OF PHYSICAL FITNESS

The demands of modern warfare require physically fit combatants: they must be able to train consistently even when not actively engaged in warfighting; demonstrate reliable performance in missions; manage the stressors presented during conflict; and endure the longer-term consequences for mental and physical health.[20] Meeting these standards has important benefits beyond the immediate. The fit service member is less likely to miss days due to musculoskeletal injury or illness and will reap significant psychological benefits.[18] Physically fit service members have been shown to have better mental health, more positive outlooks, greater happiness, and greater ability to withstand stressful environments.21,22

Evidence strongly suggests that both all-cause mortality and many chronic disease rates decrease as physical activity increases.23–26 The psychological benefits of fitness and exercise in decreasing stress and modifying the symptoms of stress-related illnesses are also well established.[27] A Cochrane review of research on depression shows that exercise is moderately more effective than a control intervention for reducing symptoms of the disease.[28] There has also been strong evidence regarding the benefits of lowering anxiety levels via exercise.29,30 Perhaps of most significance to healthy military individuals, attaining higher levels of physical fitness confers higher levels of well-being and decreases reactivity to psychosocial stressors.31,32

EXHIBIT 20-1

ARMY TRAINING PRINCIPLES DURING THE 1950s

- Running. Distance and sprint running on road and cross country.

- Jumping. Broad jumping and vertical jumping downward from a height.

- Dodging. Change of body direction rapidly while running.

- Climbing and traversing. Vertical climbing of rope, poles, walls, and cargo nets. Traversing horizontal objects such as ropes, pipes, and ladders.

- Crawling. High crawl and low crawl for speed and stealth.

- Throwing. Propelling objects such as grenades for distance and accuracy.

- Vaulting. Surmounting low objects such as fences and barriers by use of hand assists.

- Carrying. Carrying objects and employment of man carries.

- Balancing. Maintaining proper body balance on narrow walkways and at heights above normal.

- Falling. Contact with the ground from standing, running, and jumping postures.

- Swimming (in specialized situations). Employment of water survival techniques.

____________

Data source: US Department of the Army. Physical Training. Washington, DC: DA; 1950. Field Manual 21-20.

Recent research suggests that physical fitness has important consequences for resilience—a key characteristic of the effective combatant. Resilience reinforces higher levels of both mental and physical function in stressful situations, and supports more effective recovery after the initial stressors are removed. Several literature reviews have demonstrated that aerobic exercise has positive effects on self-efficacy, self-esteem, and mental toughness—physically fit individuals demonstrate higher levels of resilience than those who are unfit.33–35

Because higher levels of physical and mental resilience contribute to improved unit cohesion as well as higher levels of individual and unit confidence, these relationships have significance for military units as well as individuals. Unit fitness schedules should alternate endurance-activity days with strength- or mobility-training days to ensure a training frequency that enables units to improve and sustain individual aerobic capacity without increasing the risk of overuse injuries.

The service member who exhibits a high level of aerobic fitness can also perform activities at intensity levels lower than his or her maximum ability for longer periods of time than those less fit. This type of fitness is especially beneficial during long tactical marches, loading and unloading trucks, preparing fighting positions, maneuvering at high altitudes (>15,000 ft), and land navigation over a prolonged time period. Thus, individuals with greater aerobic fitness can perform tasks at a higher intensity levels and are less likely to succumb to fatigue. They are also able to recover faster and to move more quickly to the next task at hand. Specific physiologic benefits of endurance/aerobic training are listed in Exhibit 20-2.

Strength and power are critical components for the functional fitness of service members. Most military occupational specialties require heavy physical lifting. Many service members repetitively lift heavy machine parts, weapons, or combat gear while performing their daily duties. The US Department of Labor rates over half of Army military occupational specialties as entailing “very heavy” lifting, which means that they require the capacity to lift 50 pounds frequently and 100 pounds occasionally (Technical Bulletin 592).[36] The demands these tasks impose on today’s soldiers warrant careful attention to both strength and power training to optimize both safety and performance in performing combat-specific tasks. Load-bearing tasks in particular can put significant physical stress on the individuals who perform them. Fortunately, resistance training has been shown to improve both physical-readiness testing and performance of load-bearing maneuvers.[37] Specific physiologic benefits of resistance training are listed in Exhibit 20-3.

EXHIBIT 20-2

BENEFITS OF ENDURANCE TRAINING

- Increased stamina due to central and peripheral adaptions.

- Lower respiration (minute ventilation) at a given submaximal intensity.

- Lower heart oxygen cost for a given absolute submaximal intensity.

- Lower heart rate and blood pressure at a given submaximal intensity.

- Lower risk of injury.

- Increased blood supply (capillary density) in skeletal muscle.

- Increased maximum work capacity and power output.

- Increased capacity for prolonged work.

- Increased serum high-density lipoprotein cholesterol and decreased serum triglycerides.

- Reduced total body and intraabdominal fat.

- Reduced insulin needs; improved glucose tolerance.

- Heat acclimation.

____________

Data sources: (1) Franklin B, ed. ACSM’s Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2000. (2) American College of Sports Medicine. ACSM Fitness Book. 3rd ed. Champaign, IL: Human Kinetics; 2003. (3) Myers J. Exercise and cardiovascular health. Circulation. 2003;107(1):e2–e5.

EXHIBIT 20-3

BENEFITS OF RESISTANCE TRAINING

- Increased muscle strength.

- Increased size of muscle fibers.

- Increased speed with movement.

- Improved anaerobic capacity.

- Increased bone strength.

- Increased bone mass and mineral density.

- Increased size and strength of tendons, ligaments, and fascia.

- Increased work capacity and power output.

- Decreased muscle soreness from heavy work.

____________

Data sources: (1) Baechle TR, Earle RW. Essentials of Strength Training and Conditioning. Champaign, IL: Human Kinetics; 2000. (2) Conroy BP, Kraemer WJ, Maresh CM, Dalsky GP. Adaptive responses of bone to physical activity. Med Exerc Nutr Health. 1992;1:64–74. (3) Hather BM, Tesch PA, Buchanan P, Dudley GA. Influence of eccentric actions on skeletal muscle adaptations to resistance training. Acta Physiol Scand. 1991;143(2):177–185. (4) Kraemer WJ, Mazzetti SA, Nindl BC, et al. Effect of resistance training on women’s strength/power and occupational performances. Med Sci Sports Exerc. 2001;33(6):1011–1025. (5) Sale DG. Neural adaptation to resistance training. Med Sci Sports Exerc. 1988;20(5 Suppl):S135–S145. (6) Staron RS, Leonardi MJ, Karapondo DL, et al. Strength and skeletal muscle adaptations in heavy-resistance trained women after detraining and retraining. J Appl Physiol. 1991;70(2):631–640. (7) Wilmore JH, Costill DL. Physiology of Sport and Exercise. Champaign, IL: Human Kinetics; 1994.

KEY CONCEPTS

Below are a variety of key concepts relating to overall physical fitness. This list is not complete but provides an overview of key ideas.

Components of Physical Fitness

Components of physical fitness include both health- and skill-related attributes. The health-related components include:

- body composition

- cardiovascular fitness

- muscular endurance

- muscular strength

- flexibility

In contrast, the skill-related components include:

- agility

- power

- balance

- reaction time

- coordination

- speed

Each of these components is important for the physical fitness of service members and mission performance. Some of the components have been defined above and others require no real definition. For example, although flexibility has been defined above, it is important to note that exercises to maintain flexibility should be incorporated into any standard program to help ensure all muscles maintain their proper length and movements are performed with proper mechanics. This is key to preventing injury. Incorporating flexibility training can also improve muscle imbalances by maintaining the appropriate length-tension relationship.

The US armed forces use body composition (a measure of a person’s body fat) as one component to determine a service member’s physical fitness. If a service member is “overfat,” it can adversely affect his or her career, including the ability to be promoted and even stay in the military. Each service branch has its own standards within DoD Instruction 1308.1.[17] The Human Performance Resource Center (see Resources, below) provides a chart that compares one service’s standards to another. Because the standards change, it is important to keep up with one’s own service, but the chart is useful for service members and healthcare providers.[38]

Power

Power is a very important concept for military readiness and performance. Simply stated, power is the ability to perform muscular work per unit of time (power = work/time). If strength is defined as the ability to exert force, power is the ability to exert force quickly: being able to move a heavy weight quickly, being able to move quickly when carrying a heavy load, or being able to quickly carry an injured service member from one place to another. Power is related to strength, aerobic capacity, and speed.

Mobility

Mobility is the ability to perform functional movement patterns with no restrictions in range of motion: it involves multiple elements that influence performance. Warm-up mobility exercises (eg, posterior hip mobilization, shoulder extension, external rotation, anterior hip mobilization, ankle dorsiflexion, deep squats, couch stretch) allow the service member to prepare for performing jumping, climbing, and sprinting activities and maneuvering around obstacles more efficiently. These exercises also limit the risk of injury as they reinforce proper technique. Strength in the extremities directly relates to the ability to perform mobility tasks, which means that mobility overlaps with the strength component of fitness. Optimized mobility training can increase a service member’s capacity for strength and endurance and minimize the possibility for injury.[39]

Plyometrics

Plyometrics are exercises performed so that muscles exert maximum force in short intervals of time to achieve increasing power (speed-strength). Designed to improve lower-body mobility and power, these exercises include jumping up onto a higher surface and back down. Data suggest that plyometric training benefits service members in terms of increased maximal strength, power output, coordination, and overall performance. Combining plyometrics with lower-body strength training appears to greatly improve strength performance.40,41 Thus, current evidence supports incorporating several types of plyometrics with other types of training into fitness programs.

Physical Readiness/Fitness Tests

All of the services require some type of physical fitness assessment. Table 20-1 presents each of the tests service members must pass (unless they are on a physical profile). Currently they all include a run and sit-ups, plus either push-ups or pull-ups, and all of the services have body composition standards. The Marine Corps was the first service to develop a functional test designed to evaluate combat fitness. Thus, Marines perform two semi-annual fitness tests, a physical readiness test and a combat fitness test. The other services are developing functional tests to assess operational/combat fitness, and in 2017, the Army rolled out the Occupational Physical Assessment Test (OPAT) for all recruits and soldiers. This requirement resulted from the Army’s effort to integrate women into its previously closed combat specialties. The OPAT consists of four events: a medicine-ball throw, standing long jump, deadlift, and interval run. It will eventually be used to determine which jobs recruits are qualified to perform.

Overtraining

Overtraining is the end result of excessive training. The most common signs are a decline in physical performance with continued training, pronounced fatigue, and changes in mood. The condition involves a complex interplay among the neuroendocrine, immune, and central nervous systems, as well as psychological and social stressors in response to prolonged strenuous training without sufficient recovery.[42] Military training can be intense, and overtraining can occur particularly in the absence of adequate sleep and nutrition. The mechanisms of overtraining have not been adequately elucidated.

SPECIAL POPULATIONS

Within the military, physical fitness standards may vary depending on the population. Brief discussions about pregnancy and postpartum physical fitness; aging; and the wounded, ill, and injured are provided.

Pregnancy and Postpartum Physical Fitness

Pregnant service members constitute an important subgroup of the military population, and fitness requirements must be tailored to this condition. The American College of Obstetricians and Gynecologists recommends that pregnant women perform moderate-intensity exercise for a total of 150 minutes, spread over the course of a week.[43] Despite these recommendations, many service members do not maintain optimal physical training during pregnancy.[44] It is recognized that some women may not be able to maintain fitness due to a variety of complications, but in general, physical fitness can and should be maintained during pregnancy across the services. Service members who participate in a pregnancy wellness program (see the American College of Sports Medicine, Army Pregnancy Postpartum Physical Training, and the Human Performance Resource Center websites, under Resources, below) have been shown to have shorter labor durations and a lower incidence of premature delivery.[45] Likewise, physical fitness in the postpartum period remains a challenge for a large percentage of service members. Service-led physical fitness programs for postpartum service members have been shown to improve participants’ overall physical capacity.[46]

TABLE 20-1

PHYSICAL READINESS TESTS, BY SERVICE

Service

Task 1

Task 2

Task 3

Air Force

Sit-ups (1 min)

Push-ups (1 min)

1.5-Mile run

Army

Sit-ups (2 min)

Push-ups (2 min)

2.0-Mile run

Marines*

Crunches (2 min)

Pull-ups (males); flex-arm hang (females)

3.0-Mile run

Marines†

880-Yard run

Ammo lifts–30 lb (2 min)

Maneuver under fire (300 m)

Navy

Curl-ups (2 min)

Push-ups (2 min)

1.5-Mile run

*Marine Corps Performance Fitness Test

†Marine Corps Combat Fitness Test

Aging

Service members 40 years and older typically serve as senior military leaders. Leaders must set good examples and serve as positive role models for those under their command; this includes maintaining and demonstrating a high level of physical fitness. Even if their normal duties are stressful (but nonphysical), these service members must regularly partake in physical exercise so their fitness is maintained and does not degrade with age.

Service members who are fit at age 40 and continue to exercise show smaller decreases in many fitness-related physiological functions compared to those who exercise less often.[47] Those who have been exercising regularly can continue to exercise at the same level. Those aged 40 and over who have not been exercising regularly should start at a lower level of intensity and progress slowly. Long periods of inactivity cannot be corrected in a few weeks or even months.

Wounded, Injured, and Ill Service Members

DoD Directive 1308.1 requires that “those personnel identified with medically limiting defects shall be placed in a physical fitness program consistent with their limitations as advised by medical authorities.”[17] AR 350-15 states, “For individuals with limiting profiles, commanders will develop physical fitness programs in cooperation with health care personnel.”[48] Medical treatment and rehabilitation should be aimed at restoring these service members to a suitable level of physical fitness. Such treatment should use appropriate, progressive physical activities with medical or unit supervision (see the American College of Sports Medicine, Building the Soldier Athlete–Reconditioning [Profile] Physical Training Supplement, the Human Performance Resource Center, National Strength and Conditioning Association, and US Army Physical Readiness Training Information websites, under Resources, below). The activity levels of service members usually decrease while they are recovering from sickness or injury. With medical supervision, proper diet, and the right physical training programs, service members should be able to overcome their physical profiles more quickly and return to their normal routines and fitness levels.

All profiled service members should complete as much of the unit’s regular fitness program as possible. The Office of the Surgeon General of the Army developed DA Form 3349 to facilitate the exchange of information between healthcare personnel and their units.[49] On this form, healthcare personnel list the service member’s physical limitations along with activities the individual can perform to maintain his or her fitness level. Based on this information, the unit should direct profiled service members to participate in appropriate activities to replace those they cannot participate in.

PHYSICAL FITNESS AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer

Military medical officers (MMOs) serve critical roles in supporting achievement and maintenance of physical fitness and readiness considerations at the unit level. They are responsible for being a role model, but must first build relationships with their unit. The MMO should support human performance optimization and provide the highest level of preventive healthcare. The MMO must be able to effectively communicate with and translate medical and scientific knowledge into actionable plans that support ongoing physical training activities and military operations. The MMO should be familiar with concepts related to physical fitness and competent in key topics such as functional movement, strength and resistance training, overtraining, and exercise prescription. Additionally, knowledge about service-specific and DoD regulations and guidance regarding body composition and physical fitness are critical. Lastly, the MMO must identify physical fitness subject matter experts (SMEs) they can contact to obtain additional reliable information when necessary.

Guidance to the Commanding Officer

The MMO serves as the primary consultant to the commander regarding the overall health status of the unit. As such, the MMO is responsible for:

- Monitoring physical fitness levels and advising the unit commander on profiling those who are ill, injured, or wounded. The MMO must also ensure that standard physical fitness programs are consistent with their service’s requirements and understand both the commander’s intent and the mission goals. This information will allow the MMO to correctly identify the unit’s physical training and fitness needs.

- Monitoring musculoskeletal injuries and physical profiling of service members. This task requires a full understanding of the physical requirements of service members’ jobs, the physical fitness guidelines for the service, and the current health status of each service member. Physical limitations should protect service members from further injury while encouraging alternative activities that sustain their overall fitness level.

- Working closely with physical fitness SMEs to review the training program intended to develop individual service members at the highest level of fitness for their specific specialty.

- Ensuring the physical training program is safe and limits the risk of injuries.

- Keeping the commander updated about the physical readiness of individual service members and reviewing training plans for those with special fitness considerations such as pregnancy, illness, or injury. These tailored plans should draw on advice from fitness SMEs.

RESOURCES

- American College of Sports Medicine: http://acsm.org/

- Building the Soldier Athlete—Reconditioning (Profile) Physical Training Supplement: http://army-medicine.mil/Documents/R2D-Building_the_Soldier_Athlete_Reconditioning_profile_Supplement_-_7_Oct_09.pdf

- Air Force Fitness Program: http://www.afpc.af.mil/affitnessprogram/

- Army Comprehensive Soldier and Family Fitness: http://csf2.army.mil/

- ARMYFIT—Comprehensive Soldier and Family Fitness: https://armyfit.army.mil/

- Army Pregnancy Postpartum Physical Training: https://phc.amedd.army.mil/topics/healthyliving/al/Pages/ArmyPregnancyPostpartumPhysicalTrainingProgram.aspx

- Commander, Navy Installations Command—Fitness, Sports and Deployed Forces Support: http://www.navyfitness.org/fitness/

- Human Performance Resource Center: http://hprc-online.org/

- National Strength and Conditioning Association: https://www.nsca.com/

- US Army Public Health Center—Army Physical Fitness: https://phc.amedd.army.mil/TOPICS/HEALTHYLIVING/AL/Pages/ArmyPhysicalFitness.aspx

- US Army Physical Readiness Training Information: http://www.armyprt.com/

- US Coast Guard Office of Work-Life Programs—Physical Fitness Program: http://www.uscg.mil/worklife/physical_fitness_program.asp

- US Marine Corps Physical Fitness Program: http://www.fitness.marines.mil/

SUMMARY

Accurate assessment of strengths and vulnerabilities in the quest for optimal fitness is essential in guiding both individuals and units to peak military performance. Understanding the physiologic construct of fitness and how the factors of military fitness requirements may change can help an MMO make better decisions and recommendations to the unit commander. Appreciation of the interrelatedness of the components of physical fitness can help the MMO tailor better individual fitness plans and ensure optimal fitness for every member of the unit.

REFERENCES

1.   Kennedy JF. The soft American. Sports Illustrated. 1960;13(26):14–17.

2.   Chairman of the Joint Chiefs of Staff. Chairman’s Total Force Fitness Framework. Washington, DC: JCS; 2013. CJCS Instruction 3405.01. https://www.hprc-online.org/resources/chairman-of-the-joint-chiefs-of-staff-instruction-cjcsi. Accessed February 5, 2018.

3.   Jonas WB, Deuster PA, Macednoia C, eds. Total force fitness for the 21st century: a new paradigm. Mil Med. 2010;175(8):1–78.

4.   Horne A. Monty: The Lonely Leader, 1944-1945. New York, NY: HarperCollins; 1994.

5.   US Department of War. Manual of Physical Training. Washington, DC: Government Printing Office; 1914.

6.   Magee JC. Relationship of the health of civilians to the efficacy of the Army. Am J Pub Health. 1940;30(11):1283–1290.

7.   US Department of War. Basic Field Manual, Physical Training. Washington, DC: Government Printing Office; 1941. Field Manual 21-10.

8.   US Marine Corps. US Marine Combat Conditioning. New York, NY: Skyhorse Publishing; 2011.

9.   US Bureau of Naval Personnel. Physical Fitness Manual for the U.S. Navy. Washington, DC: Bureau of Naval Personnel; 1943.

10.   Physical Conditioning. Washington, DC: Department of War; 1944. Pamphlet No. 21-9.

11.   East WB. A Historical Review and Analysis of Army Physical Readiness Training and Assessment. Fort Leavenworth, KS: Combat Studies Institute Press; 2013.

12.   US Department of the Army. Physical Training. Washington, DC: DA; 1946. Field Manual 21-20.

13.   US Department of the Army. Physical Readiness Training. Washington, DC: DA; 1959. Field Manual 21-20.

14.   US Army Infantry School. Physical Fitness Symposium Report. Fort Benning, GA; 1970.

15.   US Department of the Army. Physical Readiness Training. Washington, DC: DA; 1973. Field Manual 21-20.

16.   US Department of the Army. Physical Training. Washington, DC: DA; 1985. Field Manual 21-20.

17.   US Department of Defense. Physical Fitness and Weight Control Programs. Washington, DC: DoD; 1981. DoD Directive 1308.1.

18.   American College of Sports Medicine position stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Med Sci Sports Exerc. 1998;30(6):975–991.

19.   US Department of Army. Training in Units. Washington, DC: DA; 1993. Army Regulation 350-41.

20.   Henning PC, Park BS, Kim JS. Physiological decrements during sustained military operational stress. Mil Med. 2011;176(9):991–997.

21.   Silverman MN, Deuster PA. Biological mechanisms underlying the role of physical fitness in health and resilience. Interface Focus. 2014;4(5):20140040.

22.   Flanagan SC, Kotwal RS, Forsten RD. Preparing soldiers for the stress of combat. J Spec Oper Med. 2012;12(2):33–41.

23.   World Health Organization. Global Recommendation on Physical Activity for Health. Geneva, Switzerland: WHO Press; 2010.

24.   Macera CA, Hootman JM, Sniezek JE. Major public health benefits of physical activity. Arthritis Rheum. 2003;49(1):122–128.

25.   Macera CA, Powell KE. Population attributable risk: implications of physical activity dose. Med Sci Sports Exerc. 2001;33(6 Supplement):S635–S639; discussion 640-1.

26.   Miles L. The new World Cancer Research Fund/American Institute for Cancer Research report. Food, nutrition, physical activity and the prevention of cancer: a global perspective. Nutr Bull. 2008;33(1):26–32.

27.   Smits JA, Berry AC, Rosefield D, Powers MB, Behar E, Otto MW. Reducing anxiety sensitivity with exercise. Depress Anxiety. 2008;25(8):698–699.

28.   Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Syst Rev. 2013;9: CD004366. DOI: 10.1002/14651858.CD004366.pub6.

29.   Carek PJ, Laibstain SE, Carek SM. Exercise for the treatment of depression and anxiety. Int J Psychiatry Med. 2011;41(1):15–28.

30.   Galper DI, Trivedi MH, Barlow CE, Dunn AL, Kampert JP. Inverse association between physical inactivity and mental health in men and women. Med Sci Sports Exerc. 2006;38(1):173–178.

31.   Crews DJ, Landers DM. A meta-analytic review of aerobic fitness and reactivity to psychosocial stressors. Med Sci Sports Exerc. 1987;19(5 Suppl):S114–S120.

32.   Tsatsoulis A, Fountoulakis S. The protective role of exercise on stress system dysregulation and comorbidities. Ann N Y Acad Sci. 2006;1083:196–213.

33.   Ekeland E, Heian F, Hagen KB, Abbott J, Nordheim L. Exercise to improve self-esteem in children and young people. Cochrane Database Syst Rev. 2004;1:CD003683.

34.   Young MD, Plotnikoff RC, Collins CE, Callister R, Morgan PJ. Social cognitive theory and physical activity: a systematic review and meta-analysis. Obes Rev. 2014;15(12):982–995.

35.   Deuster PA, Silverman MN. Physical fitness: a pathway to health and resilience. US Army Med Dep J. 2013;Oct-Dec:24–35.

36.   US Department of the Army. Prevention and Control of Muskuloskeletal Injuries Associated with Physical Training. Washington, DC: DA; 2011. Technical Bulletin 592.

37.   Knapik JJ, Harman EA, Steelman RA, Graham BS. A systematic review of the effects of physical training on load carriage performance. J Strength Cond Res. 2012;26(2):585–597.

38.   Uniformed Services University of the Health Sciences, Consortium for Health and Military Performance. Body fat standards by service branch. Human Performance Resource Center website. https://www.hprc-online.org/articles/body-fat-standards-by-service-branch. Accessed November 17, 2017.

39.   Nalcakan GR. The effects of sprint interval vs. continuous endurance training on physiological and metabolic adaptions in young healthy adults. J Hum Kinet. 2014;44:97–109.

40.   Villareal SS, Requena B, Newton RU. Does plyometric training improve strength performance? A meta-analysis. J Sci Med Sports. 2010;13(5):513–522.

41.   Taylor J, Macpherson T, Spears I, Weston M. The effects of repeated-sprint training on field-based fitness measures: a meta-analysis of controlled and non-controlled trials. Sports Med. 2015;45(6):881–891.

42.   Purvis D, Gonsalves S, Deuster PA. Physiological and psychological fatigue in extreme conditions: overtraining and elite athletes. PMR. 2010;2(5):442–450.

43.   Committee on Obstetric Practice. ACOG committee opinion. Exercise during pregnancy and the postpartum period. Int J Gynaecol Obstet. 2002;77(1):79–81.

44.   Kwolek LA, Berry-Caban CS, Thomas SF. Pregnant soldiers’ participation in physical training: a descriptive study. Mil Med. 2011;176(8):926–931.

45.   Lombardi W, Wilson S, Peniston PB. Wellness intervention with pregnant soldiers. Mil Med. 1999;164(1):22–29.

46.   Gilcreast DM. Pregnancy Soldier Wellness Program: An Evaluation. Fort Bragg, NC: Triservice Nursing Research Program; 1997. https://www.usuhs.edu/node/3305. Accessed February 5, 2018.

47.   Elia EA. Exercise and the elderly. Clin Sports Med. 1991;10(1):141–155.

48.   US Department of the Army. The Army Physical Fitness Program. Washington, DC: DA 1989. Army Regulation 350-15.

49.   US Department of the Army. DA Form 3349: Physical Profile. 2007.

Chapter 21

PERFORMANCE NUTRITION

PATRICIA A. DEUSTER, PHD, MPH,* AND JONATHAN SCOTT, PHD†

INTRODUCTION

DEFINITIONS

HISTORY OF MILITARY NUTRITION

Importance of Nutrition and Mission Success

Committee for Military Nutrition Research

BACKGROUND

Establishing Nutrient Requirements

Evolution of Performance Nutrition

SCOPE OF PRACTICE

KEY CONCEPTS

Nutrient Timing

Protein Requirements

Dietary Supplements

Caffeine Dosing

PERFORMANCE NUTRITION AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer

Guidance to Commanding Officer

RESOURCES

SUMMARY

*Professor and Director, Consortium for Health and Military Performance (CHAMP), Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Assistant Professor, Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

The contributions of nutrition to health and performance are well established,1–3 and within the Department of Defense (DoD), nutritional fitness (NF) is a key component of total force fitness (TFF). NF is intricately woven into each TFF domain, including the medical, behavioral, psychological, environmental, physical, social, and spiritual domains. Nutritional choices and habits affect every aspect of life: sleep, mood, physical and cognitive performance, sense of purpose, health, and more.

The readiness status of current and future service members is markedly affected by their NF. Fast food restaurants and physically passive recreational outlets (eg, video games, television, movies) are omnipresent in civilian and military communities alike. NF must be a priority of military medical and line leaders at every level. Importantly, a comprehensive/holistic approach can ensure NF and serve to inform the military enterprise and bases, and teach leaders and troops how to promote, implement, achieve, and maintain good health in addition to demanding, endorsing, and supporting the concept of NF.

DoD Instruction (DoDI) 6130.05, DoD Nutrition Committee,[4] directs nutrition education within the DoD, and nutrition education is key to NF. Education must encompass performance nutrition, health promotion, dietary supplements, and optimal fuel choices in dining facilities and other fueling environments. First and foremost, performance fueling needs to be incorporated into all leadership courses and into various types of individual and unit training, including unit mission-essential task lists, joint exercises, and predeployment training (to provide nutrition information specific to environmental conditions and threats in the area of operations). This will ensure performance fueling is taught from the individual through the unit level. Additionally, the application of performance fueling must be incorporated into all military doctrine to ensure its continuation across time.

DEFINITIONS

Exhibit 21-1 defines a variety of important nutrition terms commonly used within the DoD, including NF, performance nutrition, and the military dietary reference intakes (MDRIs). Likewise, Exhibit 21-2 presents key nutrition terms and definitions used across the nation to ensure comparability with regard to nutrient intake.

HISTORY OF MILITARY NUTRITION

The military community has a long history of interest in nutrition, and many military leaders made extraordinary strides in the nutritional sciences. In 1753, Dr James Lind, a Scottish physician who is considered the father of military nutrition, wrote A Treatise of the Scurvy, detailing experiments he conducted in an effort to prevent and treat scurvy in the Royal Navy. Ultimately, he determined citrus fruits, specifically oranges and lemons, could be used to prevent and treat scurvy because they contained Vitamin C, an essential nutrient. In 1778, American Dr Benjamin Rush wrote Directions for Preserving the Health of Soldiers, which advocated for a diet consisting chiefly of vegetables for soldiers. Military nutrition research in the United States formally began in 1917 when the Surgeon General’s Office established a food division for the purpose of “safeguarding the nutritional interests of the Army.”[5] Military nutrition has always been associated with safety, health, readiness, and performance.

In 1940, the US Food and Nutrition Board was established to investigate nutritional issues that might “affect national defense.”[6] Areas of interest included the safety and adequacy of the US food supply and principles and guidelines for good nutrition. Now a part of the US Department of Health and Human Services (HHS), the Food and Nutrition Board remains an authority on how nutrition and food choices affect overall health and disease.

In 1949, when the National Military Establishment was renamed the Department of Defense (DoD), the energy and nutritional demands of service members engaged in training and missions became of interest. The activities of service members are often unique and vary greatly from the general population, particularly with regard to environmental exposures (eg, heat, cold, depth, and altitude) and physical activity. Service members must be well nourished to remain healthy and fit for service. Today, developing, implementing and evaluating effective nutritional strategies to optimize performance before, during, and after training and operations remains a high priority for the DoD.

Importance of Nutrition and Mission Success

Mission success has always hinged upon adequate nutrition. From the ancient Egyptians to the Greeks, Persians, and Romans, every successful military relied on appropriate nutrition. The universal quote highlighting the importance of military nutrition comes from either Fredrick the Great or Napoleon Bonaparte: “A military marches on its stomach.” Never were such words truer than during Napoleon’s 1812 winter campaign in Russia. During this period Napoleon lost nearly 500,000 men due to their deviations from supply train routes and instructions to live off the land.7,8

EXHIBIT 21-1

DEPARTMENT OF DEFENSE NUTRITION TERMS

- Nutritional fitness. Having the appropriate quantity, quality, choice, and timing of safe fuels, nutrients, and fluids and the requisite nutritional environment to sustain and optimize physical and cognitive performance, wellness, and health; accelerate healing; and protect against disease. An eating environment that makes healthy choices the easy choice, along with performance-based nutrition education, will help promote nutritional fitness and a resilient and fit force. When necessary, dietary supplements may be recommended to supplement the diet.

- Performance nutrition. Nutritional contribution to the execution of physical and cognitive actions by the human body to the greatest degree attainable under specified conditions and objectives.

- Military dietary reference intakes. Nutritional standards for military feeding, operational rations, and for restricted rations, as noted in US Army Regulation 40-25 (AR 40-25, OPNAV Instruction 10110.1, Marine Corps Order 10110.49, Air Force Instruction 44-141). The proponent of AR 40-25 is the Army surgeon general, who has the authority to approve exceptions or waivers to the regulation that are consistent with controlling laws and regulations. MDRIs are identical to recommended nutrient intakes cited in the above references, except when known differences in the military population require adjustment of a particular nutrient.

EXHIBIT 21-2

NATIONAL ACADEMY OF SCIENCES NUTRITION TERMS

- Dietary reference intakes. A set of four reference values that are quantitative estimates of nutrient intakes to be used for planning and assessing diets for healthy people:

- Estimated average requirement. Reflects nutrient intake levels to meet the needs of ~50% of healthy individuals.

- Recommended dietary allowance. Daily dietary intake level considered sufficient by the Food and Nutrition Board to meet requirements of nearly all healthy individuals (97%–98%) in each life-stage and gender group. RDAs are revised every 5-10 years.

- Adequate intake. The recommended average daily intake level based on observed or experimentally determined approximations or estimates of nutrient intake by a group (or groups) of apparently healthy people that are assumed to be adequate. Used when an RDA cannot be determined.

- Tolerable upper intake levels. Highest level of daily consumption that current data have shown to cause no side effects in humans when used indefinitely without medical supervision.

- Daily value. The percent of daily value is shown on the labels of dietary supplements and foods and is usually similar to the RDA or adequate intake for that nutrient. This term was developed by the Food and Drug Administration to help consumers determine how much (what percentage) a serving of the product contributed to the daily value of various nutrients.

- Acceptable macronutrient distribution range. Reflects an intake range for carbohydrate, protein, and fat associated with reduced risk of chronic disease while providing adequate nutrients.

In the US Revolutionary War, rations provided to soldiers consisted of salt-cured meat, beans or peas, rice or “Indian meal” (cornmeal), milk, flour or hard bread, and spruce beer or cider. During the Civil War, cattle drives followed soldiers in an effort to provide them with more fresh meat. World War I saw the advent of canned foods. As many as 23 different rations were available to meet the diverse needs of service members during World War II and the Korean War. During the Vietnam War, freeze-dried rations became available to forward operating Special Forces units in an effort to remove metal containers from rations. The first Meal, Ready-to-Eat (MRE) was developed in 1980 and was widely distributed to service members in 1983. MREs are still used and serve as the main individual ration for the deployed service member. In addition to the MRE, 16 additional categories of rations are produced to meet a variety of needs from religious dietary restrictions to survival situations and humanitarian efforts.[9]

Service members today operate all over the world in a variety of climates, environments, and altitudes. Accordingly, the Combat Feeding Directorate is tasked with developing rations to meet the nutritional needs of all service members. The directorate’s mission is to “sustain the Department of Defense’s most decisive weapons platform—the individual Warfighter.”[10] MREs must comply with the nutritional requirements described in Army Regulation 40-25, Nutrition and Menu Standards for Human Performance Optimization.[11] Additionally, the Joint Services Operational Rations Forum meets annually to approve new rations and changes to components within rations.

On average, one MRE provides approximately 1,300 calories, 170 g of carbohydrates (CHO), 40 g of protein, and 50 g of fat. The number of rations provided to service members is dependent upon gender and activity level. MREs are designed to meet all nutritional requirements of the service member when consumed in their entirety. MREs can be used as the sole source of calories for up to 21 days. Currently, 24 different MRE options are available.[10]

New rations continue to be developed to meet the needs of service members around the world. The First Strike Ration (FSR) is the newest individual ration developed by the Combat Feeding Directorate. Fielded in 2008, the FSR was specifically developed for multiday, high-intensity combat missions. The FSR consists of several hand-held items designed to be eaten while moving. On average, one FSR provides approximately 2,900 calories, 375 g of CHO, 100 g of protein, and 110 g of fat. Service members are provided one FSR per day, and FSRs can be used as the sole source of calories for up 10 days. Currently, nine different FSR options are available.[10]

Committee for Military Nutrition Research

The Committee on Military Nutrition Research was established in October 1982 under the direction of the assistant surgeon general of the Army. Committee members, who served a 3-year term, had diverse backgrounds including human nutrition, nutritional biochemistry, performance physiology, immunology, food science, and psychology.[12] The committee’s mission was to advise the DoD on nutrient requirements for performance during operational missions and deployment and to identify gaps within military nutrition research.[12] The committee had four tasks:

1. identify nutritional factors that may critically influence the physical and mental performance of military personnel under all environmental extremes;

2. identify deficiencies in the existing database regarding the relationship between diet and performance of military personnel;

3. recommend research that would remedy these deficiencies as well as approaches for studying the relationship of diet to physical and mental performance; and

4. review and advise on standards for military feeding systems.

A subcommittee was established to review topics specifically related to female service members. Topics of interest included postpartum return-to-duty standards, military recommended dietary allowances, and individual and collective impact of physical activity and nutritional practices on the health, fitness, and readiness of female service members. Subject matter experts in body composition assessment, physical fitness and performance, pregnancy and lactation, women’s nutrition, weight management, epidemiology and survey design, and cognitive performance were included. Additionally, a liaison panel of service members from the Army, Navy, and Air Force with expertise in body composition, fitness, and nutrition research and policy-making were included to ensure military relevance.[12] Between 1992 and 2011, the committee produced approximately 18 publications on a variety of nutritionally relevant topics; it disbanded in 2013.[13]

BACKGROUND

Establishing Nutrient Requirements

In 1941, the Food and Nutrition Board released the first recommended dietary allowances (RDAs). The committee developed RDA values for selected nutrients known at the time, based on age and gender, as well as for women during pregnancy and lactation. The first RDAs were intended to be “a table of allowances which would represent the best available evidence on the amounts of the various nutritive essentials desirable to include in practical diets.”[14] Essential nutrients were identified when dietary deficiency led to the development of a well-defined disease or a failure to grow. An animal growth model was used to identify essential nutrients and to quantify requirements. RDAs were updated every 5 to 10 years over the next 5 decades as new science emerged.[15]

In the mid-1990s, the United States and Canada set out to establish a single set of nutrient-based dietary reference intakes (DRIs) to replace the RDAs. More than 40 nutrients were reviewed and recommendations were based on the totality of available scientific evidence. Nearly 20 years later, six volumes of DRI recommendations have been released. Each nutrient DRI is intended to meet the needs of healthy people (not individuals with disease), including age-specific recommendations that reflect the current knowledge of biological patterns, and providing sex-specific recommendations if reasonable scientific evidence was available. DRIs are not updated on a regular basis but rather as new bodies of scientific literature emerge.16,17

Evolution of Performance Nutrition

The first Olympiad of ancient Greece was held in 776 BCE. Written text from the 3rd century CE documents the importance of nutrition and athletic performance dating back to the 6th century BCE.[18] Ancient text describes athletes consuming a diet of figs, moist cheese, and wheat.[18] Further evolution of dietary practices in ancient Greece incorporated meat from oxen, bulls, deer, and goats, along with bread made from barley and unleavened bread made from wheat. Ancient texts also highlight the negative effects of excessive wine consumption on athletic performance by stating that overeating was not the problem, but rather drunkenness.19,20

Upon conclusion of the last Olympiad in 393 CE, limited scientific papers examining nutrition and athletic performance were produced over the next 15 centuries. At the 1936 Olympics, scientist Paul Schenk meticulously recorded what Olympians from nearly all countries ate in the Olympic village. According to Schenk’s analysis, athletes consumed an average of 320 g of protein, 270 g of fat, 850 g of CHO, and up to 7,300 kcals per day. Unfortunately, Schenk did not analyze his data for relationships between dietary intake and athletic performance, but he did acknowledge the importance of fruits and vegetables for Olympic athletes regardless of sport.[20] Few changes in sports nutrition occurred over the next 3 decades due to the outbreak of World War II and the limited methodologies available for metabolic and exercise physiology research.

During the 1960s and 1970s, Swedish researchers demonstrated that CHO consumed during exercise could delay fatigue. Further, Ahlborg and colleagues found a direct relationship between a high-carbohydrate diet and endurance performance, thus starting the “carbo-loading” craze of the 1970s.[21] CHO continue to be the body’s preferred fuel source for endurance activities; however, recent publications suggest ketone bodies, a class of organic compounds that can be used for fuel, may be a superior fuel source for aerobic activity.22,23 Ketone bodies are produced by the liver, derived from fat. Production is increased during periods of prolonged fasting or adherence to a strict ketogenic diet.

Sports nutrition became a recognized field of study during the 1980s, coinciding with the increase in exercise physiology research. Early on, the majority of sports dietitians worked with endurance athletes due to their unique energy and CHO requirements. By the late 1990s, sports dietitians were becoming an integral part of collegiate, professional, and Olympic teams. In 2009, the American Dietetic Association, American College of Sports Medicine, and Dietitians of Canada released a joint position paper evaluating the totality of evidence regarding nutrition and athletic performance.[24] Recognized benefits of sports nutrition now apply to athletes from young to old, elite to recreational, civilian and military. Sports nutrition continues to expand into new fields. If one considers the warrior athlete paradigm, military applied nutrition is consistent with sports nutrition.

SCOPE OF PRACTICE

A registered dietitian (RD) who practices sports nutrition is commonly referred to as a sports RD. A sports RD may receive further credentialing from the Academy of Nutrition and Dietetics with a board certification as a specialist in sports dietetics (CSSD). CSSD eligibility includes meeting a minimum practice experience requirement (1,500 hours of specialty practice) and successfully passing a nationally accredited examination. Sports RDs implement evidence-based knowledge in physical activity and exercise/training to address the diverse nutritional needs of physically active individuals. A sports RD’s individual scope of practice includes assessment, diagnosis, intervention, monitoring, and evaluating of what, how much, and when to consume foods and fluids.

Although individual client goals differ, general goals of sports RDs include maintenance of health, appropriate body weight and composition, and instruction on how to properly fuel the body for physical activity and exercise, training and conditioning, and physical performance. Sports RDs educate individuals regarding energy, nutrient, and fluid intake before, during, and after exercise, as well as on menu planning, recipe modification, grocery shopping, and food preparation and storage. Sports RDs facilitate behavior change and promote problem solving, adaptation, and progression toward achieving nutritional goals that promote overall health and wellness. Regularly, sports RDs evaluate dietary supplements for legality, safety, effectiveness, quality, and application to sport. Lastly, sports RDs provide guidance regarding compliance with the rules and regulations of sports organizations and governing bodies.[25]

KEY CONCEPTS

Nutrient Timing

Overall goals of training include optimization of physiologic and molecular adaptations. Training goals are realized when appropriate nutritional strategies are implemented before, during, and after training. “Nutrient timing” is the term originally coined by doctors John Ivy and Robert Portman[26] to indicate that “when food is consumed” is as important as “what food is consumed.” Ivy and Portman describe nutrient timing as “a revolutionary new system of exercise nutrition that will allow you to build more strength and lean muscle mass in less time than ever before.”[26] The three phases of nutrient timing are shown in Figure 21-1: (1) during exercise; (2) the refueling interval immediately after exercise (recovery); and (3) the time between exercise sessions (maintenance and growth).

Figure 21-1. The three major phases for nutrient timing: maintenance and growth, exercise, and the refueling interval for recovery. Heights of the bars are indicative of protein and carbohydrate balance; exercise indicates the breakdown of energy stores; the refueling interval reflects rebuilding energy stores; and maintenance represents homeostasis.

Various strategies have been developed to maintain adequate energy stores, enhance recovery, stimulate muscle protein synthesis, maximize glycogen repletion, and minimize/protect against training injuries.[24] Nutrient timing, combined with adequate rest and recovery periods, are important components to any training program. However, another consideration for optimal performance is familiarity: foods and fluids consumed before and during exercise should be consistent with those used in training to minimize possible gastric distress from unfamiliar foods. The overall goals of nutrient timing are noted in Exhibit 21-3.

EXHIBIT 21-3

GOALS OF NUTRIENT TIMING

- Enhance performance.

- Accelerate recovery.

- Improve/maintain muscle integrity.

- Increase muscle mass/nitrogen balance.

- Replete glycogen stores.

- Prevent musculoskeletal injuries.

- Restore skeletal muscle integrity.

Pre-Exercise Meal/Snack

No consensus statement for optimal content and timing of a pre-exercise meal or snack has been published. However, consuming a meal or snack providing 200 to 300 g of CHO 3 to 4 hours before heavy training or competition will allow sufficient time for the food to be digested and for gastric emptying to occur. Consuming up to 25 g of protein before exercise may be important for those primarily engaged in strength training to maximize training adaptations.[27] If a larger meal is desired, more time should be allowed for digestion.

During Exercise

During exercise, energy stores are being used to provide energy to the working muscles and muscle protein is being broken down. Consuming small amounts of CHO at regular intervals can minimize metabolic distress and enhance athletic performance, especially when the exercise duration is longer than 1 hour.[28] During exercise lasting longer than an hour, ingesting CHO in a fluid can also help sustain hydration. Studies have shown that ingesting 0.7 g CHO per kilogram of bodyweight (approximately 30–60 g CHO/h or 7–20 g CHO every 15–20 min) can extend endurance performance.[27] When the exercise duration is greater than 3 hours, CHO intakes of up to 110 g per hour may be needed, depending on the intensity of the exercise.[29] For exercise longer than 3 hours, individuals typically eat both solid and liquid foods to meet CHO needs.

Service members should try various foods during training to determine which are most suitable. The amount of CHO and fluid required and tolerated by any individual will be determined by the exercise intensity, duration, environmental conditions, and mode of exercise (running vs marching vs manual labor). The service member should simulate mission events to determine his or her optimal fuel sources. Consuming protein during events confers no discernable benefit.[30]

Recovery: Refueling Interval

After exercise, the metabolic environment within the body needs to transition from a catabolic state to an anabolic one to promote recovery and restore what was depleted during the exercise phase. This is the “refueling interval.” Release of insulin, an important hormone for inhibiting muscle protein breakdown, is stimulated by ingestion of both CHO and certain amino acids.[31] Thus, the recommended time to begin the refueling interval is no later than 60 minutes after activity, when glycogen stores and muscle protein synthesis are lowest; this provides the body with the requisite nutrients and fuels. To enhance muscle glycogen synthesis following prolonged, strenuous exercise (over 60 minutes), consuming approximately 50 g of CHO within 60 minutes after the activity is recommended, followed by approximately 1.0 to 1.5 g per kilogram of bodyweight (0.5–0.7g/lb) CHO (as liquid, gel, or solid food) at 2-hour intervals for up to 6 hours.24,27,28

Although somewhat controversial, it is generally believed that ingesting some protein (12–25 g) with CHO during recovery can increase muscle protein synthesis and improve nitrogen balance more effectively than consuming CHO without protein.24,32 Consuming foods with essential amino acids—especially leucine—will promote the post-exercise muscle protein synthesis needed for building and repairing muscle tissue.33,34 Foods containing leucine include eggs, dairy, and chicken. Without appropriate refueling after a hard training session or mission, performance may be compromised, especially if a second workout or mission is required the same day or in less than 24 hours.

Protein Requirements

The RDA for both men and women is 0.80 g of high-quality protein per kilogram of body weight (or 0.36 g/lb body weight).[35] The recommendation is based on careful analyses of published nitrogen balance studies. The acceptable macronutrient distribution range for protein is 10% to 35% of total energy intake. Given that 1 g of protein is equivalent to 4 calories, on a 3,000-calorie diet, protein intake would be 75 g at 10% and 262 g at 35% of the total energy. There is no upper intake level for protein due to insufficient data to define an upper limit. However, it must be remembered that amino acids are not good sources of energy. Protein recommendations for service members can be met through diet alone, without the use of protein or amino acid supplements (Table 21-1).

Dietary Supplements

According to the Dietary Supplement Health and Education Act of 1994, the term dietary supplement refers to “a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin; a mineral; an herb or other botanical; an amino acid; a dietary substance for use by man to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of any ingredient.”[36]

TABLE 21-1

PROTEIN RECOMMENDATIONS BASED ON PHYSICAL ACTIVITY LEVELS

Activity Level/Conditions

Grams/lb body weight

Grams/kg body weight

Low to moderate*

0.4–0.5

0.8–1.0

Endurance†

0.5–0.6

1.2–1.4

Strength‡

0.5–0.9

1.2–2.0

High energy demands combined with insufficient calories

0.7–0.9

1.5–2.0

*Low- to moderate-level activities include sitting quietly or engaging in light exercise such as a brisk walk, yoga, hiking, or softball.

†Endurance training is vigorous exercise that challenges the aerobic system. Examples include running, cycling, swimming, and sports such as basketball or racquetball. For endurance athletes, about 0.5 to 0.6 g of protein per pound of body weight each day is sufficient to sustain events.

‡Strength training involves resistance exercise such as weight training, lifting heavy objects, and use of resistance bands. Typically the goal of muscle building is to increase lean body mass without gaining fat, so it’s important to eat right and maintain energy balance. About 0.5 to 0.9 g of protein per pound of body weight each day is enough protein for strength training, even for the hardcore bodybuilder, as long as energy intake is sufficient to support daily activities.

The use of dietary supplements has become increasingly popular among service members to enhance performance. Consumers of dietary supplements should be aware that although the Food and Drug Administration (FDA) regulates dietary supplements, the regulations are not as strict as they are for drugs. Consequently, some unsafe and contaminated products end up on the market. FDA has identified certain “high-risk” dietary supplement categories: bodybuilding, weight-loss, and sexual enhancement products; these products are more likely than vitamin and mineral supplements to contain unsafe and contaminated ingredients. In addition, many “high-risk” supplements may not conform to the labeling regulations required by FDA and may contain illegal (eg, analogues of drugs, amphetamines) or controlled (eg, steroids) substances. Such ingredients may be intentionally left off the label because they would not meet the definition of a dietary supplement. Thus, service members should be careful when purchasing dietary supplements. Operation Supplement Safety is a DoD initiative to educate all service members on how to select safe supplements (http://opss.org).

Supplements displaying seals from third-party verification/certification programs are better choices (Figure 21-2) because they are (a) unlikely to contain contaminants; (b) likely to have ingredients present in the amounts listed on the Supplement Facts panel; and (c) likely to have accurate labels. Service members should also be aware that (a) concentrations and combinations of ingredients are arbitrarily created by manufacturers with little to no supporting scientific research, and (b) using any dietary supplement, especially those in high-risk categories, increases the probability of experiencing an adverse event. Adverse events associated with dietary supplements can range from very mild physical discomfort to severe, life-threatening incidents. Healthcare providers should report adverse events and should educate patients on how to report adverse events through Natural Medicines’ MedWatch website (http://naturalmedicines.com/tools/natural-medwatch.aspx). Service members should always proceed with caution when considering and using dietary supplements. Primary care providers should query their patients about supplement use and discuss general safety issues with all patients.

Figure 21-2. Examples of logos and seals from organizations that third-party verify/certify dietary supplements. Reproduced with permission from each.

Caffeine Dosing

Caffeine is the world’s most widely consumed psychoactive substance. Previous research on caffeine has demonstrated positive effects on several military-relevant tasks including marksmanship, reaction time, vigilance, and logical reasoning.37–41 In athletics, the ergogenic benefits of caffeine include improvements in endurance and time to exhaustion, and a reduction in perceived effort of exertion. Previous studies used a wide range of caffeine doses, ranging from 200 to 400 mg or 3 to 5 mg per kilogram of body weight (1.4–2.3 mg/lb).37–41 However, the ergogenic benefits of caffeine are dose-dependent, with adverse events often reported when intake exceeds 500 to 600 mg; the recommended dosing is 100 to 200 mg every 4 hours. Caffeine is provided in military rations in various forms, including some chewing gum, mints, applesauce, pudding, and mini First Strike bars.

PERFORMANCE NUTRITION AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer

The military medical officer (MMO) must be a performance nutrition role model. The MMO should not only be familiar with concepts related to performance nutrition, but should also practice these concepts on a daily basis in front of subordinates and superiors alike. MMOs should be competent in key topics, including nutrient timing, macronutrient distribution, and strategic use of caffeine. Additionally, knowledge about service-specific and DoD regulations and guidance regarding healthy body weight and dietary supplements is critical. Lastly, the MMO is responsible for knowing where to obtain reliable information.

Service-specific guidelines detail height, weight, and body composition standards required for all service members. Guidance is provided under Army Regulation 600-9,[42] Air Force Instruction 36-2905,[43] Navy OPNAV Instruction 6110.15J,[44] Marine Corps Order 6110.3,[45] and DoDI 1308.3.[46]

Guidance to the Commanding Officer

The commanding officer has the responsibility of understanding and promoting performance nutrition with regard to time and access to quality food. Further, the commanding officer should create an environment supportive of performance nutrition. Like the MMO, the commanding officer should model appropriate nutritional behaviors to subordinates. Additionally, the commanding officer needs to understand who he or she can contact for assistance on any issues related to performance nutrition and may rely on the MMO for information if a unit RD is not available.

RESOURCES

Several electronic DoD resources are publicly available. The Consortium for Health and Military Performance (CHAMP) at the Uniformed Services University of the Health Sciences hosts the Human Performance Resource Center (HPRC) (http://hprconline.org/). HPRC is a clearinghouse for evidence-based information regarding TFF and contains key resources to help service members and their families in all aspects of performance. HPRC is comprised of eight domains representing TFF, including physical fitness, environment, nutrition, family and relationships, and mental fitness.[47]

Operation Supplement Safety (OPSS) (http://opss.org) is a DoD-wide effort, including partnerships with other government and professional organizations, to provide evidence-based, up-to-date information on dietary supplements. OPSS educates service members and retirees, their family members, leaders, healthcare providers, and DoD civilians about dietary supplements and gives them tools to be informed supplement users. OPSS has also partnered with the US Anti-Doping Agency to develop a dietary supplements high-risk list. The high-risk list is intended to help service members and DoD civilians identify supplements that might pose a risk to their health or career. Other good sources of information on supplements include the Academy of Nutrition and Dietetics (http://www.eatright.org) and the Office of Dietary Supplements (http://ods.od.nih.gov/).

HPRC has partnered with the Natick Soldier Research, Development, and Engineering Center and the US Army Research Institute of Environmental Medicine to host the Combat Rations Database (ComRaD) (https://www.hprc-online.org/page/combat-rations-database-comrad). ComRaD is an interactive, educational website designed for visitors to view accurate, up-to-date nutritional information on individual combat ration menus (MREs, FSRs, and Meal Cold Weather/Long Range Patrol), group rations (Unitized Group Ration-A and Unitized Group Ration Heat & Serve), and an enhancement pack (Modular Operational Ration Enhancement), as well as the individual food components packed inside them. ComRaD enables service members, military RDs, food service officers, and leaders to learn about the nutritional content of their combat rations and use this information to help with fueling for optimal performance.

The National Academies of Sciences’ Engineering and Medicine Health and Medicine Division, formerly the Institute of Medicine, is an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision-makers and the public. The division focuses on asking and answering the nation’s most relevant questions regarding health and healthcare. All Engineering and Medicine Health and Medicine Division reports are available electronically (http://www.nationalacademies.org/hmd/Reports.aspx) at no cost. Hundreds of reports are available on a variety of topics from food and nutrition to public health, diseases, and veterans’ health.

Nutrition and Menu Standards for Human Performance Optimization[11] details the unique nutrition requirements of service members known as MDRIs. The MDRIs are based on DRI updates from the Food and Nutrition Board. Differences in nutritional requirements based on height, weight, gender, level of physical activity, and environmental factors including cold environments, hot environments, and altitude are discussed within the regulation. Compliance with this regulation is required for all food service operations including the DoD Combat Feeding Program.[11]

The US Department of Agriculture (USDA) provides a multitude of resources to consumers on a variety of topics related to nutrition. The USDA and HHS are responsible for developing the Dietary Guidelines for Americans,[48] which encourages Americans to eat a healthful diet; MyPlate (https://www.choosemyplate.gov/),[49] a visual depiction of how eat according to the Dietary Guidelines; and SuperTracker (https://www.supertracker.usda.gov/),[50] a free online food and activity tracking program. The Academy of Nutrition and Dietetics (http://www.eatright.org) also provides free publications and electronic resources.

SUMMARY

Military nutrition has always been associated with safety, health, readiness, and performance. Nutrition plays a vital role in every aspect of life: sleep, mood, physical and cognitive performance, sense of purpose, and health. The activities of service members are often unique and vary greatly from the general population, particularly with regard to environmental exposures and physical activity. Service members must be well nourished to remain healthy and fit for service. Today, developing, implementing and evaluating effective nutritional strategies to optimize performance before, during, and after training and operations remains a high priority for the DoD. Consistent messaging surrounding nutrition must encompass performance nutrition, health promotion, dietary supplements, and optimal fuel choices in dining facilities and other fueling environments. To support nutrition efforts, the DoD has intricately woven components of nutrition into several important policy documents. Support from MMOs and commanding officers is mission critical and will drive successful implementation of performance nutrition.

REFERENCES

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10.   U.S Army Research, Development, and Engineering Command. Operational Rations of the Department of Defense. 9th ed. Natick, MA: RDECOM; 2012. Natick Pamphlet 30-25.

11.   US Department of the Army. Nutrition and Menu Standards for Human Performance Optimization. Washington, DC: DoD; 2017. Army Regulation 40-25, OPNAV Instruction 10110.1, Marine Corps Order 10110.49, Air Force Instruction 44-141.

12.   National Research Council. Committee on Military Nutrition Research: Activity Report 1994-1999. Washington, DC: National Academies Press; 1999.

13.   National Academies of Sciences, Engineering, and Medicine. Publications. http://www.nationalacademies.org/hmd/Reports.aspx?sa.x=0&sa.y=0&sa=Search&site=iom_reports&client=iom_frontend&output=xml_no_dtd&filters=inmeta:activity%3DMilitary+Nutrition+Research&getfields=nap_id.description.report_date&sort=date:D:R:d1&filter=0&ie=UTF-8&ip=216.230.117.99&access=p&entqr=3&entqrm=0&wc=200&wc_mc=1&q=site:nationalacademies.org/hmd+inmeta:activity%3DMilitary%2520Nutrition%2520Research&dnavs=inmeta:activity%3DMilitary%2520Nutrition%2520Research&ulang=&q=(filetype:html+%7C+filetype:aspx+)&start=0. Accessed February 2, 2018.

14.   National Research Council. Recommended Dietary Allowances. Washington, DC: National Academies Press; 1941. https://doi.org/10.17226/13286. Accessed February 2, 2018.

15.   Harper AE. Origin of Recommended dietary allowances—an historic overview. Am J Clin Nutr. 1985;41(1):140–148.

16.   Sheffer M, Taylor CL. Development of DRIs 1994-2004: Lessons Learned and New Challenges: Workshop Summary. Washington, DC: National Academies Press; 2008.

17.   Atkinson SA. Defining the process of dietary reference intakes: framework for the United States and Canada. Am J Clin Nutr. 2011;94(2):655s–657s.

18.   Laertius D. The Lives and Opinions of Eminent Philosophers. London, England: GH Bohn; 1853.

19.   Applegate EA, Grivetti LE. Search for the competitive edge: a history of dietary fads and supplements. J Nutr. 1997;127(5 Suppl):869s–873s.

20.   Grivetti LE, Applegate EA. From Olympia to Atlanta: a cultural-historical perspective on diet and athletic training. J Nutr. 1997;127(5 Suppl):860s–868s.

21.   Ahlborg B, Bergström J, Ekelund L-G, Hultman E. Muscle glycogen and muscle electrolytes during prolonged physical exercise. Acta Physiol Scand. 1967;70(2):129–142.

22.   Cox PJ, Clarke K. Acute nutritional ketosis: implications for exercise performance and metabolism. Extrem Physiol Med. 2014;3:17.

23.   Volek JS, Noakes T, Phinney SD. Rethinking fat as a fuel for endurance exercise. Eur J Sport Sci. 2015;15(1):13–20.

24.   Rodriguez NR, Di Marco NM, Langley S. American College of Sports Medicine position stand. Nutrition and athletic performance. Med Sci Sports Exerc. 2009;41(3):709–731.

25.   Steinmuller PL, Kruskall LJ, Karpinski CA, Manore MM, Macedonio MA, Meyer NL. Academy of nutrition and dietetics: revised 2014 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in sports nutrition and dietetics. J Acad Nutr Diet. Apr 2014;114(4):631-641.e643.

26.   Ivy JL, Portman R. Nutrient Timing: The Future of Sports Nutrition. Laguna Beach, CA: Basic Health Publications, Inc.; 2004: 449.

27.   Kerksick C, Harvey T, Stout J, et al. International Society of Sports Nutrition position stand: nutrient timing. J Int Soc Sports Nutr. 2008;5:17.

28.   Burke LM. Fueling strategies to optimize performance: training high or training low? Scand J Med Sci Sports. 2010;20(Suppl 2):48–58.

29.   Stellingwerff T, Cox GR. Systematic review: Carbohydrate supplementation on exercise performance or capacity of varying durations. Appl Physiol Nutr Metab. 2014;39(9):998–1011.

30.   McLellan TM, Pasiakos SM, Lieberman HR. Effects of protein in combination with carbohydrate supplements on acute or repeat endurance exercise performance: a systematic review. Sports Med. 2014;44(4):535–550.

31.   Martinez-Lagunas V, Ding Z, Bernard JR, Wang B, Ivy JL. Added protein maintains efficacy of a low-carbohydrate sports drink. J Strength Cond Res. 2010;24(1):48–59.

32.   Howarth KR, Phillips SM, MacDonald MJ, Richards D, Moreau NA, Gibala MJ. Effect of glycogen availability on human skeletal muscle protein turnover during exercise and recovery. J Appl Physiol (1985). 2010;109(2):431–438.

33.   Pasiakos SM, McClung HL, McClung JP, et al. Leucine-enriched essential amino acid supplementation during moderate steady state exercise enhances postexercise muscle protein synthesis. Am J Clin Nutr. 2011;94(3):809–818.

34.   Pasiakos SM, McClung JP. Supplemental dietary leucine and the skeletal muscle anabolic response to essential amino acids. Nutr Rev. 2011;69(9):550–557.

35.   Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). Washington, DC: National Academies Press; 2005.

36.   Dietary Supplement Health and Education Act of 1994. Pub L No. 103-417. https://www.congress.gov/bill/103rd-congress/senate-bill/784. Accessed February 2, 2018.

37.   Brunye TT, Mahoney CR, Lieberman HR, Giles GE, Taylor HA. Acute caffeine consumption enhances the executive control of visual attention in habitual consumers. Brain Cogn. 2010;74(3):186–192.

38.   Judelson DA, Preston AG, Miller DL, Munoz CX, Kellogg MD, Lieberman HR. Effects of theobromine and caffeine on mood and vigilance. J Clin Psychopharmacol. 2013;33(4):499–506.

39.   Kamimori GH, McLellan TM, Tate CM, Voss DM, Niro P, Lieberman HR. Caffeine improves reaction time, vigilance and logical reasoning during extended periods with restricted opportunities for sleep. Psychopharmacology (Berl). 2015;232:2031–2042.

40.   Lieberman HR, Stavinoha T, McGraw S, White A, Hadden L, Marriott BP. Caffeine use among active duty US Army soldiers. J Acad Nutr Diet. 2012;112(6):902–912, 912.e901-904.

41.   Tharion WJ, Shukitt-Hale B, Lieberman HR. Caffeine effects on marksmanship during high-stress military training with 72 hour sleep deprivation. Aviat Space Environ Med. 2003;74(4):309–314.

42.   US Department of the Army. The Army Body Composition Program. Washington, DC: DA; 2013. Army Regulation 600-9.

43.   US Department of the Air Force. Air Force Fitness Program. Washington, DC: DAF; 2013. Air Force Instruction 36-2905.

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45.   US Department of the Navy. Marine Corps Body Composition and Military Appearance Program. Washington, DC: DN; 2008. Marine Corps Order 6110.3.

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47.   Uniformed Services University of the Health Sciences. Human Performance Resource Center. http://hprc-online.org/. Accessed May 6, 2015.

48.   US Department of Agriculture. Dietary Guidelines for Americans, 2015–2020. 8th ed. Washington, DC: DoA; 2015.

49.   US Department of Agriculture. ChooseMyPlate.gov. http://www.choosemyplate.gov/. Accessed May 6, 2015.

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Chapter 22

ENVIRONMENTAL EXTREMES: HEAT AND COLD

FRANCIS G. O’CONNOR, MD, MPH*; RICHARD A. SCHEURING, DO, MS†; AND PATRICIA A. DEUSTER, PHD, MPH‡

INTRODUCTION

DEFINITIONS

MILITARY HISTORY AND EPIDEMIOLOGY

MILITARY APPLIED PHYSIOLOGY

Heat

Cold

HUMAN PERFORMANCE OPTIMIZATION STRATEGIES FOR EXTREME ENVIRONMENTS

Heat Strategies

Cold Strategies

HEAT AND COLD STRESS AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer

Guidance to the Commanding Officer

MILITARY RESOURCES

SUMMARY

*Colonel (Retired), US Army Medical Corps; Professor and former Department Chair, Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Colonel, US Army Reserve Medical Corps; Associate Professor, Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

‡Professor and Director, Consortium for Health and Military Performance (CHAMP), Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

Service members on today’s battlefield confront a variety of environmental challenges, particularly with the emergence of unconventional, asymmetric, and hybrid warfare. Knowledge of these environmental challenges, as well as strategies to mitigate against the stressors that impact optimal performance and provide an advantage against enemy combatants, are essential for the military medical officer (MMO). This chapter specifically addresses the environmental challenges of heat and cold exposures as applied to today’s warfighter; the focus is on enhancing performance in these settings. Specifically discussed are core definitions applied to these stressors, relevant military history and epidemiology, applicable applied physiology, and detailed prevention strategies. Specific guidance and resources are provided to assist the MMO in identifying and preventing the consequences of environmental stress experienced by combatants.

DEFINITIONS

Common terminologies related to thermal challenges (heat and cold) that confront service members are presented in Exhibits 22-1 and 22-2. First, basic and specific applied physiologic definitions are provided to assist the MMO in interpreting relevant literature and established military doctrinal guidance. These definitions are followed by terms associated with common medical conditions and injuries in that particular environment.

MILITARY HISTORY AND EPIDEMIOLOGY

Extremes of both heat and cold have always plagued soldiers.1–3 Old Testament authors documented the health risks of wearing heavy body armor in the heat, noting, “when the sun stands still in the heavens,” it helps the Hebrews fight the more heavily armored Canaanites. In 400 BCE, in one of the first reliable reports on the effect of heat in military operations, Herodotus described the effects of load carriage, protective clothing, and heat stress during an Athenian and Spartan conflict as both armies were worn out by the “thirst of the sun.” In 325 BCE, while returning home from his conquests, Alexander the Great and 40,000 troops were exposed to 2 months of extreme heat and inadequate water. The army arrived home with only 5,000 soldiers remaining. Hannibal lost nearly half his army from cold injury while crossing the Alps from Spain in 153 BCE. The Roman legionary had knowledge of heat illness and associated risk factors, including load carriage, and instituted mitigation strategies: headgear included the capability to insert rushes in the helmet, which were kept wet with water, and noncombatant auxiliaries were utilized to carry supplies and weapons to preserve the legionnaires’ strength for fighting.

The principal of heat acclimatization became apparent during the Middle Ages when English King Edward’s heavily armored crusaders were defeated by lighter Arab horsemen in one of the final battles of the Crusades; the English loss was attributed to the advantage the native Arabs had by living regularly in the heat.[1] Military environmental casualties and loss of troop effectiveness have remained significant operational concerns in modern warfare; it is estimated that in the early period of World War II in the Pacific theater of operations, there were over 100 casualties from heat or illness for every combat casualty. In the European theater, between autumn 1944 and spring 1945, 46,000 cases of cold weather injury were reported, and nearly 10% of all injuries were secondary to cold exposure.1,2

Currently, the Armed Forces Health Surveillance Center publishes the Medical Surveillance Monthly Report, an important document for all MMOs to be familiar with. The report regularly provides critical insight into disease trends in the US military. Table 22-1 presents patterns of heat and cold injuries from 2010 through 2014. Clearly, cold injuries were less common than heat injuries during these years.4,5

Unfortunately, recent efforts to mitigate exertional heat stroke casualties have not reduced injury rates. The annual rate (unadjusted) of cases of heat stroke in 2014 was slightly higher than in 2013 and similar to rates in 2011 and 2012. In 2014, the incidence of heat stroke was highest among males and service members younger than 20 years of age, Asian/Pacific Islanders, Marine Corps and Army members, recruit trainees, and combat-specific occupations. Heat stroke rates in the Marine Corps were 50% higher than in the Army, and Army heat injury rates were more than 9-fold those in the other two services. The incidence was 86% higher among males than females.

The rate of cold injuries was higher in 2014 than previous years, despite robust training, doctrine, procedures, and protective equipment and clothing to counter the threat from cold exposure. The Army and Marine Corps accounted for most of the increase in cold injuries from the year before, and like heat injury, the rate was highest among those under 20 years of age. In contrast, cold injuries were higher in females than in males across the 5-year period, for reasons that are not completely understood. Since then, increased efforts in training, equipment, and education among the troops have still not resulted in reduced injury rates due to cold exposure.[5]

EXHIBIT 22-1

HEAT AND COLD APPLIED PHYSIOLOGY TERMINOLOGY

General Thermoregulation Terms

- Acclimation. Physiological adaptations to environmental stress that occurs through experimentally induced stressors, eg, exercising in a hot or cold chamber.

- Acclimatization. Physiological adaptations to the environmental stress that occur from natural environmental stressors, eg, exercising in a hot and humid, or cold and wet, environment.

- Habituation. The diminishing of a physiological response to a frequently repeated stimulus, eg, repeated cold exposure leads to blunted shivering and decreased cold-induced vasoconstriction.

- Conduction. Direct heat transfer to an adjacent, cooler object.

- Convection. Transfer of heat to a gas or liquid moving over the body. Heat transfer occurs when the gas or liquid is colder than the body. Convective heat loss by water can be large because the convective heat transfer coefficient of water is 25 times more than air.

- Evaporation. Occurs when water from eccrine sweat glands vaporizes from the skin. Evaporation is an effective mechanism for dissipating excess heat, associated with a heat loss of 580 kcals/L of sweat.

- Radiation. Emission of electromagnetic heat waves; does not require direct contact or air motion.

- Thermal balance equation. S = M – (±W) ± (R + C) ± K – E, where S = rate of body heat storage, M = rate of metabolic energy production, W = mechanical work of exercise, R + C = rate of radiant and convective energy exchange, K = rate of conduction, and E = rate of evaporative loss.

Heat Terms

- Thermotolerance. Ability to compensate for heat stress and sustain work. Individuals who are unable to sustain heat and whose body temperatures rise faster than others in comparable conditions are heat intolerant. Heat intolerance can be congenital (eg, ectodermal dysplasia); functional (eg, lack of acclimatization); or acquired (eg, infection, prior heat stroke).

- Heat stress and strain (compensated and uncompensated). Heat stress refers to the environmental and host conditions that increase body temperature; heat strain is the physiological and psychological consequence of heat stress. Compensated heat stress occurs when heat gain and loss are balanced so that a steady state is reached and work can be maintained; uncompensated heat stress occurs when cooling requirements are exceeded, a steady state cannot be maintained, and physiologic fatigue results.

- Wet bulb globe temperature (WGBT). An index developed by the military to calculate overall environmental heat load. The WBGT integrates radiant heat, ambient temperature, and relative humidity.

WBGT = 0.1 × dry bulb temperature (ambient air temperature) + 0.7 × wet bulb temperature (relative humidity) + 0.2 × globe temperature (radiant heat)

Cold Terms

- Cold stress. Environmental and/or personal conditions that tend to remove body heat and decrease body temperature. Cold stress is frequently measured by the wind chill temperature.

- Cold strain. Physiologic and/or psychological consequences of cold stress.

- Wind chill temperature. A quantity expressing the effective lowering of the air temperature caused by the wind, especially as it affects the rate of heat loss from an object or human body or as it is perceived by an exposed person.

- Hypothermia. A decline of 2°C or 3.6°F in normal human core temperature (37°C or 98.6°F).

- Rewarming (passive and active). Passive rewarming is preventing further heat loss. Active rewarming is applying an external or internal (core) source of heat.

- Rewarming shock. Vascular collapse during rewarming, secondary to depressed myocardium, vasodilation, and hypovolemia.

- After-drop. Further cooling of the body core after removal from cool environment; caused by cool blood from the periphery returning to the core.

EXHIBIT 22-2

HEAT AND COLD INJURY TERMINOLOGY

Exertional Heat Illness

- Heat exhaustion. Characterized by the inability to maintain adequate cardiac output due to strenuous physical exercise and environmental heat stress. Other symptoms generally include difficulty continuing with exercise, core body temperature between 101° and 104°F (38.3°–40.0°C), possible dehydration, but no significant dysfunction of the central nervous system (eg, seizure, altered consciousness, persistent delirium).

- Heat injury. Characterized by evidence of hyperthermia and possible end organ damage, but without significant neurologic manifestations. Other symptoms generally include a core temperature from 104° to 105°F (40.0°–40.5°C); clinical and laboratory manifestations of metabolic acidosis, rhabdomyolysis, acute kidney injury, and liver failure; and the absence of neurologic findings.

- Exertional heat stroke. A multisystem illness characterized by central nervous system dysfunction (encephalopathy) and additional organ and tissue damage (eg, acute kidney injury, liver injury, rhabdomyolysis), as well as a core temperature above 104°F (40°C) measured immediately following collapse during strenuous activity. Central nervous system dysfunction can manifest as a wide range of possible symptoms and signs, including disorientation, headache, irrational behavior, irritability, emotional instability, confusion, altered consciousness, coma, or seizure.

Cold Injury

- Hypothermia. Defined as a body core temperature below 35.0°C (95.0°F). Symptoms depend on the temperature. In mild hypothermia, there is shivering and mental confusion. In moderate hypothermia, shivering stops and confusion increases. In severe hypothermia there may be paradoxical undressing, where a person removes their clothing, as well as an increased risk of the heart stopping.

- Mild hypothermia: 90°F (32°C) – 95°F (35°C)

- Moderate hypothermia: 82°F (28°C) – < 90°F (32°C)

- Severe hypothermia: < 82°F (28°C).

- Frostbite. Medical condition in which localized damage is caused to skin and other tissues due to freezing.

- Trench foot. A nonfreezing medical condition caused by prolonged exposure of the feet to damp, unsanitary, and cold conditions.

TABLE 22-1

THERMAL INJURIES IN ACTIVE COMPONENT SERVICE MEMBERS, 2010–2014

*per 10,000 person-years

Data sources: (1) Update: heat injuries, active component, US armed forces, 2014. MSMR. 2015;22(3):17–20. (2) Nagarajan S. Update: cold weather injuries, active and reserve components, US armed forces, July 2010–June 2015. MSMR. 2015;22(2):7–12.

MILITARY APPLIED PHYSIOLOGY

Human performance is compromised by extremes of temperature, as well as depth and increased altitudes above sea level. Work efficiency can be reduced at all extremes, and efficiency must be considered in any temperature, altitude, flight, or undersea mission. Understanding the basic principles of applied physiology that contribute to these performance decrements are critical for the MMO, who is frequently called on for the proper interpretation of resources and guidelines that discuss environmental stress. Knowledge of physiology enables the MMO to identify and modify those factors that can be mitigated or leveraged for success in the operational environment, while promoting prevention by educating the individual warfighter as well as the unit leadership.

Heat

Although the human body has remarkable resilience against cold, it can tolerate only minor temperature elevations (up to 9°F) without developing systemic dysfunction, which ultimately leads to multiorgan failure and death, if body temperature cannot be lowered.[6] Accordingly, the human body has multiple mechanisms to dissipate heat, including convection, conduction, radiation, and most importantly, evaporation (Figure 22-1).

During exercise, the human body acts to dissipate the excess heat generated by skeletal muscle; this requires an intact cardiovascular system that uses blood to transfer heat from the body core to the skin, where the mechanisms for dissipating heat can take effect. However, when the ambient temperature is higher than the body’s core temperature, convection, conduction, and radiation are no longer effective. Environmental conditions also effect evaporative cooling. A water vapor pressure gradient must exist for sweat to evaporate and release heat into the environment. In high humidity (relative humidity >75%), evaporation becomes ineffective for transferring heat. Thus, in hot and humid conditions, service members become susceptible to exertional heat illness.

Limitations on heat dissipation in hot and humid weather are exacerbated during intense exercise by a finite supply of blood that must fulfill multiple functions, including meeting the metabolic demands of active skeletal muscle and transporting heat to the skin surface for cooling. Further complicating matters is the dehydration that most individuals develop during intense exercise in the heat, which decreases plasma volume. Studies suggest that during intense exercise in the heat, for every 1% of body weight lost from dehydration, there is a concomitant increase in core body temperature of 0.22°C (0.4°F).[6] In other words, other factors being equal, a service member who loses only 1% of body weight from dehydration during intense exercise in the heat would be 1°C cooler compared to a buddy who loses 6% of body weight. This would equate to a temperature difference of approximately 39°C (102°F) versus 40°C (104°F) at the end of a training session. A number of additional factors influence the rate at which a person’s core body temperature rises during vigorous activity, including fitness level, degree of acclimatization to heat, clothing/equipment, use of certain types of nutritional supplements, and physiologic response (eg, degree of tachycardia).

Figure 22-1. Physiological and environmental mechanisms of heat generation and dissipation.

During exercise the body’s temperature becomes elevated in response to the increase in metabolic heat production; a modest rise in temperature is thought to represent a favorable adjustment that optimizes physiologic functions and facilitates heat loss mechanisms (as described in Figure 22-1). With compensated heat stress, the body achieves a new steady-state core temperature proportional to the increased metabolic rate and available means for dissipating heat. Studies in runners describe this mechanism as exercise-induced hyperthermia; runners have demonstrated that they can complete events successfully with significantly elevated core temperatures (103°–104°F) and remain entirely asymptomatic.[7] Uncompensated heat stress results when cooling capacity is exceeded and the service member or athlete cannot maintain a steady temperature. Continued exertion in the setting of uncompensated heat stress increases heat retention, causing a progressive rise in core body temperature and increasing the risk for severe heat illness.

Service members, unfortunately, do not always have time to properly acclimatize, and may encounter scenarios in which a failure to compensate may result in an exertional heat illness. Body temperature can increase through a number of mechanisms: exposure to environmental heat (impeded heat dissipation); physical exercise (increased heat production); fever from systemic illness (elevated set point with subsequent activation of shivering); and medications that may cause neuroleptic malignant syndrome and malignant hyperthermia.

Importantly, febrile persons have accentuated elevations in core temperature when exposed to high ambient temperature, physical exercise, or both. Environmental temperature and humidity, medication, and exercise heat stress in turn challenge the cardiovascular system to provide high blood flow to the skin, where blood pools in warm, compliant vessels such as those found in the extremities. When blood flow is diverted to the skin, reduced perfusion of the intestines and other viscera can result in ischemia, endotoxemia, and oxidative stress.[8] In addition, excessively high tissue temperatures can produce direct tissue injury (heat shock: >41°C [105.8°F]).

Figure 22-2. Effects of cold exposure on heat conservation (left) and heat dissipation (right).

The magnitude and duration of heat shock influences whether cells respond by adaptation (acquired thermal tolerance), injury, or death (apoptotic or necrotic). Heat shock, ischemia, and systemic inflammatory responses can result in cellular dysfunction, disseminated intravascular coagulation, and multiorgan dysfunction syndrome. In addition, reduced cerebral blood flow, combined with abnormal local metabolism and coagulopathy, can lead to dysfunction of the central nervous system. This situation is an example of uncompensated heat stress, which can severely denigrate a service member’s performance, put the individual at risk for significant morbidity and mortality, and compromise the unit’s mission.

Cold

As previously stated, the human body is much more resilient against cold and lowered changes in temperature than heat. Despite this hardiness, cold exposure can significantly impact warfighter performance, and ultimately the completion of the mission. The principles of heat exchange discussed above remain the same; however, the MMO must be aware of several additional factors related to cold.

Convection becomes critically important when service members lose significant amounts of heat in windy environments in the absence of protective clothing; the wind chill temperature calculation factors convective heat loss into risk. Convective loss can become even more important when soldiers are exposed to cold water because the convective heat transfer coefficient of water is about 25 times greater than that of air.[9] Radiant heat loss can become an issue as the sun goes down and service members are exposed to a clear night sky. Conductive heat loss can be a concern with soldiers sleeping on cold ground or snow; heat loss can become even more magnified if clothing is wet. Non-evaporative sweat in cold weather can also lead to wet clothing, decreasing its insulation capacity.

Heat conservation is supplemented by mechanisms to increase heat production. Cold exposure leads to an increase in metabolic heat production, which can help offset heat loss. Body temperature is normally regulated through two parallel processes: behavioral temperature regulation and physiologic temperature regulation. Behavioral thermoregulation includes reducing direct cold exposure using clothing or protective shelter, and increasing physical activity. Unfortunately, mission requirements may prevent these actions, causing service members to rely on the physiologic mechanisms of peripheral vasoconstriction and shivering to preserve body heat. Shivering can be sustained longer than exercise, but exercise results in twice the rate of heat production. Shivering does come with a metabolic cost with an increase in oxygen uptake.

TABLE 22-2

HUMAN PERFORMANCE STRATEGIES TO MITIGATE HEAT AND COLD INJURY

Environment

Performance Risk Factor or Challenge

Strategy

Heat

Lack of heat acclimatization

Acclimatization strategy (TB MED 507/Air Force Pamphlet 48-152, Heat Stress Control and Heat Casualty Management)

Heat

Lack of aerobic fitness

Improve aerobic fitness (FM 7-22, Army Physical Readiness Training)

Heat

Mismatch of hydration and work/rest

Institution of appropriate work, rest, and hydration guidance
(Army Institute of Environmental Medicine/Army Public Health Center work/rest and water consumption table, Table 22-4)

Cold

Lack of cold weather acclimatization

Acclimatization/habituation strategy
(Army TB MED 508, Prevention and Management of Cold Weather Injuries)

Cold

Inappropriate environmental clothing

Appropriate clothing
(Army TB MED 508, Prevention and Management of Cold Weather Injuries)

Heat conservation through peripheral vasoconstriction is the principal physiologic mechanism utilized to mitigate cold stress (Figure 22-2). The resulting decrease in peripheral blood flow reduces convective heat transfer from the body’s core to the shell (skin, subcutaneous fat, and muscle). This vasoconstrictor response results in a lower skin temperature while preserving the body’s core temperature. The vascular shunting of blood from the skin and limbs to the vital organs, while defending the core temperature, can paradoxically contribute to the etiology of cold-induced injuries.

Multiple individual factors can contribute to modifying the physiologic response to cold.[9] Individuals with a high body surface area to mass ratio (ectomorphs) lose more body heat than those with lower body surface area to mass ratios (endomorphs). Gender and ethnicity have been demonstrated to be risk factors as well. Females and African Americans have twice the rate of cold injury, which may be secondary to long, slender fingers and a greater body surface area to mass ratio. Fitness and training, which are significant risk factors for heat injury, do not have an effect on cold temperature regulation. However, fatigue is an important militarily relevant risk factor for cold injury and can impair both peripheral vasoconstriction and shivering. Finally, inadequate nutrition can be a key contributor to a risk for cold injury because hypoglycemia can impair the shivering response.

HUMAN PERFORMANCE OPTIMIZATION STRATEGIES FOR EXTREME ENVIRONMENTS

Primary prevention is the cornerstone to optimizing human performance in extreme environments. This section discusses military relevant human performance optimization strategies to assist in preventing injury and optimizing performance among service members. Table 22-2 lists evidence-based strategies, including the targeted risk factor, to optimize warfighter performance in environmental extremes.

Heat Strategies

Tolerance of extreme heat and humidity depends upon a number of functional, acquired, and congenital factors, the most important of which is acclimatization (Table 22-3).[10] Acclimatization is the body’s ability to improve its response to and tolerance of heat stress over time. Thus, allowing sufficient time and using optimal training strategies that enable service members to acclimatize is critical for improving performance and mitigating the risk for exertional heat illness (EHI). Observational studies have found that the first week of training in high heat and humidity, for both service members and athletes, is the period of greatest risk for EHI.6,11 Acclimatization requires at least 1 to 2 weeks. However, any improved tolerance of heat stress generally dissipates within 2 to 3 weeks of returning to a more temperate environment. Acclimatization in warfighters is accomplished with a combination of environmental exposure with exercise; the Army/Air Force publication Heat Stress Control and Heat Casualty Management (TB MED 507/Air Force Pamphlet 48-152) details optimal acclimatization strategies.[6]

TABLE 22-3

FACTORS UNDERLYING HEAT INTOLERANCE IN THE YOUNG ACTIVE POPULATION

Congenital

Functional

Acquired

Ectodermal dysplasia
Chronic idiopathic anhidrosis

Low physical fitness
Lack of acclimatization
Low work efficiency
Reduced skin area to body mass ratio

Sweat gland dysfunction
Dehydration
Infectious disease
X-ray irradiation
Drugs, supplements
Large scarred burn areas
Previous heat stroke

The major physiologic adjustments that occur during heat and humidity acclimatization include expanded plasma volume, improved cutaneous blood flow, lowered threshold for initiation of sweating, increased sweat output, lowered salt concentration in sweat, and lowered skin and core temperatures during a standard exercise.[12] These adaptations allow for better dissipation of heat during exercise and limit increases in body temperature compared to service members who have not acclimatized. Exhibit 22-3 describes the known physiologic benefits of acclimatization. Table 22-4 details current guidance for ground units published by the US Army Institute of Environmental Medicine.[6] The table’s recommendations are based upon an assessment of the wet bulb globe temperature to determine the heat category.

Improving performance in the heat also leverages many proactive strategies to keep service members cool and mitigate the risk of heat illness. A strategy utilized in the military is “heat dumping,” in which heat is transferred to the environment using techniques such as cool mist showers. One novel intervention used in the military is the arm immersion cooling system (AICS) (Figure 22-3). The AICS is a simple, efficient method for facilitating body (core and skin) temperature cooling and reducing the risk of serious heat illness. The AICS takes advantage of the rapid rate of heat transfer from the skin directly into cool water (compared to transfer into evaporative sweat or air), and the large surface area to mass ratio of the forearms. Several studies have reported that hand and forearm immersion in cool (50°–68°F) water reduces core and skin temperature faster than a noncooling control, extends tolerance time, and increases total work time.[13]

EXHIBIT 22-3

ACTIONS OF HEAT ACCLIMATIZATION

- Thermal comfort: improved

- Exercise performance: improved

- Core temperature: reduced

- Cardiovascular stability: improved

- Heart rate: lowered

- Stroke volume: increased

- Blood pressure: better defended

- Myocardial compliance: improved

- Sweating: improved

- Earlier onset

- Higher rate

- Redistribution

- Hidromeiosis resistance

- Fluid balance: improved

- Electrolyte loss: reduced

- Skin blood flow: improved

- Earlier onset

- Higher rate

- Total body water: increased

- Metabolic rate: lowered

- Plasma volume: increased and better defended

TABLE 22-4

WORK/REST AND WATER CONSUMPTION TABLE

Table courtesy of the US Army Institute of Environmental Medicine and US Army Public Health Center.

Cold Strategies

Although service members can successfully leverage acclimatization as a strategy to prevent heat illness, strategies for acclimatization are not as well developed as a protective mechanism to combat cold stress. Cold acclimatization manifests in three different patterns of thermoregulatory adjustments: habituation, metabolic acclimatization, and insulative acclimatization. Habituation involves the blunting of both shivering and cold-induced vasoconstriction with prolonged exposure. Studies have demonstrated that short, intense cold exposures (<1 hour) several times a week for 2 to 3 weeks can stimulate a habituation response.[9] Metabolic acclimatization involves an exaggerated shivering response, while insulative acclimatization involves enhanced heat conservation methods. With insulative acclimatization, cold exposure elicits a more rapid and more pronounced decline in skin temperature and lower thermal conductance at the skin than in the unacclimatized state.

Because acclimatization is not an optimal strategy to mitigate cold stress, other strategies to combat cold stress injuries and optimize performance must be considered. Selected strategies involve avoidance, appropriate work/rest cycles, and suitable clothing. Cold-weather clothing is specifically designed to protect against hypothermia by reducing heat loss to the environment (Figure 22-4). Protective insulation is determined by how much air is effectively trapped by clothing. Service members require clothing that can accommodate a range of ambient temperatures and physical activity levels, and that can protect against wind, rain, and snow. This is accomplished by following two important concepts when dressing for activities in the cold: layering and staying dry. Multiple layers of clothing allow air to be trapped to serve as insulation, and allow the individual to adjust layers according to environmental conditions and activity level. Layers can be removed as the ambient temperature or physical activity levels increase, thereby reducing sweating and moisture buildup within clothing. The Army publication Prevention and Management of Cold Weather Injuries (TB MED 508)[9] is an excellent resource that details the practical prevention of cold weather injuries through the appropriate selection of clothing.

Figure 22-3. Arm immersion cooling system.

Figure 22-4. Generation III Extended Cold Weather Clothing System. Provides soldiers a multi-layered, versatile insulating system adaptable to varying operational and environmental conditions. March 2, 2010. Army Program Executive Office (PEO) Soldier photo.
Reproduced from: https://www.flickr.com/photos/peosoldier/4777344669/.

HEAT AND COLD STRESS AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer

MMOs are expected to have scientific background in the physiology of extreme environments, as well as the medical knowledge to provide recommendations for prevention of environmental injuries, to assist in the treatment of such injuries, and to make return-to-duty determinations when restriction from activity or deployment may be essential. Above all, the best treatment strategy for all potential environmental injuries or illness is primary prevention. In addition to leveraging acclimatization, the MMO must be proactive in assessing environmental stress and implementing appropriate work/rest and hydration strategies.

The services systematically approach risk management for environmental stress comparably to approaches for other stresses, utilizing a series of steps.[14] The five steps of risk management—identify the hazards, assess the hazards, develop controls and make risk decisions, implement controls, and supervise and evaluate—are used across the services to help them operate as a joint force and optimize readiness (Figure 22-5).

Figure 22-5. The Army risk management process.

When leadership identifies an environmental risk of EHI, the risk management process is carefully planned to assess the risk and implement mitigation strategies. Activities implemented to reduce risk include those previously discussed: education, acclimatization, appropriate adjustment of activities to include work/rest and hydration strategies, and being prepared for early EHI management. Depending upon the degree of assessed risk, leaders of increasing rank are required to review and approve training plans. Arguably the military’s most important tool in preventing EHI is leadership; all leaders are expected to proactively implement preventive measures to mitigate the threat of heat casualties.

To mitigate the consequences of cold exposure, the MMO should know that physiologic acclimatization to cold stress can occur, but it is generally considered modest at best, and requires more time to develop and is less practical than heat acclimatization. MMOs must review all possible techniques and strategies to minimize cold injuries.

Guidance to the Commanding Officer

Ultimately, MMOs serve in support of the commanding officer, and they must remain aware of issues related to environmental conditions. Developing credibility and trust are key; without them, an MMO will be less effective in mitigating environmental risks. Being aware of individual service member needs, having access to resources for finding new strategies, and identifying realistic countermeasures are important for success.

MILITARY RESOURCES

General

- The Medical Surveillance Monthly Report (https://www.afhsc.mil/Search/SearchMSMR) provides evidence-based estimates of the incidence, distribution, impact, and trends of illnesses in service members and associated populations. Annual reports are published on topics such as environmental illnesses, which allow for comparisons of prior year data and assessment of preventive strategies.

Heat

- The US Army Public Health Command Heat Injury Prevention website (http://phc.amedd.army.mil/topics/discond/hipss/Pages/HeatInjury-Prevention.aspx) provides heat casualty prevention information such as the Composite Risk Management for Heat Injury Prevention, Identification, and Response, FY 2010.

- The US Army Research Institute of Environmental Medicine (http://www.usariem.army.mil/) has additional resources such as the Ranger & Airborne School Students Heat Acclimatization Guide.

- Commanders and healthcare providers in the Army and Air Force should use TB MED 507/Air Force Pamphlet 48-152, Heat Stress Control and Heat Casualty Management,[6] to develop a comprehensive heat illness prevention program. This program should be complemented with Army risk management doctrine, as detailed in FM 5-19, Composite Risk Management. These documents provide the framework for early recognition of climatic injuries and implementation of preventive measures.

- The US Army Training and Doctrine Command has published regulations providing guidance to commanders for prevention of heat casualties in TRADOC Regulation 350-29, Prevention of Heat and Cold Casualties (http://www.tradoc.army.mil/tpubs/regs/tr350-29.pdf).

- Navy medical personnel can find guidance on the management of exertional heat illness published by the Bureau of Medicine and Surgery. Current policy is identified in Technical Manual NEHC-TM-OEM 6260.6A, Prevention and Treatment of heat and Cold Stress Injuries (http://www.med.navy.mil/sites/nmcphc/Documents/policy-and-instruction/oem-prevention-andtreatment-of-heat-and-cold-stress-injuries.pdf).

Cold

- Cold Injury Prevention (Army Public Health Center [Provisional] webpage: https://phc.amedd.army.mil/Pages/default.aspx).

- Army TB MED 508, Prevention and Management of Cold Weather Injuries,[9] a quintessential military resource detailing guidance on cold injury, was published in 2005 and supersedes TB MED 81/NAVMED P-5052-29/AFP 161-11, 30 September 1976.

SUMMARY

This chapter has introduced the basics of optimizing service member performance in hot or cold operational settings. Specifically, the historical relevance of the environment to success in military operations, the basic applied physiology relevant to understanding the warfighter in the environment, and evidence-based strategies demonstrated to preserve performance in environmental extremes are discussed. The MMO operates in a unique setting with limited resources, where urgency and proper planning can mark the difference between success and failure on the battlefield. It is important to remember that MMOs serve not just to treat wounded, but also to provide guidance to the commanding officer to optimize the unit’s performance and ultimately support mission success.

REFERENCES

1.   Goldman RF. Introduction to heat-related problems in military operations. In: Wenger CB, ed. Medical Aspects of Harsh Environments. Vol 1. Washington, DC: Borden Institute; 2001: 3–49.

2.   McCallum JE. Military Medicine: From Ancient Times to the 21st Century. Santa Barbara, CA: ABC-CLIO, Inc; 2008.

3.   Gabriel RA. Between Flesh and Steel: A History of Military Medicine from the Middle Ages to the War in Afghanistan. Washington, DC: Potomac Books; 2013.

4.   Update: heat injuries, active component, US armed forces, 2014. MSMR. 2015;22(3):17–20.

5.   Nagarajan S. Update: cold weather injuries, active and reserve components, US armed forces, July 2010–June 2015. MSMR. 2015;22(2):7–12.

6.   US Department of Defense. Heat Stress Control and Heat Casualty Management. Washington, DC: Headquarters, Department of the Army and Air Force, March 2003. Army Technical Bulletin Medical 507/Air Force Pamphlet 48-152.

7.   Ely BR, Ely MR, Cheuvront SN, Kenefick RW, Degroot DW, Montain SJ. Evidence against a 40 degrees C core temperature threshold for fatigue in humans. J Appl Physiol (1985). 2009;107(5):1519–1525.

8.   Bouchama A, Knochel JP. Heat stroke. N Engl J Med. 2002;346(25):1978–1988.

9.   US Department of the Army. Prevention and Management of Cold Weather Injuries. Washington, DC: Headquarters, DA; April 2005. Army Technical Bulletin Medical 508.

10.   Epstein Y. Heat intolerance: predisposing factor or residual injury? Med Sci Sports Exerc. 1990;22(1):29–35.

11.   Casa DJ, Armstrong LE, Ganio MS, Yeargin SW. Exertional heat stroke in competitive athletes. Curr Sports Med Rep. 2005;4(6):309–317.

12.   Glaser EM. Acclimatization to heat and cold. J Physiol. Dec 1949;110(3-4):330–337.

13.   DeGroot DW, Kenefick RW, Sawka MN. Impact of arm immersion cooling during Ranger training on exertional heat illness and treatment costs. Mil Med. 2015;180(11):1178–1183.

14.   US Department of the Army. Risk Management. Washington, DC: Headquarters, DA; April 2014. Army Techniques Publication 5-19.

Chapter 23

ENVIRONMENTAL EXTREMES: ALTERNOBARIC

RICHARD A. SCHEURING, DO, MS*; WILLIAM RAINEY JOHNSON, MD†; GEOFFREY E. CIARLONE, PHD‡; DAVID KEYSER, PHD§; NAILI CHEN, DO, MPH, MASC¥; AND FRANCIS G. O’CONNOR, MD, MPH¶

INTRODUCTION

DEFINITIONS

MILITARY HISTORY AND EPIDEMIOLOGY

Altitude

Aviation

Undersea Operations

MILITARY APPLIED PHYSIOLOGY

Altitude

Aviation

Undersea Operations

HUMAN PERFORMANCE OPTIMIZATION STRATEGIES FOR EXTREME ENVIRONMENTS

Altitude

Aviation

Undersea Operations

ONLINE RESOURCES FOR ALTERNOBARIC ENVIRONMENTS

SUMMARY

*Colonel, Medical Corps, US Army Reserve; Associate Professor, Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Lieutenant, Medical Corps, US Navy; Undersea Medical Officer, Undersea Medicine Department, Naval Medical Research Center, Silver Spring, Maryland

‡Lieutenant, Medical Service Corps, US Navy; Research Physiologist, Undersea Medicine Department, Naval Medical Research Center, Silver Spring, Maryland

§Program Director, Traumatic Injury Research Program; Assistant Professor, Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

¥Colonel, Medical Corps, US Air Force; Assistant Professor, Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

¶Colonel (Retired), Medical Corps, US Army; Professor and former Department Chair, Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

Service members on the modern-day battlefield confront a variety of environmental challenges, particularly since the emergence of unconventional, asymmetric, and hybrid warfare. Knowledge of the environmental challenges confronting fighters, and strategies to mitigate against stressors that degrade optimal performance and provide advantages against enemy combatants are essential for the military medical officer (MMO). This chapter focuses on pressure extremes as applied to today’s combat environment, at elevated altitudes, in aviation, and in undersea operations. The general term for alterations in ambient pressure is “alternobaric.” This chapter focuses on enabling the MMO to understand the alternobaric environment and take measures to enhance service members’ performance in alternobaric environments. Specifically discussed are core definitions applied to alternobarics, relevant military history and epidemiology, applicable applied physiology, and detailed prevention strategies. Specific guidance and resources are provided to assist the MMO in the identification and prevention of alternobaric stress.

DEFINITIONS

Tables 23-1 and 23-2 define common terms related to alternobaric (altitude, flight, and undersea) environmental challenges that may confront service members. First, basic and specific applied physiologic definitions are provided to assist the MMO in interpreting relevant literature and military policies. These definitions are followed by terms associated with common medical conditions and injuries in each environment. The MMO must have a clear understanding of all related terminology to interpret relevant literature and ultimately optimize warfighter performance through education, preparation, and anticipation of outcomes due to alternobarics.

TABLE 23-1

ALTERNOBARIC APPLIED PHYSIOLOGY TERMINOLOGY

Term

Definition

Absolute pressure

Total static pressure at the reference point; pressure relative to a vacuum.

Altitude diving

Diving at a location where the water surface is at an altitude that requires modification of decompression schedules (higher than about 300 m/980 ft above sea level).

Ambient pressure

Pressure of the environmental surroundings.

Ascent rate

Rate at which depth is reduced at the end of a dive; an important component of decompression.

ata

Atmospheres absolute; unit of absolute pressure equivalent to standard atmospheric pressure.

1 ata = 1 bar = 760 mm Hg = 14.7 psi = weight of the atmosphere.

Bottom time

Time used in calculating decompression obligation from decompression tables. For most tables, this is defined as the elapsed time from starting the descent to starting the final ascent to the surface, excluding ascent and decompression time.

Boyle’s law

At a constant temperature, the pressure (P) of a gas and its volume (V) are inversely related:

P_1V_1=P_2V_2

Clinically, a trapped gas in the body will expand as altitude increases because there is less pressure on it from the ambient atmosphere, or alternatively contract when altitude decreases or if taken to a depth underwater.

Charles’s law

At a constant pressure and mass, the temperature and volume of a gas vary directly. This is important in air MEDEVAC operations where air-filled devices, eg, endotracheal cuffs, air splints, and pneumatic anti-shock garments (PASGs), which are not rigid, will expand or contract as the ambient temperature increases or decreases.

Dalton’s law

The pressure of a gas mixture is equal to the sum of the partial pressures of the component gasses:

P = P_1 + P_2 + P_3 + Pn…

Related to human physiology, as the atmospheric pressure increases or decreases, the partial pressure of oxygen correspondingly increases or decreases even though the percentage remains constant. Clinically, oxygen toxicity can occur in diving operations or hypoxia at altitude.

Decompression tables

Printed cards or booklets that allow divers to determine a decompression schedule for a particular dive profile and breathing gas.

Divers Alert Network (DAN)

A nonprofit organization that conducts medical research on recreational scuba diving safety and assists divers in need.

Dive profile

The variation of depth with elapsed time during a dive, often depicted as a graph.

FSW

Feet of sea water; unit of pressure equal to 1/33 atm. Not a linear measure of depth.

Gauge pressure

Gauge pressure is zero-referenced against ambient air pressure, so it is equal to absolute pressure minus atmospheric pressure.

HBO

Hyperbaric oxygen

Heliox

Mixtures of helium and oxygen for use as a breathing gas, used most commonly in deep sea commercial diving. The exact mixture of He and O_2 varies with the type of operation.

Henry’s law

The amount of gas dissolved in a solution varies directly with the partial pressure of the gas over that solution. This relationship is the basis for decompression sickness, ie, taking a diver to altitude following a dive too quickly can cause dissolved nitrogen in the blood to form gas bubbles that are released from that solution into surrounding tissues.

High altitude

Altitude above sea level (ASL) can be broken down into the following categories based on physiologic impacts:

Low: sea level to 1,200 m/3,937 ft

Moderate: 1,200 m/3,937 ft to 2,400 m/7,874 ft

High: 2,400 m/7,874 ft to 4,000 m/13,123 ft

Very high: 4,000 m/13,123 ft to 5,500 m/18,046 ft

Extreme: higher than 5,500 m/18,046 ft

Hooka (airline diving)

Surface-supplied diving in which the breathing air is supplied to the diver by a simple hose. The diver usually breathes through a mouth-held demand valve.

NEDU

US Navy Experimental Diving Unit, located in Panama City, FL.

Nitrox

A mixture of nitrogen and oxygen for use as breathing gas, also known as enriched air. Usually has a higher oxygen percentage than air.

NOAA

National Oceanographic and Atmospheric Administration

Off-gassing

Diffusion of gas from tissue into blood, where it is transported to the lungs, where it diffuses into the lung gas and is eliminated by exhalation.

Oxygen fraction

Fraction by volume or pressure of the gas mixture made up by oxygen.

Partial pressure

The pressure that a component gas of a gas mixture would exert if it alone was present in the volume occupied by the gas mixture.

Rebreather

Breathing apparatus used by special forces that recycles most of the exhaled gas, removing carbon dioxide and topping up oxygen before the gas is breathed again.

Recompression chamber

A hyperbaric chamber used to treat divers suffering from certain diving disorders, such as DCS.

Trimix

Mixture of three gases, oxygen, nitrogen, and helium, for breathing. The gas fractions are usually specified during deep sea commercial diving.

UHMS

Undersea and Hyperbaric Medical Society

Valsalva maneuver

Technique for equalizing the middle ear by moderately forceful attempted exhalation against a closed mouth and blocked nose.

TABLE 23-2

ALTERNOBARIC INJURY TERMINOLOGY

Term

Definition

AGE

Arterial gas embolism; blockage of an artery by a gas bubble. A possible consequence of lung overpressure injury.

Alternobaric vertigo

Dizziness caused by a difference of pressure between the middle ears.

AMS

Acute mountain sickness; a sickness and/or symptoms derived from climbing high altitudes, typically above 2,438 m/8,000 ft above sea level.

Barotrauma (“squeeze”)

Injury caused by pressure difference, eg, increased pressure to the middle ear while the pressure of the auditory canal is at a lower pressure; the higher pressure causes tension and injuries to the tympanic membrane.

Bends (type I DCS)

A symptom of decompression sickness following exposure to a hypobaric pressure environment, when nitrogen bubble formation in the musculoskeletal tissues results in joint or limb pain. The joint pain may involve single or multiple joints and resolves with hyperbaric pressure exposure. Type I DCS presents as severe single or multiple joint pain (the “bends”) or pruritic rash (the “creeps”).

Chokes (type II DCS)

A symptom of decompression sickness manifested by shortness of breath, caused by a large number of venous gas bubbles in the lung capillaries, which interfere with gas exchange. Type II DCS is a potentially life-threatening condition involving cardio-respiratory compromise (the “chokes”) or neurological deficits.

DCI/DCS

Decompression illness/sickness; a condition arising from dissolved inert gases (eg, nitrogen) emerging from solution after a reduction in ambient pressure as bubbles in the tissues, organs, and blood vessels. In addition to types I and II, a type III DCS has been proposed combining AGE with DCS neurological symptoms.

HACE

High altitude cerebral edema; involves clinical symptoms and pathological injury to the brain during climbing to high altitude. The brain swells with fluid, with the clinical hallmark of ataxia.

HAPE

High altitude pulmonary edema, involves clinical symptoms and pathological injury to the lung during climbing to high altitude. It is a life-threatening, noncardiogenic pulmonary edema presenting with cough and dyspnea.

HPNS

High-pressure nervous syndrome, a neurologic and physiologic diving disorder that results when a diver descends below about 150 m/500 ft while breathing a helium–oxygen mixture.

Hypobaric hypoxia

Usually associated with increasing altitude above sea level and decreased barometric pressure; consequently, there is inadequate oxygen partial pressure to supply oxygen for body tissues, whether in quantity or molecular concentration. The result is altered biochemical reactions leading to functional impairment.

Nitrogen narcosis

Also known as narcs, inert gas narcosis, raptures of the deep, martini effect; a reversible alteration in consciousness that occurs while breathing gases containing nitrogen under elevated partial pressure, similar to alcohol intoxication or nitrous oxide inhalation. Can occur during shallow dives, but usually does not become noticeable until greater depths, below 30 m.

Oxygen toxicity

A condition resulting from the harmful effects of breathing molecular oxygen at elevated partial pressures.

Shallow water black-out

A loss of consciousness caused by cerebral hypoxia toward the end of a breath-hold dive in water typically shallower than 16 ft/5 m, when the swimmer does not necessarily experience an urgent need to breathe and has no other obvious medical condition that might have caused it.

VENTID-C

Acronym for oxygen toxicity symptoms: Vision-tunnel, Ears-ringing, Nausea, Twitching, Irritability, Dizziness, Convulsions.

MILITARY HISTORY AND EPIDEMIOLOGY

Altitude

“A general who allows himself to be decisively defeated in an extended mountain position deserves to be courtmartialed.”

—Carl von Clausewitz[1]

Warfare at elevated altitudes has played a major role in recorded military history, as evidenced by the high-altitude engagements fought in Africa, Asia, and South America over the last few centuries. Victory or defeat usually went to the military units that were either well- or ill-prepared for altitude operations, respectively. Early in World War I, the Austro-Hungarian Empire recognized the strategic importance of the Carpathian Mountains (2,655 m/8,711 ft), but failed to appreciate the physiologic impacts of high altitude exposure on troops’ performance. General Franz Conrad von Hotzendorf planned and strategized for a short, surprise campaign to take the Carpathian Mountains from the Russians in a high altitude operation. Most of his troops were accustomed to operating at lower altitudes, whereas the Russian troops were accustomed to elevated climate and terrain. Curiously, Conrad made no plans for acclimating, equipping, or training his troops in mountain warfare. Three separate campaigns were fought and lost to the Russians during the winter of 1915, due in part to the lack of preparation for operations at elevated altitudes.

More recently, US troops engaged in battles with Taliban fighters in the Afghanistan Hindu-Kush region (elevations above 3,000 m/9,842 ft). One notable battle occurred in the Shok Valley in Nuristan Province in April 2008.[2] Fifteen US Special Forces soldiers and airmen from the Operational Attachment-A (ODA) 3336, 3rd Special Forces Group, and 100 Afghan commandos from the 1st Company, 201st Commando Battalion, Afghan National Army (ANA), fought approximately 200 Hezb-e-Islami Gulbuddin (HIG) forces. The following quote from one of the US ground force combat air controllers, Senior Airman Zachary J. Rhyner, highlights the environmental challenges facing warfighters and the MMOs who support them in high altitude terrain:

Initial infiltration began [at altitude] … with snow on the ground, jagged rocks, a fast-moving river and a cliff. There was a 5-foot wall you had to pull yourself up. The ridgeline trail was out of control.[3]

The US/ANA forces trained and acclimated in this environment for weeks in preparation for this mission, which lasted nearly 7 hours (Figure 23-1). They sustained four wounded US and two fatally injured ANA soldiers, versus 150 to 200 HIG fighters killed in action.

These examples show that troops engaged in mountain operations must be physically acclimated to higher altitudes in addition to having the special training and equipment required for challenging terrain and weather.[4] Generally regarded as altitudes above 2,438 m/8,000 ft, the mountain environment poses many challenges to combat personnel: reduced barometric pressure resulting in decreased partial pressure of oxygen, frequently cold and unpredictable weather, intense solar and ultraviolet radiation, dry conditions that cause insensible fluid loss leading to dehydration, and lack of natural resources.[5] Undulating, narrow, and wooded terrain often makes resupply and transport of artillery difficult, if not impossible. Conventional rotary-wing air support above 3,962 m/13,000 ft is not reliable due to the inability of rotor blades to create sufficient lift in the rarified air.

Figure 23-1. Members of Operational Detachment Alpha (ODA) 3336 of the 3rd Special Forces Group recon the remote Shok Valley of Afghanistan, where they fought an almost 7-hour battle with insurgents in a remote mountainside village, 2008. US Army photo by SPC David N. Gunn.
Reproduced from: https://commons.wikimedia.org/wiki/File:Zachary_Rhyner_and_Army_SF_in_Shok_Valley.jpg.

The epidemiology of altitude-related injuries during combat operations, such as acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE), is not well defined. Slow acclimation to the altitude is the best way to mitigate these injuries. Noncombat-related orthopedic injuries related to hazardous terrain and thermal injuries from environmental exposure are documented in anecdotal reports. The mechanisms for these injuries are understood and taken into account when planning operations in mountainous terrain.[6]

Aviation

Advances in hot air balloon technology and operations were pioneered in the early 1800s. During this time frame, French physiologist Dr Claude Bernard led initial efforts to understand the physiologic changes occurring during high altitude exposure. One of his students, Dr Paul Bert, wrote a treatise titled “Barometric Pressure: Researches in Experimental Physiology,”[7] which contributed to the understanding of oxygen toxicity (termed the “Paul Bert effect”) with changes in barometric pressure. Bert went on to elucidate the root causes of altitude sickness, oxygen toxicity, and decompression illness. In France, hot air balloons were used extensively for ground observation and terrain analysis for military purposes throughout the 19th century, but limited maneuverability and technical challenges prohibited widespread use of these aircraft for combat operations.

The tactical advantages of utilizing powered heavier-than-air aircraft in support of military ground operations were realized soon after Wilbur and Orville Wright designed, tested, and flew the original Wright Flyer in December 1903. The US Army initially funded the Wright brothers’ early studies at Hoffman Prairie, what is now Wright Patterson Air Force Base in Dayton, Ohio.[8] In 1908, the Army accepted the technology designed by the Dayton natives, and began flight testing and training with the fledgling Army Air Corps. The same year, the US Army had it first aviation casualty, First Lieutenant Thomas Selfridge, who died in an air crash while on a test flight with Orville Wright at Ft Myer, Virginia (Figure 23-2).

The following year lieutenants Frederic E. Humphrey and Frank P. Lahm completed their solo flights and became the first Army pilots. Subsequently, serious interest in aviation and human performance led to the Army’s formal recognition of aviation medicine. In 1911, a medical officer, Lieutenant John P. Kelly, became the Army’s first medical officer assigned to a flight school for aeromedical support. The following year, the US War Department formally adopted aviation medical standards. In 1914, Congress created an aviation section within the Army Signal Corps, and by 1916, Army pilots and planes were used as scouting aircrafts, some 13 years after the Wright brothers’ first flight. The same year, Major Ralph Greene was the first medical officer placed on flying orders, becoming the first “flight surgeon.”

Figure 23-2. The first aviation-related fatality, First Lieutenant Tom Selfridge at Ft Myer Field, Virginia, on September 17, 1908. He and Orville Wright crashed in a Wright Flyer from approximately 150 ft above sea level.
Photo courtesy of the National Museum of Health and Medicine; Otis Historical Archives 233.05, Medical Illustration Service Library, Photo ID: MIS 63-720-15.

Following World War I, the War Department fully realized the potential of airpower when Brigadier General Billy Mitchell and his aircrew sank the German battleship Ostfriedland in July 1921. Since then, the airplane has been transformed from a simple propeller aircraft to a high-performance jet aircraft utilized for reconnaissance and bombing missions. Rotary-wing aircraft, or helicopters, also rapidly advanced, from simple, twin rotor-blade configurations, with limited speed and carrying capacity, to robust, turbo-powered multiple rotor-blade aircraft with airspeeds in the mid-100-knot range and thousands of pounds of payload carriage. Tactically, helicopters today are used as utility aircraft for troop and cargo transport, aeromedical evacuation (MEDEVAC), observation, and, equipped with high-precision munitions, in attack configurations (Figure 23-3).

Undersea Operations

For more than 5,000 years, humans have been diving for the purposes of gathering food and materials, conducting salvage and covert military operations, and exploration, research, and development.[9] Initially, diving was confined to shallow waters and limited by the capacity of humans to breath-hold. While human biological shortcomings have not changed, research has increased the understanding of undersea conditions and led to technological advancements, enabling us to descend deeper, for prolonged periods of time. There remains much to learn about the ocean depths, and continued exploration, research, and development are essential for maintaining warfighter superiority in the undersea environment. Because humans are not aquatic mammals, an understanding of the forms of diving and associated equipment is a prerequisite to learning how the body responds to submersion and the complications that can arise during diving operations. There are three forms of diving: breath-hold (free-diving), surface-supplied, and self-contained underwater breathing apparatus (SCUBA).

Figure 23-3. (a) Utility helicopter (UH-60) Black Hawk. A US Army UH-60 Black Hawk helicopter prepares to land during a medical evacuation (MEDEVAC) drill for a notionally injured soldier during a Table XII Live Fire Exercise, Novo Selo Training Area, Bulgaria, August 23, 2018. This exercise is in support of Atlantic Resolve, an enduring training exercise between NATO and US forces. US Army National Guard photo by Sgt. Jamar Marcel Pugh, 382nd Public Affairs Detachment/1st ABCT, 1st CD/Released.
Reproduced from: https://www.dvidshub.net/image/4671108/1-cav-table-xii-gunnery/.

Surface-supplied diving involves the delivery of air or gas mixtures from the surface to the submerged diver via a tube or hose. In fact, snorkeling is classified as surface-supplied diving despite its simplicity. In the 16th century, with motivations to dive deeper, surface air was brought beneath the surface with diving bells. These were large, weighted, bell-shaped apparatuses with open bottoms that would trap air inside during submergence for the divers to breathe. In 1690, Edmund Halley enhanced diving bell technology by introducing an air recycling method to increase dive duration.9,10 Well into the 20th century, diving bells were still used for undersea operations, particularly for construction and submarine rescue.[10]

A similar technology was used in the 19th century to construct caissons, permanent underwater structures that recycle air delivered from the surface through high-capacity pumps. Caissons were used for excavating bridges and forming tunnels. A notable use of caissons was during the building of the Brooklyn Bridge, which led to the first identification of mass decompression sickness (DCS). Originally called caisson disease, the condition became evident when construction workers who felt normal during their subterranean/subaquatic shifts developed sharp pains or dizziness when leaving the caisson upon returning to the surface. Many of the workers developed a “bent” appearance due to their joint pains and, possibly, muscle weakness. From these presentations, the disease became more commonly known as “the bends.” In 1878, Paul Bert determined the cause to be inert gas (eg, nitrogen) and pressure changes (from high to low). His research led to recommendations for slower decompression rates and the development of hyperbaric chambers for preventing and treating DCS.9,11,12

Figure 23-3. (b) Attack helicopter (AH-64) Apache. A US Army Apache helicopter with D Company, 1st Battalion, 3rd Aviation Regiment (Attack Reconnaissance) returns from a maintenance test flight August 17, 2018, at Katterbach Army Airfield in Ansbach, Germany. US Army photo by Charles Rosemond.
Reproduced from: https://www.dvidshub.net/image/4660413/ah-64-apache-helicopter-maintenance-testflight.

Although diving bells and caissons improved diving capabilities and construction efforts, divers’ maneuverability remained limited. This changed in 1839 when Augustus Siebe, a German-born English engineer, developed the first practical diving dress, which consisted of a helmet, suit, and surface-supplied air hose, paving the way for the US Navy’s Mark V and Kirby Morgan 37 helmets.

SCUBA diving requires divers to carry their gas supply. Two types of SCUBA are used today: open-circuit and closed-circuit. In open-circuit SCUBA, the diver inhales gas from a tank and exhales gas into the atmosphere, whereas in closed-circuit SCUBA, the diver’s gas is recycled, eliminating exhaled bubbles and rendering the diver undetectable from the surface (Figure 23-4). The use of closed circuits began in the late 19th century; however, these systems were challenging to use and had depth limitations. The depth problem was overcome in the early 20th century with the addition of compressed air tanks to the rig.9,13,14 With this advancement, Jacques-Yves Cousteau and Emile Gagnan developed the Aqua Lung in the 1940s, which included an open-circuit SCUBA system and a demand regulator that no longer required divers to control their airflow. This rig became widely popular due to its portability and functionality.[9]

In 1957, Captain George F. Bond, a Navy diving medical officer, theorized that there was a maximum amount of inert gas the body could store at a given depth (ie, saturation). His theory was corroborated through a series of diving experiments conducted during the 1960s. Based on the principles of gas equilibrium, the quantity of gas that dissolves in liquid is proportional to the partial pressure of the gas (Henry’s law). Upon saturation, the inert gas burden cannot change because the gas gradient no longer exists. Because the inert gas burden is directly related to decompression obligation (the amount of time required to ascend from a given depth to minimize the risk of DCS), a saturated diver’s decompression obligation will not change. Thus, divers can work at a given depth for days, weeks, or even months without increasing their decompression time, significantly reducing time to task completion. For example, oil rig construction projects often span days to months. A 40-hour task to be completed at 200 ft of seawater (fsw) could be accomplished as a saturation dive or a series of non-saturation dives. In the former, the divers would work for 5 days at this depth and accrue 2 days of decompression obligation. In a series of non-saturation dives, even on gas mixtures designed to prolong bottom time and minimize decompression obligation, the divers would reach exceptional exposure limits after 45 minutes of diving and incur a decompression obligation of approximately 3 hours. At this rate, more than 40 days would be required to complete this job. Thus, saturation diving offers significant advantages when assignments are conducted over several days to months.[9]

MILITARY APPLIED PHYSIOLOGY

Human performance is compromised at depth and at increased altitudes above sea level. Work efficiency may be reduced at all extremes, and this must be considered in any altitude, flight, or undersea mission. Understanding the basic principles of applied physiology that contribute to this performance decrement is critical for the MMO, who is frequently called upon for the proper interpretation of resources and guidelines on environmental stress. Knowledge of physiology enables the MMO to identify and modify those factors that can be mitigated or leveraged for success in the operational environment, and to promote prevention by educating individual service members as well as unit leaders.

Figure 23-4. Navy diver using “closed-circuit” rebreather device for undersea operations. The air tank is considerably smaller and more efficient for breathing air than conventional open-circuit air tanks and produces few air bubbles to the surface. The sailor, assigned to Explosive Ordnance Disposal Group One (EODGRU 1), during “mask up” of his MK-16 rebreathers while conducting an underwater demolition training exercise off the coast of San Diego on May 25, 2017. Navy EOD is the world’s premier combat force for countering explosive hazards and enabling freedom of movement on land or at sea. US Navy Combat Camera Photo by Mass Communication Specialist 2nd Class Dan Rolston/Released.
Reproduced from: https://www.dvidshub.net/image/3439691/eod-training-unit-underwater-demolition.

Altitude

Physiologic alterations associated with altitude, secondary to progressive hypobaric hypoxia, generally begin with ascent to altitudes greater than 2,438 m/8,000 ft above ground level. While the percentage of oxygen (O_2) in one liter of air (21%) does not change at altitude, the partial pressure of O_2 (PO_2) declines with increasing altitude, according to Dalton’s law of partial pressures (PO_2=PB × %O_2). At sea level the pressure barometric (PB) is approximately 760 mm Hg, and the PO_2 in atmospheric air is about 160 mm Hg (760 mm Hg × 0.21). At 5,800 m, PB is approximately 380 mm Hg, and the PO_2 in atmospheric air is only 80 mm Hg (380 mm Hg × 0.21). In addition to the decreasing PO_2 with altitude, the arterial oxyhemoglobin saturation (Sao_2) begins to change dramatically at altitudes over 2,400 m, as one enters the steep decline on the hemoglobin O_2-saturation curve, with resultant dramatic changes in performance (Figure 23-5).

Figure 23-5. Scheme for categorizing altitude based on the relationship between altitude and physiological and function (work performance and altitude illness) outcomes.
Reproduced from: US Department of the Army. Altitude Acclimatization and Illness Management. Washington, DC: DA; 2010. Technical Bulletin, Medical, 505:12.

The initial symptoms for the non-acclimatized individual include global headache, dizziness, nausea/vomiting, and anorexia; dehydration and alcohol can intensify these effects. Rarely, these symptoms may progress to unconsciousness due to a sudden exposure to low oxygen partial pressure, although the exact mechanism is not well understood. The aforementioned symptoms are secondary to a reduced oxygen concentration, which stimulates a number of compensatory mechanisms. Principal among these processes is the hypoxic ventilatory response. The carotid body signals the central respiratory center to increase the ventilation rate, in addition to a moderate increase in blood pressure and heart rate. The decreased Pao_2 also leads to transient pulmonary hypertension, increased fluid retention, and increased central blood volume. The hyperventilation in turn leads to a respiratory alkalosis, and a subsequent compensatory bicarbonate diuresis. Renal bicarbonate excretion, in combination with an increased 2,3-diphosphoglycerate production, promotes O_2 unloading from hemoglobin. With continued ascent, symptoms of AMS become apparent, and limitations in physical stamina and concentration have the biggest impacts on performance.

The MMO should educate service members and leadership about the potential operational impacts of conducting missions in the mountains: hypoxia’s role in tasks requiring concentration, psychomotor skills, and memory; degraded physical performance from fatigue and exertion; and the medical conditions resulting from acute hypoxic exposures in unacclimatized individuals. Taken together, these impacts on service members are often the first enemy they encounter at high altitude.

As altitude elevation increases without proper adaptation, cerebral hypoxia can lead to an increase of cerebral blood volume and increased intracranial pressure. Without corrective measures, the altered cerebral physiology can lead to HACE. The individual will develop a progressive neurologic deterioration manifested as altered mental status, ataxia, and stupor, progressively leading to coma and death. Similarly, pulmonary hypertension and fluid retention in the lungs can lead to HAPE. The clinical symptoms for HAPE are dry cough with interstitial edema, dyspnea on exertion, audible rales, observable cyanosis, and marked weakness.

When HAPE or HACE develop, the individual must descend immediately to the lowest altitude possible on oxygen via a face mask. They should be transferred to the nearest hyperbaric chamber for treatment if symptoms do not improve. Operationally, descent to altitude may not be practical or safe (alternatives to descending altitude to increase hyperbaric exposure are discussed below).

The effects of hypoxia on cognition and performance have been studied in military populations. Krykskow et al studied the relationship between changes in AMS severity and military task performance.[15] Non-acclimatized military personnel performed simple (disassemble and reassemble a rifle) or complex (rifle marksmanship) tasks at various altitudes between high (2,500 m/8,202 ft) and very high (4,300 m/14,107 ft) altitudes to determine where the threshold for performance decrements and clinical symptoms existed.[15] Simple tasks were not significantly affected at high or very high altitudes. However, significant reductions in marksmanship speed and target accuracy were observed at very high altitudes. The authors concluded that complex psychomotor performance was degraded at very high altitudes due to increased sleepiness and hypoxemia. Short periods of acclimatization (<30 h) did not improve these skills, suggesting that longer periods of acclimating to very high altitudes are necessary to maintain complex performance proficiency.

The effects of high altitude (>3,700 m/12,139 ft) and exercise on marksmanship were studied by Tharion et al in the early 1990s.[16] The authors looked at several variables related to exercise and hypoxia and subsequent time to acclimate to altitude. Exercise with acute ascent to altitude significantly reduced marksmanship accuracy compared to sea level values. However, after a period of rest and acclimation to hypoxia, marksmanship accuracy and sighting time returned to baseline. Consistent with these findings, in 2014 Moore and colleagues found both increasing altitude and exercise significantly decreased marksmanship (P < 0.05).[17] They concluded that increasing altitude impaired marksmanship, with a threshold at 3,000 to 4,000 m/9,842 to 13,123 ft. The decreased marksmanship was closely related to a decrease in arterial oxygen saturation and increased ventilation; the latter increased movement of the chest wall, which impacted the shooter’s ability to steady their aim.

Norris et al studied the development of high altitude headache (HAH) and AMS at moderate elevations in a military population during training exercises.[18] For the purpose of their study, the authors defined moderate altitude as 1,500 m/4,921 ft to 2,500 m/8,202 ft and high altitude as over 2,500 m/8,202 ft. Dehydration and recent arrival at altitude were significantly associated with the development of AMS. HAH was considered to be associated in part to decreased sleep at altitude. No reported cases of HACE or HAPE occurred in the study’s 202 marines and sailors. The study suggested that maintenance of hydration and adequate sleep may reduce the likelihood and severity of HAH and AMS occurrence. Additionally, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) seemed to reduce the symptoms in affected individuals.

Aviation

Aviation poses physiologic stressors similar to those encountered in operations at altitude, related to the hypoxic and hypobaric environment. However, the challenge for the aircrew and the MMO is that flying is a dynamic activity with multiple stressors occurring rapidly and sometimes simultaneously, independent of the low pressure and oxygen environment. Aircrews are required to have recurrent hypobaric chamber training for hypoxia awareness, and aeromedical specialists must understand human performance during all phases of flight. MMOs must have a knowledge of how acceleration (G forces), pressure and gas volume changes related to Boyle’s law, thermal stress, vibration, noise, motion sickness, fatigue, and spatial disorientation all impact human performance during normal flight operations. The risk of sudden cabin depressurization and resultant hypoxia adds to the complexity of treating aviation-related conditions. Limitations on crew duty day, medication and nutritional supplement use, and waivers for medical conditions are all responsibilities of the aeromedical specialist.

The occupational exposure to repetitive high-g accelerations and chronic vibration are particular areas of injury in which the flight surgeon must be well trained. For example, operational aviation research has noted a high rate of acute injury to muscle and ligament of the cervical spine due to G-force exposure in fighter pilots.[19] There is a higher incidence of cervical spine degeneration among pilots who have been exposed to G force versus those who have not. A meta analysis of eight studies also found an increase in degenerative spine diseases with repeated G-force exposure (P < 0.001).[19] Spinal trauma from repetitive low-frequency vibration exposure in rotary-wing aircraft has resulted in significant cervical and lumber spine injury in Army aviators. Aircraft type has been implicated as well in lumbar spine pain. Pilots of utility (UH) and attack (AH) helicopters, such as the UH-60 Black Hawk and AH-64 Apache, have an increased likelihood of low back pain compared to high-performance jet aircraft pilots or the general population.20–22

In pressurized aircraft, the cabin “altitude” is a controlled environment. For jet aircraft, the cabin pressure, or equivalent effective cabin altitude, is created by air that is bled off the engine at the compressor stage, thermally adjusted, filtered, and humidified. A balance is maintained between a pressure altitude that limits structural fatigue on the aircraft fuselage and one that limits the likelihood of physiologic impacts on passengers. Aircraft operating above altitudes of 3,800 m/12,000 ft mean sea level (MSL) require differential pressure regulation, which sets the cabin altitude between 2,100 m/6,900 ft and 2,400 m/8,000 ft MSL. Oxygenation in healthy individuals at these altitudes is not an issue. However, sudden and rapid cabin depressurization results in tissue deoxygenation, and subsequent loss of consciousness, unless supplemental oxygen is readily available with simultaneous descent to lower altitude. Slow cabin leaks are more subtle and may progress without obvious notice. It is vitally important that the MMO and aircrew know their individual response to hypoxia and take corrective actions. Altitude chamber training is the standard for assessing hypoxic response, which varies by individual and includes tachycardia, loss of color vision, facial flushing, tachypnea, a sensation of “air hunger,” and difficulty concentrating, progressing to tunnel vision and loss of consciousness.

Transitions during aircraft take-off and landing, when pressure and volume changes occur dynamically, pose the greatest threat to anatomic structures that contain trapped gas, such as the middle ear, facial sinuses, and lungs. MMOs must ensure that aircrew can effectively equalize the pressure in their middle ears (“clear their ears”) with a Valsalva maneuver to reduce the risk of ear and sinus barotrauma. Observing the tympanic membranes for movement while simultaneously having the individual blow against pinched nostrils is a direct confirmation of ability to equalize pressure. An ear or sinus block occurs when trapped gas volume cannot be equalized during pressure changes. The crewmember will complain of sudden intense pain and discomfort in the middle ear or sinuses that may impair the capacity to operate an aircraft safely. Severe cases can create marked barotrauma with rupture of the tympanic membrane and hearing loss. During most flight phases, descent from altitude will result in increased pressure and decreased gas volume. If the pressure cannot be equalized, the trapped gas will result in a relative negative pressure against the tympanic membrane or sinuses, causing severe pain or possible rupture. In the lungs, trapped air in the chest cavity from a small pneumothorax can expand at altitude, potentially compromising pulmonary function.

Acceleration forces are a unique aspect of the operational aviation environment. Evasive maneuvers in high-performance jet aircraft, such as pitch up or steep banked turns, can subject aircrew to high acceleration forces, or “pulling Gs.” One G is the gravitational pull at 1 atmosphere at ground level. Since each level of G is measured on a logarithmic scale, a person experiencing 2 positive (+) Gs is likely to experience 2 times their own body weight. Jet fighter aviators and astronauts often experience much higher levels of +G force. Depending on the vehicle launch parameters, an astronaut can experience up to 4 to 6 +Gs. Airmen in a high-performance aircraft or in an acrobatic plane can experience over 9 +Gs during an angular acceleration. In relative terms, this is like having nine or more people sitting on top of their head. The direction of the acceleration force vector on the body is another factor impacting physiology. A +Gz vector is in the head-to-toe direction; a +Gx vector is front to back; and a +Gy load is experienced side to side. Of the three axial planes of acceleration loading, the +Gz force has the greatest performance impact on aircrew.

Physiologically, these acceleration forces primarily affect the circulatory and pulmonary system of the aircrew. For example, a pilot who pulls back on the stick, causing a pitch-up maneuver, is exposed to a +Gz acceleration force. The result of +Gz loading on the heart is a reduction of effective cardiac output to the brain and movement of the column of oxygenated blood in the carotid arteries to the brain. The consequence when no oxygenated blood reaches the brain is either G-induced loss of consciousness (G-LOC) or almost loss of consciousness (A-LOC). With A-LOC, an airman cannot perceive color or cannot see anything at all. With G-LOC, blood no longer perfuses to the brain, and the airman loses consciousness. Likewise, in +Gz and +Gx, the pulmonary system is affected because the weight generated contracts the diaphragm, impairing the inspiratory phase, in addition to mechanical limitation in moving the chest wall anterior to posterior. A relative splinted breathing results, impairing effective respiration.

Extreme noise, in excess of 120 to 140 dB, and low-frequency vibration exposures are also common environmental threats to the airman. Prolonged exposure to loud noise can damage hair cells in the inner ears, potentially causing permanent hearing loss. Aircraft vibration, particularly in the 17- to 34-Hz range of rotary-wing aircraft, can cause air sickness, and aircrews or passengers may experience physiologic stress, discomfort, jaw pain, chest pain, back pain, and damage to the intervertebral discs.

Likewise, spatial disorientation in flight is a significant aviation risk, due to the complex visual, vestibular (otolithic and semicircular canals), and proprioception effects on the brain, along with environmental factors. The inner ear otolith organs are the “gravitoreceptors,” which, along with the eyes and proprioceptive organs throughout the body, provide a position sense to the brain. This is what enables a person to know which direction is up, down, right, and left relative to the Earth. Working together, the eyes, otoliths, and proprioceptors provide accurate position sense, but can be fooled if any one or more of these sensory organs are not functioning properly or are receiving misinformation. For example, in a plane flying across the Atlantic Ocean at night with no moonlight, the pilot might not realize the plane is upside-down because the only visual input would be a dark visual field. Without a correct visual reference point, the brain, correctly sensing the pulling of gravity from the otoliths, has lost its “up-down” orientation. While the plane is actually descending at a rapid rate, the pilot may sense a paradoxical climb due to the sense of gravitational pull. This disorientation in space has resulted in countless aviation mishaps over the past century of flight.

Lastly, motion sickness can be problematic for aircrew. During flight, motion sickness is caused by a sensory conflict or neural mismatch (ie, information sent to the brain from the eyes does not match information sent to the brain through the neurovestibular system), inducing a vagal response. The symptoms are manifested as a spectrum from stomach “awareness” to frank nausea and vomiting.

Undersea Operations

For a diver to successfully inhale from a gas supply underwater, the gas must be pressurized to just above the ambient pressure. Inhalation of the pressurized gas results in an increased number of gas molecules in the lungs, and eventually, in the peripheral tissues. Gas enters the body at a constant pressure (P), temperature (T), and volume (V), factors that are highly influenced by variations in depth, body temperature, and environment. Before considering the physiologic effects of gases, it is important to understand how the physical properties of gases depend on these three interrelated factors. For example, the general gas law states that a change in any one of these factors will result in a change in at least one other, such that:

(P_1V_1)/T_1 = (P_2V_2)/T_2

Importantly, only one of the three variables can be unknown to predict the change, but if any of these variables remains constant, it is simple to predict how a specific gas will behave, as shown in the following gas laws.

Boyle’s law predicts how the pressure and volume of a gas change when temperature remains constant. The law states that at constant temperature, pressure and volume are inversely proportional, such that:

P_1V_1 = P_2V_2

Thus, if the pressure of a gas is increased, there will be a proportional decrease in its volume, and vice versa. A practical example of this phenomenon is an air-filled balloon. At rest, the pressure inside the balloon is in equilibrium with the surrounding atmosphere; thus, the volume of the balloon remains constant. If you were to squeeze the balloon (ie, decrease its volume) the pressure inside the balloon will increase. Eventually, if you decrease the balloon’s volume to the point where the pressure critically exceeds the ambient pressure, it will pop.

This principle explains barotrauma and pulmonary over-inflation syndrome (POIS) in diving and high altitude operations, where air-filled cavities or organs, such as the middle ear or lungs, act like the balloon in the example. Barotrauma occurs in enclosed, gas-filled spaces with rigid walls and vascular/lymph-lined membranes that are exposed to changes in ambient pressure. The space must be enclosed so that the pressure within does not readily equilibrate with ambient pressure, creating a pressure gradient that shrinks or expands the enclosed space. POIS includes a diverse set of clinical presentations thought to occur due to over-pressurization of the lungs, which causes rapid gas bubble dispersal into normally gas-free areas. POIS develops on ascent as the air within the lungs expands according to Boyle’s law. If this expansion occurs too rapidly, gas may forcefully exit, and consequently rupture, the alveoli, enter the perivascular sheath, and continue to the neck, mediastinum, and/or the vasculature, with subsequent arterialization. This can result in four presentations: pneumomediastinum (and pneumopericardium), subcutaneous emphysema, pneumothorax, and air gas embolism.23,24

Boyle’s law explains the relationship between pressure and volume when temperature is constant; however, temperature fluctuations can significantly alter a gas’s pressure and volume. Charles’s and Gay-Lussac’s laws predict how the pressure or volume of a gas reacts when temperature changes. Charles’s law states that when pressure remains constant, a gas’s volume is directly proportional to its temperature, such that:

V_1/T_1 = V_2/T_2

Thus, if the temperature of a gas increases, so too does its volume, and vice versa. Similarly, Gay-Lussac’s law states that when volume remains constant, a gas’s pressure is directly proportional to its temperature, such that:

P_1/T_1 = P_2/T_2

Thus, if the temperature of a constant volume of gas within a fixed container increases, so too will its pressure, and vice versa.

Air composition is approximately 21% O_2, 78% nitrogen (N_2), 0.03% carbon dioxide (CO_2), and 1% argon and other trace gases. The percentages in Earth’s atmosphere are independent of the ambient pressure; that is, increases or decreases in pressure result in a higher or lower density of composite molecules respectively, with no change in percentages. One method for quantifying the amount of a particular gas with respect to its effects on the body is to calculate its partial pressure. As previously discussed in the section on altitude physiology, Dalton’s law states that the total pressure exerted by a gas mixture is the sum of the partial pressures exerted by each gas within the mixture. Thus, the partial pressure of a gas is the product of the ambient pressure of the gas mixture and the fractional concentration (percentage/100) of the gas within that mixture.

Atmospheric gases can impact pathophysiologic states if their partial pressure varies greatly or changes rapidly, affecting operator safety and mission success. Thus, an understanding of a gas’s partial pressures and their corresponding symptoms becomes critical when determining gas mixtures to be used for missions of different depths and lengths. In diving, US military convention is to express pressure in atmospheres absolute (ata) or fsw (Table 23-3). At sea level, atmospheric or ambient pressure is equal to 1 ata, which is the equivalent of 14.7 pounds per square inch (psi) or 760 mm Hg (ie, at sea level, we are exposed to the weight of one atmosphere of gas pressing upon us). Air, however, is less dense (1.275 kg/m^3) than sea water (1,028 kg/m^3) and fresh water (1,000 kg/m^3), and the equivalent to 1 ata of gas is added for every 33 fsw and 34 ft of fresh water. For example, when descending to 33 fsw, a diver will be exposed to a total pressure of 2 ata (1 ata of air + 1 ata of sea water); at 66 fsw the total pressure will equal 3 ata; and so on. The following examples, in addition to Table 23-3, provide an understanding of how gas partial pressures are affected by depth and gas mixture composition:

TABLE 23-3

EFFECTS OF DEPTH ON VOLUME, PRESSURE, AND GAS PARTIAL PRESSURE*

Relative Lung Volume

Depth, fsw (m)

Absolute Pressure, ata (psi)

PO_2, ata (% air)

PN_2, ata (% air)

1

0

1 (14.7)

0.21 (21)

0.78 (78)

0.5

33 (10)

2 (29.4)

0.42 (21)

1.56 (78)

0.33

66 (20)

3 (44.1)

0.63 (21)

2.34 (78)

0.25

99 (30)

4 (58.8)

0.84 (21)

3.12 (78)

*Note that as absolute pressure increases, the partial pressure of a specific gas increases while its percentage within the mixture does not.

Example 1. What is the partial pressure of O_2 (PO_2) and N_2 (PN_2) in air at sea level?

PO_2 = total pressure of air at sea level (1 ata) × fractional concentration of O_2 (0.21) = 0.21 ata
PN_2 = total pressure of air at sea level (1 ata) × fractional concentration of N_2 (0.78) = 0.78 ata

Example 2. What are the PO_2 and PN_2 in a 65% O_2, 35% N_2 breathing mixture at 2 ata (33 fsw)?

PO_2 = total pressure (2 ata) × fractional concentration of O_2 (0.65) = 1.3 ata
PN_2 = total pressure (2 ata) × fractional concentration of N_2 (0.35) = 0.7 ata

Example 3. What are the PO_2 and PN_2 in air at 100 fsw? (Hint: don’t forget to include the Earth’s atmosphere.)

PO_2 = total pressure at 100 fsw [(100 + 33)/33)] × 0.21 = 4 ata × 0.21 = 0.84 ata
PN_2 = total pressure at 100 fsw [(100 + 33)/33)] × 0.78 = 4 ata × 0.78 = 3.12 ata

Gases enter the body via the lungs and interface with the bloodstream at the alveoli. Here, gases dissolve into and out of the blood following their respective concentration gradients. Under normal physiologic conditions at sea level, O_2 in the alveoli rapidly diffuses into capillary beds and moves into pulmonary arterial blood for transport back to the heart and throughout the body. Conversely, CO_2 produced in tissues from oxidative phosphorylation rapidly diffuses into the bloodstream and is returned to the lungs, where it is exhaled. Importantly, while the body can adapt to chronic alterations in PO_2 and PCO_2, acute changes in barometric pressure and/or breathing mixtures can result in extreme symptomology. For example, O_2 can be toxic to the central nervous system (eg, causing seizures) or lungs (eg, pulmonary edema) if administered at an elevated PO_2 for an extended period.

While O_2 and CO_2 are examples of metabolically active gases that are constantly being exchanged and transported, gases such as N_2 and helium are believed to be chemically and metabolically inert, meaning that gas inhaled is identical to the gas exhaled, because the body does not require its use for metabolism. Inert gases are also transported from the atmosphere into the lungs, by the same pathways, and subsequently into the peripheral tissues. For example, when breathing N_2 at hyperbaric pressures, the PN_2 in the lungs increases (per Dalton’s law). Accordingly, tissue PN_2 increases in accordance with Henry’s law, which states that the solubility of a gas is directly proportional to its partial pressure, written as P=kC, where P, k, and C are the pressure, Henry’s law constant, and concentration, respectively, of a given gas. Increasing lung PN_2 will, therefore, result in elevated tissue PN_2, which will remain dissolved until pressure is decreased. Excessive tissue N_2 is not problematic as long as adequate time is allowed for the N_2 to dissolve out of tissues and be exhaled by the lungs.

Dive tables have been developed to allow for proper inert gas washout based on depth, time at depth, and breathing mixture to prevent inert gas complications such as DCS.[9] DCS can result from any dive that includes breathing an increased partial pressure of inert gases, specifically gases with higher lipid solubility such as N_2. Because exposure to increased pressure increases N_2 dissolved in peripheral tissues, equilibration will occur with respect to the PN_2 in the lungs. In general, risk of DCS is lower when depth, dive duration, and N_2 load are decreased. When these factors are increased, a diver incurs a larger decompression obligation, resulting in a longer period of staged ascent or surface decompression to avoid DCS. If ascent occurs too quickly, N_2 will supersaturate and form expanding bubbles (Boyle’s law) that can cause joint pain, paralysis, and increased risk of venous and arterial emboli.

Immersion in water can significantly alter normal human physiology. With increasing depth, the body is subjected to greater hydrostatic pressure, which is the force exerted by the surrounding water. As hydrostatic pressure increases with depth, so too will the partial pressures of breathing gases. Importantly, organs and air-filled cavities equilibrate at different rates, inducing pressure differentials that result in the displacement of gases and fluids throughout the body. Upon immersion, the increased hydrostatic pressure also results in compression of blood vessels, effectively decreasing venous capacity and increasing venous return to the heart.[25] The resulting increase in cardiac volume causes an increase in end-diastolic volume, which increases stroke volume and cardiac output. These changes result in an increase in pulse pressure, stimulation of atrial stretch receptors, release of atrial natriuretic peptide (ANP), and activation of the arterial baroreflex. ANP is a cardiac hormone that acts on the kidneys to reduce the activity of the renin-angiotensin-aldosterone reflex and increase the glomerular filtration rate. The net effects are an increase in sodium and fluid excretion, which reduces blood volume and pressure, and a pressure-dependent baroreflex-mediated increase in parasympathetic tone, which decreases heart rate and stimulates vasodilation.

Diving also affects ventilation. Increased hydrostatic pressure on the thorax, combined with an increase in airway resistance from breathing denser gas, results in an increased work of breathing that can lead to respiratory muscle fatigue and hypercapnia.[2] Indeed, hypercapnia is common in divers and is exacerbated by exercise, hyperoxia-induced hypoventilation, and rebreathing of CO_2 within the excess dead space of a diver’s breathing apparatus.

HUMAN PERFORMANCE OPTIMIZATION STRATEGIES FOR EXTREME ENVIRONMENTS

The MMO is expected to have scientific background in the physiology of extreme environments, as well as the medical knowledge to provide recommendations for prevention of environmental injuries, to treat such injuries, and to assist in return-to-duty determinations when restriction from activity or deployment is essential. Above all, the best treatment strategy for all potential environmental injuries and illness is primary prevention. Primary prevention is the cornerstone of optimizing human performance in extreme environments. This section discusses military-relevant human performance optimization strategies the MMO should leverage to assist in preventing injury and optimizing human performance. Table 23-4 integrates evidence-based strategies, including the targeted risk factor/challenge, to optimize service members’ performance in environmental extremes.

Figure 23-6. Recommended staging altitude and duration combinations to produce effective altitude acclimatization in previously unacclimatized soldiers.
Reproduced from: US Department of the Army. Altitude Acclimatization and Illness Management. Washington, DC: DA; 2010. Technical Bulletin, Medical, 505:25.

Altitude

The MMO is a critical asset to commanders for mitigating the risk of AMS and optimizing performance at altitude. The foremost recommendation is to leverage acclimatization through appropriate staging. Staging involves temporary residence at a moderate altitude prior to moving to a higher altitude. Figure 23-6 depicts the optimal duration at a given altitude prior to further ascent to optimize acclimatization. Acclimatization should start at elevations below 10,000 ft and proceed at stages high enough to acclimatize but low enough to avoid altitude illness. Military personnel should not ascend above 2,400 m/7,870 ft during their first 24 hours of ascent if not already acclimatized. Above that point, they should avoid ascending more than 300 m/1,000 ft per day. Plan staging and rest days at each elevation, adding an additional rest day with each stage. The MMO should also recommend work/rest cycles and adequate hydration. Warfighters should have good physical strength and optimize their individual aerobic capacity () based on body size and gender. Finally, service members should also understand strategies to mitigate heat and cold stressors often encountered in altitude operations.

TABLE 23-4

HUMAN PERFORMANCE OPTIMIZATION STRATEGIES TO MITIGATE RISK FACTORS IN ALTERNOBARIC ENVIRONMENTS

Environment

Performance Risk Factor or Challenge

HPO Strategy

Undersea

AGE/DCI/DCS

Avoid breath holding on ascent; adherence to Dive Table descent–ascent rates and gas mix; transfer to hyperbaric chamber immediately for definitive treatment.

Undersea

Oxygen toxicity

Proper gas mix and adherence to maximal depth and bottom time guidance.

Undersea

Barotrauma

Adherence to Dive Table descent–ascent rates and proper breathing technique.

Altitude

AMS

Acclimatization; work/rest/hydration guidance; prescription medications; slow ascent; supplemental oxygen; overnight rest at a lower altitude.

Altitude

HACE/HAPE

Acclimatization; work/rest/hydration guidance; prescription medications; slow ascent; supplemental oxygen; overnight rest at a lower altitude. If present: immediate descent with subsequent oxygen chamber treatment.

Aviation

Grey-out, black-out, G-LOC

Maintain optimal health; work/rest/hydration/strengthening or resistance exercise and guidance; avoid diving 24 h prior; avoid donating blood 72 h prior; participate in preflight flight simulation or centrifuge training and use it to anticipate flight maneuvers that would cause G-LOC.

Aviation

Motion sickness

Work/rest/hydration guidance; participate in preflight flight simulation or centrifuge training and use it to anticipate flight maneuvers; do not fly with empty stomach and no greasy food consumption prior; frequent simulation training with or without 3-D rotational simulation chair; cool/cold air temperature may help during flight.

Aviation

Spatial disorientation

Work/rest/hydration guidance; good visual acuity; frequent simulation training.

Aviation

Barotrauma

Maintain optimal health; Valsalva maneuver during flight; avoid flying when sick; medication such as oral or topical decongestants for acute symptoms.

Aviation

Acute decompression

Immediate descent; oxygen supplementation; transfer to hyperbaric chamber immediately for definitive treatment.

Aviation

Cold/heat/sound/vibration/radiation

Work/rest/hydration guidance; proper personal protective equipment and environmental design.

Aviation

Circadian dysynchrony

Good sleep hygiene with preplanned sleep schedules; benzodiazepine or non-benzodiazepine hypnotics (use only in specific instances, especially in military operation contingency).

AGE: arterial gas embolism

AMS: acute mountain sickness

DCI: decompression illness

DCS: decompression sickness

G-LOC: G-induced loss of consciousness

HACE: high altitude cerebral edema

HAPE: high altitude pulmonary edema

HPO: human performance optimization

LOC: loss of consciousness

Another preventive measure is intermittent hypoxic exposure (IHE)—repeatedly exposing an individual to altitude for a short period of time. A protocol-driven exposure, IHE can be done using terrestrial altitude, flight in an unpressurized aircraft, flight in a pressurized aircraft with high cabin altitudes, or a normobaric hypoxic device. When using a normobaric hypoxic device, a face mask or hood alone is not sufficient; an oxygen delivery system with the capability of supplying a lower than ambient oxygen concentration is also required. Table 23-5 lists recommended exposure procedures.

Supplemental medication may also help climbers avoid AMS. These medications include acetazolamide to promote bicarbonate diuresis, furosemide to promote diuresis and decrease edema, and aspirin and acetaminophen for headaches (NSAIDs may be used sparingly but are not highly recommended due to increased risk of bleeding and fluid retention). Corticosteroids such as dexamethasone may also be used. Prochlorperazine may be used for nausea or vomiting. Also, carbohydrate and caffeine intake just prior to physical activity may help optimize physical performance at altitude. Other supplements have not been demonstrated to help prevent AMS. Alcohol and sedative hypnotics should be avoided due to depressive effects on respiration. Technical Bulletin 505, Altitude Acclimatization and Illness Management, contains a detailed review of medications for the prevention and treatment of AMS.[6]

TABLE 23-5

RECOMMENDED INTERMITTENT HYPOXIC EXPOSURE PROCEDURES TO INDUCE ALTITUDE ACCLIMATIZATION IN PERSONNEL BASED AT LOW ALTITUDE*

Session Duration (h)

Days

Frequency

Altitude (m)

Activity

3–4

7–14

daily

4,000–4,500

Rest, may include exercise at 50%–60% maximum heart rate

>7

>5

daily

2,500–4,000

Rest, sleep, may include exercise at 50%–60% maximum heart rate

*To avoid sleep disturbances, the first 1–2 nights should not exceed 2,500 m altitude.

If adequate time for acclimation has not occurred, supplemental oxygen is a good strategy for operations above 3,048 m/10,000 ft above sea level (ASL). However, slow, progressive ascent is the only reliable preventive measure to reduce the risk of developing HACE or HAPE. Table 23-6 details the field treatment and prevention of HACE. Above 5,486 m/18,000 ft ASL, even adequate rest/ascent schedules do not prevent these life-threatening conditions. If a climber develops HACE or HAPE, apply a tight-fitting mask with oxygen supplementation and have the person descend immediately. Warfighters can also use a mobile mono-chamber hyperbaric treatment chamber, such as a Gamow bag, for emergencies; however, definitive care at the nearest oxygen chamber facility is also required. Additional information can be found at Uniformed Services University’s Human Performance Resource Center (see resources).

Aviation

The mitigation strategies stated in Chapter 22, Environmental Extremes: Heat and Cold, also apply to personnel who will be flying or climbing. Adherence to good rest and sleep cycles and adequate hydration are essential. Additionally, MMOs can recommend that aviators perform cardiovascular and muscle strengthening/resistance training, which can improve performance in high-altitude environments up to 10%, especially during anti-G straining maneuvers. Prior to flight operations, aircrew members should discuss operation risk management and appropriate corrective actions in case of emergency. All aircrew, including the MMO, should be engaged in pre-flight planning and safety briefings. Also, the MMO should inspect the aircraft prior to flight for structural or environmental issues that might pose a safety or operational risk during flight. For example, there should be seat cushions to damp vibration, ear protection, and form-fitted flying helmets.

An MMO serving as a local flight surgeon or aviation physician assistant will assess all air crewmembers’ fitness for duty prior to flight to rule out any illness or injury that might impair their ability to perform aviation duties. All personnel flying in high performance aircraft must receive proper training for anti-G maneuvers, and the MMO must be familiar with these concepts. Centrifuge training is particularly effective at improving individual G-tolerance, and training in a 3-D rotational simulation chair may help flyers to adjust to air sickness. The MMO will also educate all aircrew on the following points:

- avoid flying within 24 hours after diving to prevent DCS risk;

- avoid donating blood 72 hours before flying;

- never fly on an empty stomach or after eating a greasy meal;

- avoid flying when ill unless appropriate medical personnel are present;

- use personal protective equipment properly; and

- perform Valsalva maneuvers to decrease the chance of barotrauma, vibration, and noise injuries.

Additionally, reducing cabin temperature may help ease motion sickness symptoms. Anti-nausea medications such as a scopolamine patch or meclizine hydrochloride should only be used by non-pilot crew because of their tendency to cause drowsiness. Finally, if problems persist or acute decompression ensues, flyers should descend as soon as possible, preferably with the use of supplemental oxygen.

TABLE 23-6

FIELD TREATMENT AND PREVENTION OF HIGH ALTITUDE PULMONARY EDEMA

Severity of HAPE

Treatment

Prevention

Mild

- Dyspnea on moderate exertion; may be able to perform light activity

- Heartbeat per min: <110

- Breaths per min: <20

1. Descend 500–1,000 m by passive means.

2. Stop ascent, bed rest and acclimatize at the same altitude.

3. Administer moderate flow oxygen at 2–4 L/min for 4–6 h. Maintain oxygen saturation at >90%.

4. Use hyperbaric bag treatment (2 psi for 4 h).

5. Nifedipine (10 mg initially followed by 30 mg every 12 to 24 h).

6. Use a combination of therapies 1–5.

7. Consider acetazolamide (125–250 mg twice daily).

1. Staged and graded ascent.

2. Avoid overexertion.

3. Avoid cold exposure.

4. Avoid rapid ascent >2,500 m.

5. Administer nifedipine (30 mg every 24 h) 1 day prior to ascent and for 3 days after ascent.

6. Consider tadalafil (10 mg twice daily), sildenafil (50 mg every 8 h), and salmeterol (125 µg twice daily).

Moderate

- Symptoms of dyspnea, weakness, fatigue with mild exertion; cannot perform light activity; headache with cough, dyspnea at rest

- Heartbeats per min: 110–120

- Breaths per min: 20–30

1. Descend immediately (500–1,000 m) until symptoms resolve.

2. If descent is impossible, treat the same as mild HAPE except supplemental oxygen should be 4–6 L/min for 4–6 h.

1. Same as for mild HAPE.

2. Treat mild HAPE early to avoid progression to moderate HAPE.

Severe

- Clouded consciousness, stupor or coma

- Severe dyspnea, headache, weakness, nausea at rest

- Loose, recurrent, productive cough

- Wheezy, difficult respirations; obvious cyanosis

- Heartbeats per min: >120

- Breaths per min: >30

1. Descend immediately (500–1,000 m) until symptoms resolve.

2. If descent impossible—

- Treat the same as moderate HAPE.

- Monitor for signs of HACE.

1. Same as for moderate HAPE.

2. Treat mild and moderate HAPE early to avoid progression to severe HAPE.

HACE: high altitude cerebral edema

HAPE: high altitude pulmonary edema

Special consideration must be taken for rotary-wing aircrew operating in hot weather (over 42°C/108°F). Insensible fluid loss in hot, dry environments can rapidly lead to dehydration if fluids are not adequately replaced. Dehydration is complicated by the use of stimulant supplements by aircrew, which is a common practice in combat settings. The fluid recommendations discussed earlier for ground units do not take into account the inability for aircrews to take work/rest cycles during flight, and aerial transportation or combat sorties often last up to 6 hours. A proposed fluid replacement strategy for aircrews operating in hot weather environments is detailed in Table 23-7.[26]

Undersea Operations

Diving is generally safe; however, the military continues to extend mission parameters with deeper and longer descents, increasing the risk of diving-related injuries. These risks can be reduced by screening divers, training MMOs, maintaining safe diving practices, and continuing diving-related medical research. Diving medical experts have an obligation to regularly screen current and future military divers for medical conditions that may be exacerbated by the strenuous hyperbaric environment. Chapter 15 of the Navy’s Manual of the Medical Department outlines screening criteria and recommendations.[27] There are five principal questions to ask when screening a (potential) diver: (1) Can this person perform strenuous activity? (2) Does this person have any condition that is not controlled and may increase his or her risk of drowning? (3) Does this person have any condition that the diving environment may exacerbate? (4) Does this person have any abnormalities on neurologic examination? (5) Can this person equalize ear pressure?

TABLE 23-7

PROPOSED FLUID MAINTENANCE SCHEDULE FOR ROTARY-WING AVIATION CREWS IN HOT WEATHER ENVIRONMENTS

Temperature

Recommended Fluid Replacement (mL/h)

42°–48°C

500–750 mL H_2O

>48°C

750–1,000 mL H_2O + 500 mL commercial electrolyte solution

All divers must propel themselves through the water, requiring considerable physical strength and, at times, endurance. Anyone who is unable to perform strenuous aerobic activity on land, particularly because of cardiac ischemia, will be put at extreme risk by diving. The Navy administers a diving physical screening test to all diving candidates to ensure an adequate level of physical fitness. For civilians or qualified military divers who are being rescreened, providers should assess the patient’s regular physical activity and identify the metabolic equivalent (MET) corresponding to that activity. Basic diving requires a 6-MET tolerance, though difficult sea states or strenuous underwater jobs may require significantly more (10–13 METs).[28] If civilian divers are only able to perform at 6 to 9 METs, the provider should discuss the risks associated with diving, recommend a land-based exercise regimen prior to diving, and consider referral to a diving medical expert for further evaluation. All military divers should be able to perform activities of at least 10 to 13 METs.

Treatable medical conditions on land are potentially life-threatening underwater because of secondary drowning. Prominent examples are myocardial infarctions and seizures. Evaluating a patient’s aerobic capacity as discussed above can mitigate the risk for myocardial infarction. Patients with uncontrolled seizures should not dive. A patient with well-controlled seizures should discuss diving risks with a provider to make an informed decision. Experts recommend being seizure free for at least 4 years prior to considering diving.[29] If a patient decides to dive, he or she should remain in shallow water and always dive with a buddy who is aware of the seizure disorder and capable of executing an emergency action plan. Deep dives should be avoided because increased PO_2 will increase the risk for seizure activity.

A primary concern with pulmonary pathology is its potential exacerbation in the diving environment. Two examples include asthma and spontaneous pneumothorax. Cold water, cold compressed gas, and high PO_2 may increase airway reactivity and the risk for an asthma exacerbation. There have also been reports of allergens in air tanks causing exacerbations. Finally, some case reports suggest that people with asthma may have a higher rate of diving-related complications such as POIS and DCS, which has led some experts to label asthma as an absolute contraindication to diving.27,30 Similarly, the risk of POIS is elevated in patients with a history of spontaneous pneumothorax, causing many experts to consider it an absolute contraindication to diving as well. At least one case report documents a series of successful dives with a chronic pneumothorax, but no evidence exists for successful diving after pleurodesis.[31] However, surgical interventions such as mechanical pleurodesis have been successful in treating aviation personnel with spontaneous pneumothoraces and returning them to duty.[32] Patients with pulmonary pathologies should be referred to diving medical experts to make an informed decision about diving based on known and theoretical risks.

Two parts of the screening process—the patient’s neurologic status and their ability to equalize pressure in the ears—should be documented both at the initial examination and prior to every dive. The screening process should document a complete neurologic examination to establish a patient’s baseline. This will be critical in the event of a possible diving-related neurologic injury, such as arterial gas embolism and DCS. Prior to every dive, divers should report any neurologic symptoms—numbness, tingling, or joint pain—that may conflate a diagnosis of arterial gas embolism or DCS. At the time of screening, all divers should demonstrate tympanic membrane mobility by equalizing ear pressure under direct observation. Divers who have difficulty with equalization may benefit from video-assisted otoscopy, which is training aimed at improving and individualizing equalization techniques. Any presence of an upper respiratory tract infection or allergies may prevent adequate equalization; thus, diving should be temporarily avoided.

Monitoring human performance biometrics is essential to proper preparation and ensuring performance optimization in the diver, submariner, and undersea personnel. Aerobic conditioning measures are critical (for more detailed information, see the Human Performance Resource Center below). Aside from personnel preparation, including mission knowledge and strategies, physical preparation for the undersea environment is a must. Water temperatures introduce limiting human performance issues that can only be addressed prior to mission initiation. Cold waters necessitate proper insulation to optimize performance. Warmer waters may call for active cooling measures to ensure even minimal work performance and mission accomplishment. Monitoring of work/rest cycles is equally important for undersea operations. The MMO must always have a strategic plan in place for responding to mission failures, including identification of compression chamber facilities, access to active cooling and warming, and responses to typical medical issues resulting from military operations.

ONLINE RESOURCES FOR ALTERNOBARIC ENVIRONMENTS

- Medical Surveillance Monthly Report (https://www.afhsc.mil/Search/SearchMSMR): provides evidence-based estimates of the incidence, distribution, impact, and trends of illnesses in service members and associated populations. Annual reports are published on topics such as environmental illnesses, which allow for comparisons of prior year data and assessment of preventive strategies.

- Divers Alert Network (http://www.diversalertnetwork.org/): promotes diver safety by providing medical information, educational opportunities, and safety resources for divers.

- Naval Sea Systems Command (http://www.supsalv.org/00c3_publications.asp?destPage=00c3): provides diving manuals and instructions.

- Duke University Center for Hyperbaric Medicine and Environmental Physiology (https://medicine.duke.edu/divisions/pulmonary-allergy-and-critical-care-medicine/about/division-programs/hyperbaric-medicine): serves the US armed forces as well as the Environmental Protection Agency and National Oceanic and Atmospheric Administration.

- Naval Submarine Medical Research Laboratory (http://www.med.navy.mil/sites/nsmrl/Pages/default.aspx): provides information on research in the undersea environment with an overall mission to protect health and enhance performance of service members.

- Navy Experimental Dive Unit (http://www.supsalv.org/nedu/nedu.htm): conducts research and development to test and evaluate diving, hyperbaric, and other life-support systems necessary for the diver.

- Professional Association of Diving Instructors Scuba Diving Society (https://www.padi.com/Scuba-Diving/scuba-community/padi-diving-society): provides courses and information about gear and other scuba topics.

- Undersea and Hyperbaric Medicine Society (https://www.uhms.org/): primary source of scientific information for diving and hyperbaric medicine physiology worldwide.

- Uniformed Services University’s Human Performance Resource Center (https://www.hprc-online.org/page/environment/altitude): provides information on performing well at high altitudes.

SUMMARY

This chapter has introduced the MMO to the basics of optimizing service member performance in alternobaric settings. It has discussed the historical relevance of the environment to success in military operations, the basic applied physiology relevant to understanding the warfighter in the environment, and finally, evidence-based strategies demonstrated to preserve performance in environmental extremes. MMOs must often operate in unique settings with limited resources, where urgency and proper planning can be the difference between success and failure on the battlefield. It is important to remember that the MMO serves not only to treat the wounded, but also to optimize performance and ultimately to strengthen the commander’s hand for success.

REFERENCES

1.   von Clausewitz C. On War. Vol 2. London, England: Routledge and Kegan Paul; 1968: 263.

2.   Jennings PR. ODA 3336 in the Shok Valley: danger close. Defense Media Network. http://www.defensemedianetwork.com/stories/danger-close-oda-3336-in-the-shok-valley/. Published May 20, 2010. Accessed March 7, 2018.

3.   Ropelis L. Air commando saves lives in Afghanistan. Air Force Special Operations Command website. Published December 23, 2008. Accessed March 7, 2018.

4.   Grau LW, Vazquez H. Ground combat at high altitude. Milit Rev. 2002;Jan–Feb. http://fmso.leavenworth.army.mil/documents/groundcombat/groundcombat.htm. Accessed March 7, 2018.

5.   Hackett PH, Roach RC. High-altitude medicine and physiology. In: Auerbach PS, ed. Wilderness Medicine. 6th ed. Philadelphia, PA: Elsevier; 2012.

6.   US Department of the Army. Altitude Acclimatization and Illness Management. Washington, DC: DA; 2010. Technical Bulletin, Medical, 505.

7.   Bert P. Barometric Pressure: Researches In Experimental Physiology. Hitchcock MA, Hitchcock FA, trans. Bethesda, MD: Undersea Medical Society, 1978.

8.   Crouch TD. The Bishop’s Boys: The Life of Wilbur and Orville Wright. New York, NY: WW Norton; 1989.

9.   Naval Sea Systems Command. US Navy Diving Manual. Rev 7. Washington Navy Yard, DC: NAVSEA; 2016.

10.   Eggen OJ. Edmond Halley. Encyclopedia Britannica. https://www.britannica.com/biography/Edmond-Halley. Accessed December 22, 2017.

11.   Paul Bert. Encyclopedia Britannica. https://www.britannica.com/biography/Paul-Bert. Accessed December 22, 2017.

12.   Paul Bert (1833-1886), aviation physiologist. JAMA. 1970;211(11):1849–1850.

13.   Marx RF. The History of Underwater Exploration. Mineola, NY: Courier Corporation; 1990.

14.   Foregger R. Development of mine rescue and underwater breathing apparatus: appliances of Henry Fleuss. J Hist Med Allied Sci. 1974;29(3):317.

15.   Kryskow MA, Beidleman BA, Fulco CS, et al. Performance during simple and complex psychomotor tasks at various altitudes. Aviat Space Environ Med. 2013;84:1147–1152.

16.   Tharion WJ, Hoyt RW, Marlowe BE, Cymerman A. Effects of high altitude and exercise on marksmanship. Aviat Space Environ Med. 1992;63(2):114–117.

17.   Moore CM, Swain DP, Ringleb SI, Morrison S. Effects of acute hypoxia and exercise on marksmanship. Med Sci Sports Exer. 2014;46(4):795–801.

18.   Norris JN, Viire E, Aralis H, et al. High altitude headache and acute mountain sickness at moderate elevations in a military population during battalion-level training exercises. Mil Med. 2012;177(8):917–923.

19.   Landdau DA, Chapnick L, Yoffe N, et al. Cervical and lumbar MRI findings in aviators as a function of aircraft type. Aviat Space Environ Med. 2006;77(11):1158–1161.

20.   Gaydos SJ. Low back pain: considerations for rotary wing aircrew. Aviat Space Environ Med. 2012;83(9):879–889.

21.   Byeon JH, Kim JW, Jeong HJ, et al. Degenerative changes of spine in helicopter pilots. Ann Rehabil Med. 2013;37(5):706–712.

22.   Grossman A, Nakdimon I, Chapnick L, Levy Y. Back symptoms in aviators flying different aircraft. Aviat Space Environ Med. 2012;83(7):702–725.

23.   Bove AA. Diving medicine. Am J Respir Crit Care Med. 2014;189(12):1479–1486.

24.   Neuman T. Arterial gas embolism and pulmonary barotrauma. In: Bennett and Elliott’s Physiology and Medicine of Diving. 5th ed. London, England: Saunders; 2003: 557–577.

25.   Pendergast DR, Moon RE, Krasney JJ, Held HE, Zamparo P. Human physiology in an aquatic environment. Compr Physiol. 2015;5:1705–1750.

26.   Scheuring RA. A proposed fluid maintenance schedule for rotary wing aviation crews in hot weather environments. Aviat Space Environ Med. 2012;83(3):453.

27.   US Navy. Manual of the Medical Department. Washington, DC: HQDN; 2005: 12. NAVMEDP-117.

28.   Bove AA. The cardiovascular system and diving risk. Undersea Hyperb Med. 2011;38(4):261–269.

29.   Bove AA. Medical aspects of sports diving. Med Sci Sports Exerc. 1996;28(5):591–595.

30.   Coop CA, Adams KE, Webb CN. SCUBA diving and asthma: clinical recommendations and safety. Clin Rev Allergy Immunol. 2016;50(1):18–22.

31.   Ziser A, Väänänen A, Melamed Y. Diving and chronic spontaneous pneumothorax. Chest. 1985,87(2); 264–265.

32.   North JJ. Thoracoscopic management of spontaneous pneumothorax allows prompt return to aviation duties. Aviat Space Environ Med. 1994,65(12):1128–1129.

Chapter 24

ENVIRONMENTAL EXTREMES: SPACE

RICHARD A. SCHEURING, DO, MS*; JOSEF F. SCHMID, MD†; AND J.D. POLK, DO‡

INTRODUCTION

DEFINITIONS

MILITARY HISTORY

MILITARY APPLIED PHYSIOLOGY

The Space Environment

Physiologic Effects

THE MILITARY MEDICAL OFFICER AND HUMAN PERFORMANCE OPTIMIZATION IN SPACE

Role of the Military Medical Officer

Guidance to the Commanding Officer

SUMMARY

*Colonel, Medical Corps, US Army Reserve; Associate Professor, Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Major General, Medical Corps, US Air Force Reserve; NASA, Johnson Space Center, Houston, Texas

‡Chief Medical Officer, NASA Headquarters, Washington, DC

INTRODUCTION

The environment outside of Earth’s atmosphere (space) is regarded by some as the future battlefield. Developed nations rely on space-based assets such as satellites to conduct day-to-day business, including communications, navigation, and financial transactions, to name a few. Military use of space for surveillance and reconnaissance has existed for decades. More recently the use of low Earth orbit (LEO) to conduct tactical operations has been proposed. Warfighters on this future battlefield will confront a variety of physiologic and environmental challenges. Knowledge of the challenges that confront service members, and strategies to mitigate against stressors that impact optimal performance, are essential for the military medical officer (MMO). This chapter specifically addresses the environmental challenges of space flight as applied to today’s warfighter, with a focus on enhancing performance in these settings. Specifically discussed are core definitions applied to these stressors, relevant military history and epidemiology, applicable applied physiology, and detailed prevention strategies. Specific guidance is provided to assist the MMO in the identification and prevention of environmental stress as applied to service members.

DEFINITIONS

Common terminology related to environmental challenges in space is shown in Tables 24-1 and 24-2. First, basic and specific applied physiologic definitions are provided to assist the MMO in interpreting relevant literature and established military guidance. Next are terms associated with common medical conditions and injuries in this environment. The MMO must have a clear understanding of this terminology in the policy and literature to ultimately optimize service member performance.

MILITARY HISTORY

During World War II, Eugene Sanger of the German Herman Goring Institute developed a theoretical “space bomber” that would be capable of reaching suborbital altitudes to extend its range and deliver a weapons payload to New York City. Years later, the Soviet Union began testing the MiG-105, a military space plane that would make use of “skip-glide” suborbital flight to deliver a payload over long distances. The successful launch of the Soviet Sputnik on October 4, 1957, from the Baikonur Cosmodrome in Kazakhstan officially started the Soviet-US space race in public awareness.

The US military, with the help of German rocket scientists who came to America after World War II, most notably Wernher von Braun, had spent the previous decade developing intercontinental ballistic missile systems for weapons payloads. Von Braun and colleagues had also envisioned developing a manned space vehicle to support military operations. By late 1957, the US Air Force had incorporated their concepts into its program to develop a hypersonic “space plane” that would achieve speeds in excess of Mach 10 after being dropped from a heavy bomber and igniting rocket engines. The delta-winged Boeing X-20A Dyna-Soar would be capable of landing on a runway after carrying out suborbital military reconnaissance, satellite maintenance, and enemy satellite interdiction. However, it was canceled in 1963[1] when Congress deemed the project lacked a relevant military mission and cost outweighed its benefits as a research platform. Several military space designs followed the Dyna-Soar program, but each failed to achieve its intended goal of supporting a manned space mission. The culmination of these efforts was the US Air Force Manned Orbital Laboratory (MOL) (Figure 24-1).

The MOL was announced to the public in 1963 as a general research program designed to “demonstrate the military value of a man in space.”[2] Intended to be operational by the early 1970s, the program’s actual purpose was reconnaissance of ground-based Soviet and Chinese military facilities. Astronauts would launch in a modified NASA Gemini spacecraft with the pressurized MOL attached as a single-use laboratory accessible through a hatch. Both would launch on a Titan IIIC booster rocket from Vandenberg Air Force Base in California to a polar orbital inclination (ie, flight orientation over the Earth) with a perigee of 89 nautical miles. Spending up to 40 days in space, astronauts would operate a sophisticated optical system capable of high-resolution still and video images of military targets on the ground, according to plans. During development, however, the MOL rapidly exceeded its budget. Analysis determined that unmanned spy satellites could match or surpass the capabilities of the MOL project. As the Vietnam War drained the nation’s defense budget, the program was canceled in mid-1969.

TABLE 24-1

GENERAL APPLIED PHYSIOLOGY TERMINOLOGY

Term

Definition

Armstrong’s line

Above an altitude of 18,900 m (63,000 ft) the total atmospheric pressure equals the vapor pressure of water at body temperature, ie, the ambient pressure is 5% that at sea level and the boiling point of water is now 98.6°F. Clinically, blood and body fluids will “boil.”

Microgravity (µg)

The result of balanced centrifugal and gravitational force vectors of an orbiting vehicle simulating the lack of true gravity. Not synonymous with zero-gravity.

Suborbital

Any flight outside Earth’s atmosphere with a maximum flight speed below the orbital velocity, thereby preventing a vehicle from completing one orbit.

Low earth orbit (LEO)

An orbit around Earth with an altitude between 160 km (99 miles) (orbital period of about 88 minutes) and 2,000 km (1,200 miles) (orbital period of about 127 minutes).

Geosynchronous earth orbit

An Earth orbit located at 35,786 km (22,236 miles) above Earth’s equator, which allows satellites to match Earth’s rotation.

Solar particle event (SPE)

An injection of energetic electrons, protons, alpha particles, and heavier particles into interplanetary space following a highly concentrated, explosive release of energy from the sun.

Galactic cosmic radiation (GCR)

Energy that originates outside the solar system, consisting of ionized atoms ranging from a single proton up to a uranium nucleus.

Extravehicular activity (EVA)

Any activity done by an astronaut outside a spacecraft beyond the Earth’s appreciable atmosphere.

Extravehicular mobility unit (EMU)

An independent anthropomorphic spacesuit that provides environmental protection, mobility, life support, and communications for astronauts performing extravehicular activity in Earth orbit.

High-performance jet aircraft

Jet planes capable of high-g acceleration, velocities approaching or surpassing the speed of sound, and operating altitudes above 9,144 m (30,000 ft) above sea level.

Hypercapnia

A condition of abnormally elevated carbon dioxide (CO_2) levels in the blood.

Hypobaric

Characterized by less than normal pressure or weight; applies to gases under less than sea level atmospheric pressure of 14.7 psi or 760 mm Hg.

Karman line

The boundary between Earth’s atmosphere and the edge of outer space, generally 100 km (62.5 miles) above sea level. The atmosphere at this altitude is too rarified to support aeronautical flight thus vehicles require rocket propulsion for maneuverability.

Mean sea level barometric pressure

Measured as 1 atmosphere (atm), 760 mm Hg, 14.7 psi, or 101.3 kPa.

Perigee

Point in orbit nearest to the center of the Earth.

The military then shifted its interest to unmanned space capabilities with the development of robust satellite systems for reconnaissance and communications. The tactical military utility of these systems was virtually nonexistent, however; most were purely strategic assets. In early 1971, the US Navy Research Laboratory created the Timation (Time-Navigation) Development Plan, based on the Space Surveillance System technology developed earlier in the decade. This capability was the basis for future highly classified navigation systems used in military operations, most notably the global positioning system (GPS).[3]

In contrast to the military efforts, civilian manned space missions dominated the late 1960s and early to mid-1970s. The six Apollo lunar surface missions fulfilled President John F. Kennedy’s vision of landing a man on the moon and returning him safely to Earth. The Soviets abandoned lunar aspirations for establishing space “stations” capable of sustaining human presence in space for extended periods of time. After the Apollo missions, the United States developed its own long-duration space station, Skylab, in 1973. The Skylab science missions ranged from 28 to 84 days and provided significant insight into the effects of microgravity (µg) on human physiology. The Apollo-Soyuz mission, the first joint US-Soviet mission in space, followed in 1975. This brief mission represented the beginning of an international collaboration in space that continues today.

TABLE 24-2

SPACE ALTERATION/ILLNESS/INJURY TERMINOLOGY

Term

Definition

Circadian desynchronization

Disturbances in the normal sleep cycle that result when external environmental cues conflict with the internal clock.

Ebullism

Formation of water vapor bubbles in the tissues brought on by an extreme reduction in barometric pressure if the body is exposed to pressures above Armstrong’s line.

Space-adaptation back pain (SABP)

Musculoskeletal pain in the lumbar spine region that occurs after initial exposure to µg and persists for 48 to 72 hours.

Space motion sickness

A syndrome ranging in symptom severity that includes nausea, vomiting, global headache, anorexia, and fatigue after initial exposure to µg. A self-limited disorder, the symptoms typically resolve within the first 24 to 48 hours of space flight.

Figure 24-1. Manned Orbiting Laboratory (MOL), an evolution of the earlier “Blue Gemini” program, which was conceived to be an all-Air Force parallel of NASA’s Gemini efforts. US Air Force photo.
Reproduced from: http://www.nationalmuseum.af.mil/Visit/Museum-Exhibits/Fact-Sheets/Display/Article/195891/manned-orbiting-laboratory/.

In 1981 NASA began launching the Space Transportation System (STS), or space shuttle, missions. The STS, initially approved as a public space vehicle by President Richard Nixon in 1972, was built with the understanding that military payloads and crew could be transported into space to support missions for the National Reconnaissance Office (NRO). The space shuttle provided crewed returns from LEO after launching from Kennedy Space Center in Florida. Beginning with the first classified Department of Defense (DoD) payload on STS-4 in 1982, the space shuttle flew nine classified missions for the DoD.4–6 Eight of these missions were considered “dedicated” military missions, flown by military astronauts.2–4 The NRO, in conjunction with the US Air Force, built a launch pad at Vandenberg Air Force Base with the intent that the space shuttle or other manned vehicles could be launched to polar orbits for high-orbital inclination, placing the spacecraft orbital path over Russia.[6]

The military had chosen its first group of space shuttle astronauts, known as manned spaceflight engineers (MSEs), in 1979. From the initial class of 13, only one MSE, Colonel Gary Payton, flew in space, on STS-51C in 1985. This mission deployed an Air Force inertial upper-stage spy satellite as a separate spacecraft from the shuttle payload bay. This permitted the payload to launch from the shuttle (in LEO) to a higher altitude geosynchronous orbit, enabling better visibility of the Earth. From 1985 to 1992, several classified DoD space shuttle missions deployed the Defense Satellite Systems, which included the ability to perform communications, surveillance, reconnaissance, weather and environmental monitoring, and nuclear missile launch detection.4,6 After the Space Shuttle Challenger accident in January 1986, however, the NRO and Air Force abandoned the manned military space program development at Vandenberg and returned to unmanned satellite deployment missions on Atlas and Titan launch vehicles.

By the 1980s, space-based communications, weather satellites, and reconnaissance satellites had matured to add tactical utility to military operations in Central America. During the Persian Gulf War in 1991, GPS navigation satellites provided highly accurate navigation data aiding US and allied military forces in the region. Also, “smart weapons” began appearing in numbers that could make a measurable tactical impact. Cold War strategic systems were also modified to assist tactical forces, beginning a trend that continues today. These systems were refined during the bombing campaign in Kosovo in the late 1990s; in 5 short years the use of precision munitions led to highly accurate weapons that resulted in few nonmilitary casualties. The conflicts in the Middle East in the first decade of the 21st century made use of standardized space-based systems throughout the armed services, leading to unprecedented warfighting capabilities in many theaters of operation.

In December 2006, Popular Science published an article called “Semper Fly: Marines in Space,” detailing a plan to develop a vehicle that could transport up to 13 marines to a military objective anywhere in the world from the United States in 2 hours via suborbital spaceflight.[7] The Marine Corps envisioned using suborbital space to develop a capability for greater operational speed and flexibility than conventional jets, called Small Unit Space Transport, or “Sustain.” Included in this vision was the ability to deploy forces outside the spacecraft at altitudes considerably above Armstrong’s line (see Table 24-1) to parachute to a ground-based objective. This goal was driven in part by expediency and to circumvent obtaining permission to use sovereign nation airspace, an issue between the United States and nations positioned along the space shuttles’ orbital track back in the early 1980s.[8] While these technical and tactical benefits may be achievable in the near future, careful consideration of the space environment’s effect on human physiology and function must be considered to optimize human performance outside Earth’s atmosphere.

MILITARY APPLIED PHYSIOLOGY

Physiologic adaptation to µg and partial-gravity environments involves the following systems: neurovestibular, cardiovascular, musculoskeletal, immune, neuroophthalmological, hematologic, gynecologic, and behavioral/performance. First, a basic understanding of the space environment is necessary to understand its physiologic impacts on humans.

The Space Environment

A spacecraft orbiting the Earth requires adequate orbital velocity carrying it into space to overcome Earth’s gravitational pull. The resultant vector keeps the vehicle “falling” around the Earth as the planet surface is constantly curving underneath it. The acceleration forces cancel each other out, resulting in µg. Outer space, that is, the environment beyond the Karman line (see Table 24-1), is the most hostile environment humans have ever encountered (Figure 24-2). Outside a pressurized vessel, an unprotected person would suffer near instantaneous death from ebullism and anoxia. In the absence of Earth’s protective atmosphere, near +/- 250°F temperature extremes exist between darkness and sunlight. A near vacuum where only a few hydrogen molecules exist, the thermosphere has an ambient pressure of roughly 10-12 mm Hg /3.2 × 10-2 Pa. Radiation (primarily charged alpha particles liberated by solar flares, ultraviolet radiation, and x-rays) and heavy charged particles from galactic sources are ubiquitous outside the protective layer of the atmosphere and geomagnetosphere. Despite the harsh environment of space, humans have lived and thrived for over 5 decades outside of Earth’s protective shell. Today’s space vehicles orbiting in LEO are designed to maintain a habitable interior with sea-level ambient pressure and gas combinations, temperature and humidity at comfortable levels, and adequate lighting and protection from harmful solar radiation. In addition, nearly instant two-way audiovisual communications support communication with astronauts and ground command and control of the vehicle.

Physiologic Effects

Neurovestibular

Physiologically, balance and coordination are among the first systems affected in space. In µg, the otoliths are off-loaded, contributing to the temporary loss of spatial orientation and space motion sickness that astronauts experience early on in spaceflight.9,10 All humans are affected to some degree with mild loss of neuromuscular coordination, nausea, and vomiting soon after orbital insertion. Reaction times are initially slowed but quickly adapt to the novel µg environment.[11] Upon return to the 1-g environment, proprioceptive challenges and loss of visual depth perception from spaceflight deconditioning last 48 to 72 hours.

On the lunar surface following a 4.3-day transit from Earth, the Apollo astronauts generally felt “a little wobbly” upon stepping on the moon. They attributed this sensation to the one-sixth Earth gravity environment and aft center of gravity of the lunar extravehicular mobility unit (EMU) rather than neurovestibular dysfunction (Figure 24-3).[12] Coordination seemed to improve steadily during the first couple of hours on the lunar surface. During three of the six lunar landings, blowing lunar dust caused loss of horizontal reference cues, complicating piloting during vehicle descent and resulting in longer descent times and deviation from the proposed landing site. Retrospectively, the Apollo crews stated that spatial disorientation did not play a factor in vehicle control. Whether environmental factors or loss of piloting proficiency played a role is unclear.

Figure 24-2. The edge of space. Fly-around view of the International Space Station (ISS) taken by an STS-119 crewmember after the undocking of the orbiter Discovery. NASA photo ID: S119E010500.
Reproduced from: https://images.nasa.gov/details-s119e010500.html.

Figure 24-3. Apollo 11 crewmember Buzz Aldrin, Jr. Crew members countered the suit aft center of gravity by leaning forward. NASA photo ID: AS11-40-5874.
Reproduced from: https://images.nasa.gov/details-as11-40-5874.html.

In LEO, correlations between mission length and landings outside (or nearly outside) planned parameters (landing too fast, too slow, or too hard) have been evaluated in operation and simulated environments.9–11 In space missions lasting between 5 and 14 days, the commanders and pilots had minimal perturbation of neurovestibular function. Consequently, neuromuscular motor control to carry out complex landing operations was minimally impacted.[9] Actual landing performance shows much greater variability than simulator performance parameters, but was within the margin of safety for short-duration missions. The implication is that short-duration spaceflight has a minor effect on pilot performance, but longer-duration µg exposures may complicate this dynamic phase of flight.

Cardiovascular

Cardiovascular changes that occur in space are most evident in cephalic fluid shift. On Earth, gravity exerts a downward force to keep blood flowing to the capacitance venous system in the lower body. Cephalad migration of nearly 2 L of intravascular volume occurs within hours of exposure to µg, when the lack of gravity causes blood and body fluid to be redistributed toward the chest and upper body. Astronauts experience nasal congestion, facial plethora, and a dull sense of taste.13,14 This “puffy face–bird leg” syndrome persists throughout the µg exposure to some degree. Initially the relative increase in cardiac pre-load results in diuresis, and the crew will urinate frequently for the first 24 to 36 hours of spaceflight. The crew then remains euvolemic in µg for the mission duration. As the lower extremities are minimally used for locomotion (the “arms become the legs” in space), there is consequent relative minor atrophy in cardiac muscle size and stroke volume. Heart rate does not change significantly, so cardiac output is naturally reduced up to 15% to 20%.

To determine the extent of cardiovascular deconditioning in µg and how it might potentially impact physical performance such as extravehicular activity (EVA), researchers have measured on-orbit maximum power outputs and oxygen uptake during exercise () in astronauts relative to their preflight baseline measurements.[15] Exercise performance, as measured by , is initially reduced in µg. Within the first 3 weeks of spaceflight, a pronounced deconditioning effect on aerobic capacity occurs without exercise countermeasures. The reduction in aerobic performance appears to peak at about 3 weeks in-flight, then slowly improves with use of a treadmill and cycle ergometer.

The cardiovascular adaptations to µg persist until reintroduction to the Earth’s 1g environment. Changes in the heart muscle, vascular reflexes, and redistribution of body fluids during flight strongly predispose crew to orthostatic hypotension post-landing to varying degrees. Upon return to the 1g Earth environment, the reduced circulating blood volume experienced by the crew in space results in decreased standing blood pressure without adequate commensurate increase in heart rate to maintain cardiac output. This condition, known as orthostatic intolerance, varies in severity but is present to some degree in most returning astronauts. The incidence for short-duration (less than 30 days) and long-duration missions ranges from 20% to 67% of crewmembers. Symptoms range from dizziness and lightheadedness to transient syncope, but usually resolve in 18 to 24 hours after landing.[16]

Musculoskeletal

Physical performance in space after the initial adaptation period of 24 to 72 hours is minimally impaired from cardiovascular alterations. However, there is potential operational impact from the musculoskeletal changes that occur in µg. Astronauts experience decreased upper body strength and stamina for EVA to some degree, depending on preflight fitness level and inflight training. Typical EVAs range in duration from 6 to 8 hours. During this time outside the spacecraft, astronauts manipulate equipment and move along the structure using mostly their hands, upper extremities, and core musculature. Crew members have described the upper body exertion during EVA as moderately physically demanding, depending on the task.

The musculoskeletal system undergoes significant adaptation in space in the form of bone and muscle loss due to the absence of gravitational loading. Prior to the use of the advanced resistive exercise device (ARED) on the International Space Station (ISS) in 2010, bone density losses of 1% to 2.4% per month in the lower extremities and spine were measured in astronauts.[17] The skeletal changes and loss of total body calcium have been noted in both humans and animals exposed to µg from 7 to 237 days. Using dual absorptiometry x-ray to measure bone mineral density (BMD), LeBlanc et al determined that BMD losses were specific to weight-bearing bones. Specifically, monthly losses of 1% at the lumbar spine and 1.5% at the femoral neck have been documented prior to the use of on-orbit resistive exercise training.[18] Astronauts returning from long-duration space flight have also demonstrated persistent loss of trabecular bone, despite return of density to preflight baseline levels.[19] Recently, finite element analysis and quantitative computed tomography have been used to assess bone architecture, in contrast to bone density measurements.[20] These methods may be more predictive of future fracture risk post-flight.

The potential clinical effects of long-duration space flight on calcium metabolism include the development of kidney stones due to increased urine and fecal calcium, as well as possible post-flight fractures. Fourteen post-flight kidney stones have been reported in short-duration space shuttle astronauts,[21] although no in-flight episodes of renal lithiasis have occurred in US astronauts to date. There have been 54 post-flight fractures among US crew members, but aerospace medicine experts attribute none of them to in-flight bone loss. Research continues on the risk of post-flight fracture.

Consistent with the skeletal adaptations, muscle morphologic change and fiber loss are evident in space compared to baseline preflight levels. Atrophy of the antigravity muscles (thigh, calf) and decrease in leg strength (approximately 20%–30%), with extensor muscles more affected than flexor muscles, have been measured in short- and long-duration astronauts. Data from rats carried aboard spacecraft showed an increase in the number of type II (fast-twitch) muscle fibers (those that are useful for quick body movements but more prone to fatigue). This effect has been confirmed with muscle biopsy in US astronaut volunteers.[22] Lower extremity muscle strength and size and overall decrease in leg volume and body mass were common prior to the current on-orbit exercise program using the ARED.

There are also significant changes to the axial skeleton in µg. Changes in the spine and antigravity muscles associated with µg exposure include lumbar back pain, fatigue, muscle stiffness and soreness, weakness, and atrophy in the core stabilizing muscles.23–27 Between 53% and 68% of astronauts experience some degree of lumbar back pain on orbit, known as space-adaptation back pain (SABP), ranging from mild to, in 10%, excruciating.[28] In-flight, there is dramatic postural change of the cervical and lumber spine with loss of lordosis from lack of gravity and the stretching of tendons and ligaments. Consequently there is an average increase in on-orbit height by 2 to 6 cm. SABP etiology is unknown but may relate to intervertebral disk and vertebral end-plate changes, thoracolumbar myofascial changes, alterations in the facet joint, and stretching of the anterior longitudinal ligament. SABP peaks in severity by 48 to 72 hours and subsides within the first week on orbit. Interestingly, the occurrence of SABP and post-flight herniated nucleus pulposus (HNP) appear to be inversely related.

As of this writing, post-flight HNP has occurred in 47 US astronauts, with 14 events occurring within the first year of return (Figure 24-4).26,28 The mechanism of the changes to the annular fibrosis that increases the risk of HNP is not well understood. The condition is equally common among short- and longer-duration crew, suggesting an unknown factor that injures the spine during µg exposure.26,29 Spacecraft type at landing (eg, space shuttle, Apollo Command Module, Soyuz) does not appear to be a factor in post-landing HNP occurrence.26,28 Many experts speculate there may be a dynamic period of stabilization of the annulus in the first few hours of return to 1g. In space shuttle crew members who were not significantly orthostatic on landing and were able to stand and ambulate, the sudden axial loading may injure the annulus, causing annular tears that predispose the person to HNP. Deconditioned crew returning from long-duration missions on the ISS are generally unable to stand for a couple of hours and subsequently remain supine until their orthostasis subsides. Therefore, maintaining supine position post-flight for a brief period of time may reduce the risk of developing HNP. The possible contribution of loss of the spinal stabilizer muscles (eg, the multifidus) in long-duration astronauts, as assessed by pre- and post-flight magnetic resonance imaging and functional muscle testing, is also being considered in astronauts with clinical symptomatology.[29]

Figure 24-4. Number of herniated nucleus pulposus (HNP) events based upon the time following the mission in years. Data source: Johnston SL, Campbell M, Scheuring RA, Feiveson A. Increased incidence of herniated nucleus pulposus among US astronauts. Aviat Space Environ Med. 2012;81(6):566–574.

Immune System

The immune system has subtle responses to short- and long-duration µg exposure. White blood cell function is impaired. Lymphocyte function is depressed in at least 50% of space crew members. Decreased lymphocyte response to mitogens in cosmonauts after space flight was reported for the first time in the early 1970s by Russian immunologists.[30] Among the possible causes of space flight-induced alterations in immune responses are exposure to µg, physical and psychological stress, exposure to radiation, and potentially more as yet undetermined causes. Delayed wound healing has been reported anecdotally.[31] Astronauts have described slowed healing of small skin wounds, up to a couple of weeks for paper cuts on their fingertips. There are also clinical implications from latent virus reactivation such as Epstein-Barr virus (EBV) and herpes simplex. Blood titers have confirmed elevations in EBV and cytomegalovirus in crew, with recrudescence of their lesions.

Neuroophthalmological

In the last decade, NASA has discovered many physiologic changes that have occurred in long-duration spaceflight that were unknown when spaceflight experience was limited to short-duration missions. Recently, changes in the neuroophthalmological system due to increased intracranial pressure (ICP) have been discovered in astronauts performing both short- and long-duration space missions.[14] ICP changes on orbit appear to affect men more than women. It is unknown whether this effect is secondary to the fluid shift, vascular compliance within the cerebral vasculature, increased blood flow to the organs that make cerebral spinal fluid, hampered reabsorption and venous distribution of the cerebral spinal fluid by the arachnoid villi, or elevated ambient CO_2 levels. These factors combined may be the source of increased ICP. The recent discovery that lymphatics have a prominent role in cerebral fluid dynamics may clarify the etiology. Whatever the cause, there are differences between space-induced ICP and the terrestrial condition. Whereas patients with pseudotumor cerebri on Earth have headache and are typically female and often overweight, astronauts at risk do not exhibit any of these characteristics on orbit. Although the outcome or end state of vision change may be similar, the mechanism is not related to terrestrial ICP pathology.

Good vision is necessary for reading and operational assessment, and the eyes are also the primary organ for position sense on orbit. However, dynamic changes take place in vision over a period of time on orbit. Currently, low-grade papilledema or choroidal folds are the manifestation of increased ICP on orbit, leading to one or more diopters of shift in visual acuity, which may be partly secondary to changes in increased ICP and its subsequent impact of the optic nerves. There is also a visual change in smooth pursuit or tracking of an object, known as saccades, in which the eyes have a jerky pursuit of the object progressing through a field of view. This effect may be secondary to loss of practice in using the eyes in tracking in space while simultaneously receiving neurovestibular signals. Saccades may have implications for human factors designs for landing instruments on exploration missions, docking and range finding of vehicles after prolonged space exposure, or target tracking in the military context.

Hematologic

Hematologic changes after short-duration µg exposures were noted on routine blood analysis during space shuttle missions.32,33 A relative reduction in circulating red blood cell mass has been documented, reflected in a 7% to 14% decrease in hematocrit levels relative to preflight baselines. This so-called “space flight anemia” is thought to be due to a sequestration of young erythrocytes by the spleen in a process known as neocytolysis. Despite the reductions in red cell numbers, crew performance does not appear to have been impacted.

Gynecologic

The physiologic effects of short-duration µg exposure on gynecologic function have been documented during space shuttle missions. These reports have confirmed that menstrual efflux and required hygiene measures are similar to those experienced on Earth. Oral contraceptives use for short-duration missions has been encouraged because this method offers the opportunity to reduce the volume of menstrual efflux and the capability to shift the menstrual cycle to avoid menses on orbit, or to totally suppress menstruation. In addition, oral contraceptives can help maintain bone density, particularly in individuals who exercise to the point of reduced estrogen levels and amenorrhea. Conception has apparently not been impaired in female astronauts following short- or long-duration µg exposures; several female astronauts have become pregnant and delivered healthy full-term babies post-flight.[14]

Behavioral

Psychological stress, as manifested in crew mood, morale, and circadian rhythm, has occurred to some degree during both short- and long-duration missions. On-orbit environmental factors that contribute to changes in crew morale include temperature, noise, odors, the relatively dry atmosphere, limited dietary choices in early space shuttle missions, and lack of family contact.[25] Symptoms of fatigue and irritability have been well documented, depending in part on the flight plan, including high work load and alterations in normal sleep patterns.

To maintain a stable altitude in LEO, a spacecraft needs to maintain a velocity of 17,500 mph. Consequently, “sunrise” and “sunset” occur every 90 minutes. The crew is subjected to fixed 6.5- to 8-hour sleep periods in an unusual sleep environment where loss of normal proprioceptive cues make falling asleep and maintaining sleep challenging. Head restraints are often needed to keep the head secured to a pillow, and loud background noise (ambient levels are 62–65 dBA) requires noise-cancelling headsets. More recently, the ambient lighting frequencies (blue-green wavelength) and elevation in local CO_2 levels have been implicated in insomnia.

All these factors have resulted in poor sleep quality and reduced sleep duration.[34] Preliminary analyses indicate sleep on 2-week shuttle missions (n = 44) averages 6 hours per night, significantly less than the 8 hours recommended by the Institute of Medicine. Analyses of a small number of ISS participants (n = 10) further indicate that sleep continues to be reduced in space in duration similar to that found during shuttle missions. Also, crew members during ISS missions regularly have schedule shifts to their work/rest schedules to meet operational demands of the mission, such as visiting vehicle operations, EVA, or repair of hardware malfunctions. Taken together, these environmental stressors can lead to circadian desynchronization resulting in sleep loss and daytime fatigue.34,35

THE MILITARY MEDICAL OFFICER AND HUMAN PERFORMANCE OPTIMIZATION IN SPACE

Role of the Military Medical Officer

The MMO supporting the space mission will be expected to have strong working knowledge of space physiology and operational space medicine. He or she will serve as subject matter expert providing recommendations to the commander for prevention of space environmental illness or injuries, assist in the diagnosis and treatment of such injuries (utilizing telemedicine), and determine when crew return to duty is appropriate following any sick leave. As in most of military medicine, the best treatment strategy for all potential environmental injuries/illness is primary prevention. Primary prevention is the cornerstone of optimizing human performance in extreme environments, and space operations are no different. Table 24-3 lists evidence-based strategies for specific risk factors or challenges to optimize warfighter performance in the extreme environment of space.

Human spaceflight provides unique challenges to human performance. Human physiology and function require significant support to adapt to the fluid shifts, neurovestibular dysfunction, musculoskeletal deconditioning, and circadian degradation associated with living in space. Radiation exposure, air quality, ambient pressure and gas component changes, toxicologic exposures, and loss of circadian rhythm control can affect every body system; these effects must be well understood by the MMO. In LEO, astronauts generally do not sustain radiation exposure levels that pose clinical risk for illness or injury. However, once missions extend beyond LEO and the protective shell of the geomagnetosphere and Van Allen belts, radiation effects on health become a major issue. The spacecraft must shield its inhabitants from radiation in these missions.[36]

Astronauts engaged in EVAs must have medical oversight to prevent decompression sickness as well as monitor for thermal, ocular, and musculoskeletal injury. Isolation, interpersonal stress, and the real threat of death provide further impact to sleep patterns and immune systems. Basic human needs must be met within the constraints posed by living in a relatively small, confined environment, and the MMO will need to understand the effects of the habitable vehicle volume on crew health and performance.[37] Countermeasures include nutrition, exercise, medication, and psychological support, along with correction of environmental anomalies. It is therefore imperative that military space operations employ physicians and medics fully trained in space physiology, mission operations, and space biomedical engineering to ensure mission success.

Sleep and Rest

During the on-orbit phase of each mission, a large team of flight controllers—experts in individual engineering areas related to spacecraft control, environmental monitoring, power generation, attitude control, and EVA—will be supporting the crew and vehicle in space from the operations control center, also known as “mission control.”[38] Highly detailed and operationally exacting work are hallmarks of space operations both on and off the ground. The space MMO must be cognizant of the impact to operations presented by the mission on the crew in space and the flight control team members on the ground. Physiologic and psychological effects of high work load, fatigue, and sleep deprivation often go unrecognized during mission operations but have the potential to affect crew and flight controller performance. Situational awareness of how medical issues could impact all phases of the space mission, and all operators, both on and above the Earth, should be the goal of the space MMO.

Preservation of optimal human performance in novel space environments will need to address changes to the circadian rhythm (or the “daily biological internal clock”), which regulates a circadian rhythm of 24.2 hours a day. Light serves as the strongest external stimulus for maintaining circadian alignment to Earth’s 24-hour day/night cycle. Melatonin, an endogenous hormone secreted by the pineal gland, serves as the biological “darkness” signal. When darkness occurs, melatonin is produced and released into the blood. Melatonin levels are high at night, resulting in decreased alertness and increased sleep inertia. Melatonin levels stay elevated through the night, then fall back to low daytime levels (which are barely detectable).

Figure 24-5. Extravehicular activity (EVA) on the International Space Station. S-116 MS Curbeam, Jr, and Fuglesang work on S1 Truss during EVA 1. NASA photo ID: STS116E05983.
Reproduced from: https://images.nasa.gov/details-s116e05982.html.

Bright light inhibits the release of melatonin. Even if the pineal gland is “switched on” by the circadian clock, it will not produce melatonin unless the person is in a dark or very dimly lit environment. Light therapy for circadian desynchrony has recently been implemented for astronauts on orbit and mission-control flight operators working the night shifts to maintain alertness.[34] Evidence shows that bright light hastens schedule shifting, improves circadian entrainment, and increases alertness and performance. Specific wavelengths optimize light as a countermeasure. Blue wavelengths (440–550 nm) mimic the morning light spectrum, hasten schedule shifting, and increase alertness, whereas red wavelengths (620–730 nm) simulate dusk and enable pre-sleep.

TABLE 24-3

TARGETED RISK FACTOR/CHALLENGES AND EVIDENCE-BASED STRATEGIES TO OPTIMIZE PERFORMANCE IN SPACE

Performance Risk Factor or Challenge

Human Performance Optimization Strategy

Space motion sickness

Antiemetic medication; preflight adaptation training; work/rest/hydration

Circadian desynchrony

Light therapy; melatonin; short-acting nonbenzodiazepine hypnotics

Muscle and bone loss

Preflight exercise program and in-flight aerobic and resistive exercise

Cardiac deconditioning

Preflight exercise program and in-flight aerobic and resistive exercise

Space adaptation back pain

NSAIDs, short-acting muscle relaxants, and spinal mobilization/compression

Extravehicular activity (EVA)

Oxygen pre-breathe; aspirin therapy

On-orbit urinary retention

Judicious use of anticholinergics; frequent voiding early in mission; trained in self-catheterization

Increased intracranial pressure

Maintain cabin PCO_2 below 3.00 mm Hg

Radiation exposure

Monitor daily radiation doses with active and passive dosimeters; high-density polyethylene shielding

Acute cabin decompression

Immediate isolation of leaking element; calculation of rate of leak and remaining time in orbit; oxygen supplementation

On-orbit visual changes

Have several diopter option eyewear available for each crew member

On-orbit headaches, congestion, confusion

NSAIDs, judicious use of oral/topical decongestants; monitor environmental CO_2 levels, maintain pressure below 3.00 mm Hg

Post-flight orthostatic intolerance

Reentry g suit; fluid load prior to pre-deorbit burn; post-landing IV fluids and antiemetics

Post-flight deconditioning

Gradual reintroduction to balance, mobility, strength, and stamina conditioning program

IV: intravenous; NSAID: nonsteroidal antiinflammatory drug

Pressure

EVAs during space missions require medical support (Figure 24-5). At altitudes above 15,240 m (50,000 ft), humans need either a pressure suit or enclosed pressurized cabin to prevent ebullism. For astronauts to operate in a space suit, the suit’s engineers must balance life support requirements with mobility. Ambient pressures greater than 6.0 psi create a stiff, almost inflexible spacesuit or EMU. Therefore, lower pressures are required to improve mobility and reduce crew fatigue. The US EMU is pressurized to 4.3 psi. The hypobaric environment has the potential to create nitrogen bubbles in the blood and tissues, leading to decompression sickness. To reduce this risk, astronauts perform “pre-breathe” of 100% oxygen for 2 to 4 hours to eliminate nitrogen gas from their tissues. They also take aspirin before beginning pre-breathe to reduce platelet adhesion and subsequent blood clot formation.13,14 The space MMO will also need to carefully monitor the spacecraft cabin’s repressurization rate after EVA to prevent ear and sinus barotrauma. A generally acceptable repressurization rate is between 0.5 and 0.7 psi per minute.

Conditioning

During spaceflight, the main countermeasure for musculoskeletal and cardiovascular deconditioning is exercise. Astronauts on both short- and long-duration missions benefit from regular physical training. Fitness plans are created by NASA astronaut strength and conditioning rehabilitation specialists. These plans include the use of the CEVIS (cycle ergometer with vibration isolation system, Figure 24-6) and the T2 (Treadmill 2 with vibration isolation system, Figure 24-7) for aerobic endurance preservation, and the ARED for muscular strength (Figure 24-8). The ISS in-flight physical fitness plan consists of 2.5 hours per day of aerobic and resistive exercise, 6 days per week, for US astronauts. This aggressive on-orbit conditioning program has been shown to preserve aerobic performance within the range of individual baseline levels and maintain moderate strength and stamina in most crew members. Flexibility in the extensor muscle groups and proprioception are still challenges faced by crew in space because of engineering constraints in exercise devices and vehicle limitations.

Figure 24-6. US Army astronaut Colonel (retired) Jeffrey N. Williams, Expedition 13 NASA space station science officer and flight engineer, exercises on the Cycle Ergometer with Vibration Isolation System (CEVIS) in the Destiny laboratory of the International Space Station. NASA photo ID: ISS013E17268.
Reproduced from: https://images.nasa.gov/detailsiss013e17268.html.

Figure 24-7. NASA astronaut Sunita Williams, Expedition 32 flight engineer, equipped with a bungee harness, exercises on the Combined Operational Load Bearing External Resistance Treadmill (COLBERT) in the Tranquility node of the International Space Station, 2012. NASA photo ID: ISS032E011701.
Reproduced from: https://images.nasa.gov/detailsiss032e011700.html.

Figure 24-8. US astronaut Steve Swanson, commander of ISS Expedition 39, performs loading exercises on the Advanced Resistive Exercise Device (ARED) onboard the International Space Station 2014. NASA photo ID: ISS039E011261.
Reproduced from: https://images.nasa.gov/detailsiss039e011261.html.

Medication

The MMO must ensure that crew ground-test all medications that could be used in space so that reactions and side effects are known. Of over 60 medications available for crew use in the on-orbit medical kit, the five most used are acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), nonbenzodiazepine hypnotics, antiemetics, and nasal decongestants. Of these, NSAIDs are the most commonly used.13,14 Conditions such as headache, low-back pain, and minor muscle aches warrant the use of NSAIDs. Melatonin and the newer generation nonbenzodiazepine hypnotics, such as zolpidem or zaleplon, are used to treat insomnia during the initial days of flight and during sleep shifting. These drugs have shorter half-lives than the older generation benzodiazepine hypnotics such as diazepam, temazepam, or triazolam. There has also been concern that the older drugs could sedate crew to a degree that wakefulness and clear cognition would be impaired during an emergency. Many crew members have prescription medications for benign medical conditions that do not preclude flying in space, such as hypertension, hyperlipidemia, hypothyroidism, or osteoarthritis, which require daily medication doses. Angiotensin-converting enzyme inhibitors, statin-class medication, thyroid replacement therapy, decongestants, and NSAIDs have been used for years in space and have been well tolerated.

On-Orbit Conditions

Several on-orbit medical conditions have occurred during NASA missions, and space MMOs must be familiar with them. Astronauts in the µg environment experience medical conditions similar to terrestrial experience, such as skin rashes, nasal congestion, dry eyes, ocular foreign bodies, serous otitis media, and constipation. Conditions that are rather unique to spaceflight include space adaptation syndrome (which includes nausea and vomiting, mild anorexia, fatigue, and insomnia), SABP, and urinary retention.21,23,39 Space motion sickness affects approximately 79% of all crewmembers, with 10% of cases felt to be severe. Approximately 70% of men and 50% of women have described symptoms ranging from a loss of appetite to nausea and vomiting. The time course is variable: onset occurs immediately post-insertion to 24 hours later, peak symptoms occur at 24 to 48 hours, and symptoms resolve at 72 to 96 hours, on average. Etiology is unclear, but contributing factors are thought to be a combination of entering a new motion environment; a sensory mismatch in which the inner ear and nervous system provide signals that do not make sense in µg; and the approximately 2-L cephalad fluid shift that occurs in space. Flight surgeons have encouraged crew to maintain a 1g orientation despite the confusing visual cues created by the weightless environment. Medication has been moderately successful in reducing nausea and vomiting. The crew should be directed to use meclizine 25 mg orally or promethazine 25 mg intramuscularly every 6 to 8 hours as needed. Inactivity or sleep, fluids, and gradual increase in activity over 24 to 48 hours restores crew members to preflight status in most cases, without recrudescence of symptoms.[16]

SABP peaks at 24 to 72 hour post-insertion and is treated with NSAIDs, short-acting muscle relaxers such as low-dose lorazepam, and assuming a fetal position to reduce pain. Urinary retention, although not unique to space flight, has been an issue due to medication side effects and mission activities that prevent bathroom breaks. Bladder distention and impaired detrusor muscle contraction has required in-flight catheterization to relieve symptoms or retention. Therefore, the MMO must ensure all crew members are trained in self-urinary-catheterization techniques for both short- and long-duration missions.

Vehicle launch and landing operations are also part of the MMO’s responsibility as crew flight surgeon. Prior to launch, flight surgeons frequently premedicate non-pilot and commander astronauts with antiemetics to minimize the post-insertion nausea and vomiting associated with space adaptation syndrome. Crews are also advised to use enemas to minimize the need to defecate early on in the mission. Contingency launch operations during the space shuttle era included launch pad abort scenarios such as hypergolic fuel chemical leaks, fire, and explosion. Post-landing operations pose significant medical challenges to the flight surgeon due to the relative dehydration, muscle loss, and neurovestibular and cardiovascular deconditioning astronauts experience in space. Additionally, the potential operational implications of reduced muscle strength and endurance from µg exposure include decreased landing proficiency and impaired vehicle egress capability. The MMO will also need to consider the vehicle landing site characteristics (eg, water vs land), and prepare recovery operations accordingly.

Guidance to the Commanding Officer

Ultimately, the MMO is responsible for supporting the medical mission for the commander and crew. Being aware of individual crew member needs and identifying realistic countermeasures to prevent adverse health effects are essential for success. It is also important to identify resources for learning about new strategies, especially during contingency operations. In this role, the mission commander can expect the MMO to support the following duties:

- Critical mission tasks

- Medical certification of astronauts for training and missions

- Medical care of astronauts and their families

- Support during medical consultations

- Military astronaut selection exams

- Operational mission tasks

- Medical support for space missions

- Oversight of crew and flight controller medical training

- Medical support to crew members prior to launch

- Monitoring EVAs

- Participation in contingency/rescue management during launch and landing.

- Being part of the flight control team in the mission command center

SUMMARY

This chapter on environmental extremes has introduced the MMO to the basics of optimizing human performance in space. Specifically, it discussed the historical relevance of the environment to success in military space operations, the basic applied physiology relevant to understanding the warfighter in the µg environment, and, finally, those evidence-based strategies demonstrated to preserve performance in LEO and partial-gravity planetary environments. The space MMO operates in a unique setting with limited resources, where urgency and proper planning can make the difference between success and failure on the battlefield. It is important to remember that the MMO is present not just to treat the wounded, but also to critically optimize performance and ultimately strengthen the commander’s hand for success.

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37.   Scheuring RA, Conkin J, Jones JA, Gernhardt ML. Risk assessment of physiological effects of atmospheric composition and pressure in Constellation vehicles. Acta Astronaut. 2008;63:727–739.

38.   Murry M, Cox CB. Apollo. New York, NY: Simon and Schuster; 1989.

39.   Thornton WE, Hedge V, Coleman E, Uri JJ, More TP. Changes in leg volume during microgravity simulation. Aviat Space Environ Med. 1992;63:789–794.

Chapter 25

PSYCHOLOGICAL WELL-BEING

ANGELA M. YARNELL, PHD*; ERIN S. BARRY, MS†; AND NEIL E. GRUNBERG, PHD‡

INTRODUCTION

DEFINITIONS

Well-Being

Psychological Fitness

Psychological Well-Being

FOUNDATIONS OF PSYCHOLOGICAL WELL-BEING

Behaviors Relevant to Psychological Well-Being

Cognitive Processes Relevant to Psychological Well-Being

Emotional Factors Relevant to Psychological Well-Being

MILITARY LIFE AND PSYCHOLOGICAL WELL-BEING

Psychological Well-Being and the Service Member

Psychological Well-Being and the Military Family

KEY INDICATORS OF PSYCHOLOGICAL WELL-BEING

Positive Affect

Mindfulness

Meaning and Purpose

Social Support

Unit Cohesion

Core Values

PSYCHOLOGICAL WELL-BEING AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer

Guidance to the Commander

PSYCHOLOGICAL WELL-BEING RESOURCES

SUMMARY

*Major, Medical Service Corps, US Army; Research Psychologist, Behavioral Biology Branch, Center for Military Psychiatry Neuroscience Research, Walter Reed Army Institute of Research, Silver Spring, Maryland

†Research Assistant Professor, Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

‡Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

The part can never be well unless the whole is well.

—Plato (circa 425–347 BCE)

The highest achievement by humans is happiness.

—Aristotle (circa 384–322 BCE)

The philosophies of Plato and Aristotle are relevant today for understanding the concept of psychological well-being. Plato expressed the idea that a human is made up of parts that contribute to a physical, psychological, and spiritual whole and that all parts that constitute the whole must be healthy for the being to be well. Aristotle built upon his mentor’s philosophy by adding that the ultimate goal of humans is happiness. He characterized this state as an achievement because it requires effort.

Military service members, their families, and civilians may strive to achieve or maintain psychological well-being. However, the life of a military service member involves challenges and situations that differ from civilian life. The US military has been an all-volunteer force since 1973, and people who decide to serve are willingly signing up for a lifestyle that includes occupational stress; the possibility of dangerous, life-threatening encounters; and separations (sometimes frequent) from significant others. These lifestyle requirements may make the people who choose military service different from people who do not. Research findings aid understanding and improvement of the lives of service members and their families in all areas, including that of psychological well-being.

Military medical officers (MMOs) play an important role in identifying individual, family, and unit opportunities to sustain or improve psychological well-being among those they serve. In addition to caring for patients, MMOs must advise commanders and maintain and practice self-care.

DEFINITIONS

Well-Being

A state of health and wellness, the ability to judge life positively,1–3 and to achieve a balance between positive and negative affect.[4] In general terms, well-being refers to physical, emotional and psychological conditions.

Psychological Fitness

Psychological fitness is one of eight components of Total Force Fitness,[5] and includes internal resources, external resources, and operational outcomes. Internal resources are present to some degree within every individual. They include awareness, levels of optimism, coping, decision-making, engagement, and active disengagement. External resources are not intrinsic to an individual; they originate from the environment and include training, leadership, and various fitness and wellness programs. Operational outcomes represent the consequences of applying internal and external resources to a circumstance. These outcomes include quality of life, mental health, sleep, drug use, and suicide. For example, an individual who is psychologically fit may have excellent coping skills and seek out wellness programs to deal with challenging situations, avoid risky behaviors, and enhance quality of life. Psychological fitness has been identified as a positive and valued state that should be achieved to help optimize human performance. Utilization of the three components described above help individuals reach that goal.

Psychological Well-Being

Integrated concepts of well-being and psychological fitness are crucial to understanding psychological well-being (PWB). PWB includes the following six components of positive psychological functioning6,7:

1. Positive evaluations of oneself and one’s past life (self-acceptance).

2. A sense of continued growth and development as a person (personal growth).

3. The belief that one’s life is purposeful and meaningful (purpose in life).

4. The possession of quality relations with others (positive relations with others).

5. The capacity to manage effectively one’s life and surrounding world (environmental mastery).

6. A sense of self-determination (autonomy).

Approaching and achieving these components of psychological fitness help achieve the goal or state of PWB.

FOUNDATIONS OF PSYCHOLOGICAL WELL-BEING

PWB is an important component of human performance optimization. It can be discussed independently, but it impacts and integrates with states of social and physical well-being. For example, poor PWB may lead to diminished social and physical well-being.[8] All conditions of well-being are needed for human balance and health.

Positive PWB is associated with biological correlates that protect health,[9] and the development of PWB for physicians can help them adapt to demands of the medical profession.[10] A good understanding of PWB can help the MMO to (1) optimally care for patients (service members and families); (2) appropriately advise commanders with regard to how PWB of service members and families impacts readiness and performance of service members; and (3) maintain and practice self-care.

Behaviors Relevant to Psychological Well-Being

To understand PWB and how to achieve or help others to achieve it first requires consideration of behaviors, cognitions, and motivations, as well as spiritual factors, that contribute to PWB. These factors must be integrated for each individual seeking to achieve PWB. Behaviors that affect PWB include exercise, leisure activities, eating, sleep, drug use, and sexual behavior. These behaviors may have a positive or negative effect.

Exercise

Individuals who exercise are more satisfied with their lives and happier than individuals who do not exercise.[11] Specifically, individuals who exercised two to three times per week are less depressed, angry, and stressed; are more trusting; and perceived their health to be better compared to people who do not exercise much.[12] Exercise is important for everyone, but may be especially beneficial for people with physical health (eg, cancer, cardiovascular diseases, arthritis, and sexual dysfunction) and psychological problems (eg, major depression[13]); pregnant women[14]; and teenagers.[15]

Leisure activities also enhance PWB.[16] Activities like tai chi[17]; yoga[18]; and group activities[19] improve PWB by reducing stress and anxiety, improving mood, increasing self-esteem, and reducing social isolation. Satisfaction with leisure activities clearly correlates with benefits to PWB.[20]

Eating

Proper nutrition (eg, eating fruits, vegetables, lean meat, fish, and whole grains) is linked to positive PWB21,22 and fewer depressive symptoms,[23] whereas a diet of processed or fried foods, refined grains, sugary products, and beer is associated with poorer outcomes.[21] Comfort foods—typically, foods high in sugar and carbohydrates—can enhance PWB acutely. Eating ice cream, for example, is associated with increased positive affect.[24] However, too much intake of these kinds of foods can lead to excessive weight gain that may decrease PWB over time.

Food deprivation generally decreases PWB and is related to psychological distress.[25] The term “hangry” has been coined to describe situations in which a person is angry as a result of hunger. Although this word may be amusing, it is a fairly common phenomenon and is possibly related to decreases in self-control as a result of hypoglycemia. Low glucose in the prefrontal cortex, the area of the brain responsible for self-control, may be related to increases in aggression and violence.[26] When the prefrontal cortex is deprived of energy, such as in the case of hypoglycemia from not eating, an individual may experience reductions in self-control. Being hangry is an interesting emotional manifestation of a state of physiological need that is important to consider in terms of well-being.

Sleep

People spend more than a quarter of their lives sleeping, and quality sleep affects performance and PWB.[27] Most healthy adults need 7 to 9 hours of sleep each night.[28] However, most individuals, including military personnel, do not get enough sleep (or enough quality sleep). Lack of sleep negatively affects PWB. Chronic insufficient sleep is related to increased experience of pain (eg, body pain, back pain, and stomach pain) as well as compromised optimistic outlook and social functioning (eg, rating on friendliness, efficiency, and sociability).[29] Getting 8 hours of sleep increases optimistic outlook and social functioning.[29]

Drug Use

Drug use can affect PWB, whether legal (eg, alcohol, nicotine, caffeine, or drugs prescribed to the user) or illegal (eg, street drugs such as opiates, prescription drug abuse, or inappropriate use of performance enhancing drugs). Licit drugs are used by many people to enhance PWB and to attenuate stress.[30] However, it is important to understand the health risks of repeated drug use, including physical health dangers and decreases in PWB when drug dependence develops and during abstinence from addictive drugs (both licit and illicit).[30] Illicit drugs also are sometimes used to enhance PWB acutely, but long-term effects usually lead to decreases in PWB for psychobiological, social, and legal reasons. MMOs must be aware of the effects drug use has on PWB and educate commanders and patients about these potential dangers.

Sexual Behavior

Being sexually active is linked to better physical health and likely to PWB. Lack of a healthy sexual relationship or being in an unhealthy sexual relationship is associated with poor PWB. For example, in women, self-reported sexual dissatisfaction is correlated with lower PWB.[31] Further, unwanted sexual behaviors (ranging from verbal comments, nonverbal communication, or uninvited touching to sexual assault) have powerful and lasting negative effects on PWB. Of particular relevance to the military community, it has been reported that women who deployed to a combat zone were more likely to have experienced sexual stressors than female service members who did not deploy.[32] In addition, sexual abuse has been associated with decreased PWB (eg, depression and poor body image).[33]

Cognitive Processes Relevant to Psychological Well-Being

Cognitive processes include attention, awareness or perception, thoughts, and beliefs. Cognitions both affect and reflect PWB.

Awareness

Awareness is an aspect of consciousness that entails a perception of one’s environment. The manipulation of awareness (eg, mindfulness) affects well-being. For example, individuals who are able to balance work and life demands, and completely detach from work during off hours, are more satisfied with their lives, have less stress, and fully engage while at work.[34] Mindfulness, used by marines and soldiers, is associated with decreases in perceived stress[35] and increased performance.[36]

Beliefs and Appraisals

The experience of stress or negative emotions depends on a person’s beliefs or attitudes about the situation or the way in which he or she assesses or appraises the situation. For example, having an optimistic outlook can lead to better PWB. The term optimism is used to describe the extent to which people hold generally favorable expectancies for their future.[37] Optimism is related to increases in PWB,[38] while pessimism (belief that bad things will happen in the future[39]) decreases PWB. Specifically, optimism is related to indicators of better psychological and physical health; responses to adversity; emotional well-being; and relationships.[37] In contrast, pessimism is related to less life satisfaction[40] and more depressive symptoms.40,41 The ability to generate vivid mental imagery of positive future events, instead of focusing on negative thoughts or “thinking traps” (eg, catastrophizing), results in better PWB.[42]

Religiosity and spirituality are also related to PWB.43–46 In particular, spiritual fitness enhances resilience, health, and well-being.[47] Spiritual fitness refers to domains related to the human spirit (eg, values, feelings, aspirations) encompassed by spiritual beliefs and practices, but is not specific to a particular religion or faith.[48]

Resilience

The American Psychological Association defines psychological resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress.”[49] Resilience factors represent individual or group-level variables that contribute to a decrease in the negative reactions to stressors.50,51 Individual resilience factors include effective behavioral and cognitive coping skills. Group resilience factors may relate to effective leadership or support from the unit. An interesting analysis of survey data collected from deployed service members (Mental Health Advisory Team [MHAT-VI]) indicated that although soldiers reported similar rates of combat exposure, there was little similarity in scores on a measure of PTSD symptoms.[52] This analysis highlights the marked variability in response to stressor exposure experienced by individual service members and suggests differential effects of resilience factors.

Resilience and resilience training are receiving substantial attention in the military to help service members prevent and recover from physical and psychological stressors. It is noteworthy that “thriving” (to grow and develop subsequent to stress such that the individual becomes stronger[53]) is an ideal that maximizes PWB. The MMO plays a key role in translating the science behind resilience into practical and applicable tools that unit commanders and individuals can use to enhance their ability to deal with stress, thereby enhancing PWB.

Emotional Factors Relevant to Psychological Well-Being

Positive emotions enhance and reflect PWB, whereas negative emotions are inversely related to PWB. Individuals who are skilled at recognizing and regulating their own emotions and the emotions of others are said to be high in emotional intelligence. High emotional intelligence is related to increased PWB.[54]

Emotional arousal (or stress) is related to performance and psychological state following the classic Yerkes-Dodson inverted U-shaped function (Figure 25-1). Some individuals seem to thrive under extreme stress (eg, Navy SEALS and other special operations forces), and the point at which the effects of stress go from positive to negative differs from person to person. Many factors seem to affect this point, including genetics, prenatal environment, childhood stress, personality, resilience, and other factors. The relationship between PWB and particular levels of arousal or stress, therefore, depend on the individual and on situations.

Medical professionals experience job stress and burnout. These demands are negatively related to PWB. Further, individuals who lack social support from supervisors and coworkers display worse PWB and more unfavorable work outcomes.[55]

Figure 25-1. Depiction of the Yerkes-Dodson Law of Optimal Arousal. As one’s arousal or stress level increases, so does performance and hedonic (or emotional) state; however, when stress is high and exceeds one’s coping ability, performance and hedonic state decrease.
Data source: Yerkes RM, Dodson JD. The relation of strength of stimulus to rapidity of habit-formation. J Comp Neurol Psychol. 1908:459–482.
Adapted from: https://en.wikipedia.org/wiki/
File:OriginalYerkesDodson.svg.

MILITARY LIFE AND PSYCHOLOGICAL WELL-BEING

Military service affects the PWB of service members and their families. It ultimately affects units and the military community, readiness, training, and even the achievement of military missions.

Psychological Well-Being and the Service Member

Military researchers have investigated the psychological effects of war for decades. Modern conflicts with increased survivability have shed new light on the relationship between stressful and traumatic encounters and individual health and performance. There is now a greater appreciation for this relationship, and increased attention is paid to the role of mental or behavioral health in readiness to fight and fitness for duty. Greater emphasis is now placed on holistic health, patient-centered care, individualized medicine, and reduced stigma. The services now recognize that military life affects PWB in service members and their families and that this impact is present in home, garrison, deployed, and combat situations.

Despite the stressful and often dangerous nature of military service, active duty military members are more likely to psychologically thrive than civilians. This thriving may occur because of beneficial resources associated with military service, including job security and financial compensation.[56] For instance, a majority of Army officers (70%) report satisfaction with pay.[57] Although many junior soldiers (about 30%) report financial hardship,[58] it is not clear if these concerns predated enlistment (eg, existing debt) or developed during military service. Free financial counseling and educational services are offered by the military and may help soldiers improve their financial situations and reduce stress. Other advantageous resources available to service members include tuition assistance, tax-free housing, subsidized childcare, free medical care, special pay, and bonuses (for retention of soldiers with specific skills).

The military culture also offers social benefits that contribute to PWB. Social support and unit cohesion are both important determinants of PWB for service members. In addition, high levels of perceived support from the community, unit leadership, and base agencies reduced service members’ concerns about their spouses’ ability to cope with deployment-related stressors.[59] This perception of support for the nondeployed spouse mitigates one potential stressor on the deployed service member.

Leadership

Another key variable for PWB in the military, given its hierarchal structure, is leadership. Quality of life in the military is highly dependent on leadership.[57] Survey data collected from deployed service members indicate that strong leadership was significantly correlated with improved morale and cohesion, fewer mental health problems, and fewer ethical violations.[60] Similar surveys of comparisons across 28 platoons revealed that leaders who exhibit positive behaviors such as clear thinking, while not displaying negative behaviors such as showing favoritism, helped to reduce effects of combat exposures.[61]

Combat Stress

Despite the benefits of military service, there are obvious risks and potentials for poor outcomes with regard to PWB. To a certain extent some reactions to deployment-related stressors are expected. The Department of the Army coined the term “combat stress reactions” to describe the physical, emotional, cognitive, and behavioral reactions to these stressors and has defined it as “expected, predictable, emotional, intellectual, physical, and/or behavioral reactions of a Soldier who has been exposed to stressful events in combat.”[62] This definition normalizes the reaction to combat-related stressors and also provides a framework to identify and assess maladaptive responses, with the intention of early intervention. Of these various reactions, service members are most likely to report physical symptoms to their medical provider. These reactions represent physiological responses and arousal to combat stressors. Muscle tension, sleep disturbances, and headaches are physical symptoms that may be reported by service members experiencing combat stress. It is imperative that medical providers understand how reactions to combat stress can manifest physically and how they may present in patients.

Injury

These stressful or traumatic exposures can have deleterious effects on PWB. In the last decade extensive research has been done on the effects of combat on mental health, indicating increased rates of posttraumatic stress disorder (PTSD), depression, anxiety, substance abuse, and other functional impairments.51,63,64 Some believe that combat-related PTSD may be an occupational hazard of military service.[65] Aside from the psychological effects of stress exposures resulting from combat, service members suffer from physical injuries as well. Injured veterans are more likely to suffer from PTSD and mood-related disorders than noninjured veterans.[66] The relationship between physical injury and negative psychological effects may be (a) direct—physical injury may cause biological changes that affect psychological state; (b) indirect—physical injury may disrupt behaviors in ways that are psychologically upsetting; or (c) by other means such as disrupting sleep, which can inhibit both physical and psychological recovery.

Transitions

Experiences during deployment have a great effect on how a service member transitions back into the garrison environment. In their model of deployment-to-home transition, Adler and colleagues describe the following factors[67]:

- deployment variables (experiences, anticipation of homecoming, meaningfulness);

- postdeployment variables (physical, emotional, cognitive, and social);

- quality of life (health, work, relationships); and

- other reintegration moderators like decompression, developing a narrative, unit variables, and anticipation of deploying again.

Deriving meaning from work while deployed and in garrison is particularly important for PWB. Finding meaning in work is associated with enhanced motivation and well-being.[68] If service members find their work while deployed to be meaningless, they may experience anger and resentment, leading to negative impacts on PWB. There may be less meaning associated with work upon return from deployment as well, for various reasons including a decrease in arousal associated with work in the postdeployment environment. Decreases in arousal postdeployment can lead to increased risk-taking behavior. This behavior may include unsafe driving, leading to more road accidents and even increased death rates due to accidents in the year following deployment.[69] Transition home can be difficult for all service members, regardless of their combat experience or mental health status, and should be appropriately planned, monitored, and assessed. Military medical providers play a key role in this entire process.

Psychological Well-Being and the Military Family

The transition to life at home for service members with families can also have a great impact on family relationships and on the PWB of family members. Military life has substantial impact on service members’ spouses and families. Family members experience various stressors such as relocation, social isolation, separation, and fear of or actual injury or death of the service member. The stressors may positively or negatively impact the PWB of the family member, depending on a number of variables. The wars in Iraq and Afghanistan have brought the longest family separations since World War II.[70] More than half of all combat deployments left at least one dependent family member behind.[58] These separations are difficult for service members and their families, and family stability is negatively affected by prolonged separation because of deployment.[71]

Spouse Well-Being

For female spouses, the length of separation is significantly associated with poor well-being.[72] More specifically, deployment has been related to decreases in health-promoting behaviors including exercise, social interaction, rest, safety-related behaviors,[73] and greater perceived stress[74] for the nondeployed spouses. Further, nondeployed spouses often have psychopathological problems including major depression or generalized anxiety disorder; emotional, alcohol, or related family problems; and functional impairment in work and life,[75] sleep disorders, acute stress reactions, and adjustment disorders.[76]

Care for Wounded Warriors

In addition to the effects of family separation, the demands associated with current wars include increased survival but greater care requirements for wounded warriors.[57] Specifically, PTSD can be a secondary traumatic stressor for family members. In one study, PTSD symptoms reported by military members predicted increased symptoms in their female spouses.[77] The MMO can impact these associations by including family members in the treatment services for PTSD and educating the family about combat-related reactions.[60] These steps may help improve treatment outcomes for the service member and lessen the impact of mental health problems on the family. Education for family members about physical injuries (eg, traumatic brain injury and limb amputation) is important so they understand the symptoms associated with these injuries (eg, fatigue, memory loss, frustration, and angry outbursts) and do not blame the service member.[78]

Relationship Quality

Given that deployment has clearly identified effects on service members and their significant others’ well-being, it is no surprise that there are further impacts on intimate relationships and satisfaction. Marital relationships are affected by military service,[79] specifically in the following ways:

- disproportionate work–family balance[80];

- preparing for or recent return from deployment[81];

- difficulty communicating, reestablishing emotional bonds, or renegotiating roles and responsibilities[82]; and

- physical or mental health concerns for one or both partners.57,83,84

Marital satisfaction is negatively correlated with PTSD and depression, although it is not significantly related to combat exposure by itself, suggesting that other factors are involved.[85] MMOs should be aware of these strains on marriage and relationships unique to military service and incorporate them into their practice and interactions with patients and families.

Coping

In addition to the perception of stress, coping style is predictive of PWB in female military spouses of deployed service members, and style of coping varies based on rank of spouse, whether she grew up in a military family, and experience of a previous deployment separation.[73] The ability of the spouse or family member to cope with the stress of military life and deployment is important. In a study of spouses from an Army infantry division, problem-focused coping strategies were more frequently endorsed than emotion-focused coping strategies. Problem-focused coping refers to changing or modifying the fundamental cause of stress, whereas emotion-focused coping refers to strategies that are effective in the management of unchangeable stressors.86–88 Problem-focused coping was related to fewer depression symptoms, especially in instances where the individual perceived little control over the situation.[89] In addition, access to social networks and sources of social support—similar to the situation for service members—is critical for families. Support from community and unit positively correlated with families’ ability to adapt to stress.[90] Spouses who did not meet criteria for major depressive disorder or PTSD were more likely to report positive effects from deployment (more independence, more self-confident problem solving) than spouses who met criteria for major depressive disorder or PTSD.[82]

Although separations because of military service are stressful and are associated with adverse psychological health outcomes, these separations are quite different from separations during past wars because of current technology (email, phone, video call) that increase opportunities for communication and connectedness. Also, Internet and virtual communities may increase connectedness of family members to available sources of support.[70]

Employment

Military spouses’ employment is another important factor that affects PWB of military family members. Working contributes to the overall satisfaction of military spouses, providing additional compensation, personal fulfillment, independence, and other benefits.[91] Unemployment can act as a chronic stressor[92] and negatively affect PWB.[93] Education level of military spouses also may play a role in better PWB.

Children

Children of service members also are affected by military separations. Children in military families, unlike most civilian children, live with the concern that their parent may be injured or killed during a combat deployment,[94] which may lead to emotional difficulties.[95] Length of the parent’s deployment and the parent’s rank (a variable that likely represents a complex set of family circumstances) are related to PWB. There is some evidence that child neglect and mistreatment increase for the children of enlisted service members during a combat deployment.[96] Increases in interpersonal violence in general are associated with combat deployment[97] and the length of deployment.[98] It is important for the MMO to be aware of these potential issues for family members, especially children. Additionally, the MMO can assist the unit command in preventing these poor outcomes associated with military service and deployment by educating them about the relationship between certain factors discussed here. For example, engaging in military-sponsored activities seems to enhance well-being.[99]

KEY INDICATORS OF PSYCHOLOGICAL WELL-BEING

Key concepts relevant to PWB include positive affect; mindfulness; purpose and meaning in life; social support; unit cohesion; and core values, which are the heart of military service. These factors may change over time and circumstances, so a clear understanding of them can be used by MMOs and the people they treat to optimize PWB.

Positive Affect

Positive affect describes how much an individual experiences positive moods such as joy, interest, and alertness. According to research, this concept appears to be more beneficial with respect to health and mortality relative to negative affect, in which individuals tend to experience negative emotions such as anxiety, sadness, fear, anger, guilt and shame, irritability, and other such feelings or states (eg, Cohen and Pressman[100]). Positive affect is directly associated with good sleep,[27] serves a protective role in cardiovascular disease,[101] facilitates healthy aging,[102] and is proposed as a buffer for the impact of psychosocial risk factors.

Mindfulness

Mindfulness can be conceptualized as the act of intentionally being acutely aware of what is going on internally and externally, without reacting.35,36,103,104 Mindfulness and its underlying awareness are inherent personality traits as well as capabilities that can be honed through training.103,104 Evidence for the benefits of mindfulness is extensive and instructive.[103] Importantly, mindfulness can be helpful for many operational, leadership, and personal activities and is likely beneficial for enhancing resilience and overall health.[103] Many current military leaders use mindfulness as a tool to better prepare for a dynamic and uncertain future. Importantly, training in mindfulness has been shown to serve as a preventive measure against physician burnout.[104] It is an important concept that can and is impacting health and performance.

Meaning and Purpose

Meaning and purpose have been studied in the social sciences since the late 1980s. Meaning is described as “making sense, order, or coherence out of one’s existence” and purpose “refers to intention, some function to be fulfilled, or goals to be achieved.”[105] Most of the literature assesses meaning and purpose in pathological and psychopathological conditions, but in some instances meaning in life has been found to have a strong correlation with positive well-being.[106]

Social Support

Social support involves the perception and reality of assistance and understanding provided by other people; this support can buffer or reduce stress and effects of stress.[107] Social support can be structural (eg, available social ties like marital, family, or church affiliations)[108] or functional (ie, not just available, but available and able to meet the person’s needs). In the military, positive unit environments facilitate social support and help individuals cope with stress.[57] Specifically, the relationships between work stress and morale, and work stress and depression, are moderated by the quality of the social environment.[109] Conversely, the absence of social support is a risk factor for physical and psychological problems.110–113

The deployed or combat environment may present conditions under which service members need the most social support because they are removed from their usual social support networks of family and friends while facing new stressors. As a result, social support from the unit and other available services (eg, buddies, effective leaders, behavioral health professionals, chaplains) is crucial in the deployed setting. Reliance on members of the unit is part of military culture and is key to successful integration into military life. An individual who successfully integrates into a group can achieve a sense of belonging and increased self-worth, which contributes to positive health outcomes,[114] whereas one who does not integrate may experience negative health effects.[115] Social support buffers deleterious effects of stress on health.[107] Positive effects of social support can be reflected in neuroendocrine and immune response biomarkers,116,117 reduced psychological despair,[118] and increased motivation toward self-care.[119]

Unit Cohesion

Unit cohesion is similar to social support, but with specific relevance for the military. It represents the degree to which individuals are bonded to one another and to their higher organization. Unit cohesion in the military is positively associated with readiness, performance of individuals and groups, and personal well-being.[120] Unit cohesion has been reported to moderate the relationship between combat exposure and posttraumatic stress in marines and Navy corpsmen.[121] Belonging to a resilient group, with high morale, has a positive impact on the well-being of the service member.[114]

EXHIBIT 25-1

SERVICE CORE VALUES

Service core values are shared fundamental beliefs that cross service boundaries, but the unique aspects of each service are reflected in the differences among their top priorities.

Army

- Loyalty

- Duty

- Respect

- Selfless Service

- Honor

- Integrity

- Personal Courage

Air Force

- Integrity First

- Service Before Self

- Excellence in All We Do

Navy and Marine Corps

- Honor

- Courage

- Commitment

Core Values

Core values are qualities representing an individual’s or organization’s deeply held beliefs and fundamental driving forces. They define what an organization believes and how it resonates and appeals to others within the organization and throughout the external world. Core values should be part of each military member’s belief system. Core values represent the solid core of each person, who they are, what they believe, and who they should want to be going forward. They provide guiding principles and can be used as a touchstone for service members. Each of the services has its own set of core values, as do most individuals. These core values are extremely important for PWB within, across, and throughout military communities (Exhibit 25-1).

PSYCHOLOGICAL WELL-BEING AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer

The MMO plays a key role in PWB education, training, and evaluation for service members and their families. The MMO is charged with explaining the role of behaviors, cognitions, and motivations with respect to PWB. The MMO should educate individual patients and unit commanders about factors that impact PWB.

Enhancing PWB may be as simple as improving eating, sleeping, or exercising. Patients may also alter the way they think about an issue. This is a more difficult way to enhance PWB but MMOs can assist and provide guidance. Changing motivations is the most difficult way to enhance PWB. If the issues go beyond the MMO’s ability to treat (eg, psychopathology), the MMO must refer the patient to the next appropriate level of care. If psychological and behavioral healthcare can be found in the same place as the MMO is providing care, then it may be as easy as walking the patient down the hall. In other cases it may be more difficult for an MMO to easily transition the patient to psychological care. MMOs should be aware of the referral process and available resources at each facility in which care is provided.

MMOs are also responsible for managing their own well-being, by monitoring and manipulating the factors discussed in this chapter. MMOs should be aware of the importance of self-care to maintain high levels of performance and to avoid physical or psychological burnout. A valuable complement to self-awareness is to rely on and encourage input from significant others and trusted colleagues with regard to the MMO’s PWB. Perhaps the most valuable guideline to optimize one’s own PWB is to remember the importance of balance in all aspects of professional and personal life.

Guidance to the Commander

The first step is to make the unit commander aware of potential threats to PWB and ways to improve PWB, and to educate the commander about how to make changes within the unit. Threats to PWB include the following:

- drug use,

- bias or prejudice,

- stress,

- injury, and

- transitions.

Framing the threats or challenges as detractors from accomplishing unit mission or decreasing readiness are often the most successful ways to effectively communicate the importance of PWB.

MMOs should remind the commander that psychological fitness is a key component to overall fitness and readiness. Commanders can support PWB among soldiers in a unit by promoting or providing the following:

- physical exercise;

- healthy eating;

- sufficient sleep;

- mindfulness;

- optimism;

- spirituality;

- social support;

- unit cohesion; and

- effective leadership.

It is recommended that MMOs educate unit commanders on specific threats and countermeasures to PWB.

PSYCHOLOGICAL WELL-BEING RESOURCES

Many tools and resources are available to MMOs, commanders, and soldiers and their families, ranging from online support to programs on base, such as:

- Adler AB, Bliese PD, Castro CAE, eds. Deployment Psychology: Evidence-Based Strategies to Promote Mental Health in the Military. Washington, DC: American Psychological Association; 2011 (https://www.ajol.info/index.php/smsajms/article/viewFile/97397/86707).

- Human Performance Resource Center (http://hprc-online.org/about-us/about-hprc).

- Family and morale, welfare and recreation (MWR) programs on base.

- Community service programs on base.

- Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (http://www.dcoe.mil/).

- Center for Deployment Psychology (http://deploymentpsych.org/).

SUMMARY

Healing is a matter of time but it is sometimes also a matter of opportunity.

—Hippocrates (460 BCE–370 BCE)

Psychological well-being is relevant to the lives of all people, but the challenges faced by service members and their families underscore the importance of maintaining and enhancing PWB. As discussed in this chapter, various behaviors, cognitions, and motivations/emotions affect and reflect PWB. But as Hippocrates, the “father of Western medicine,” wisely advised more than 2 millennia ago, we can wait to heal and hope to achieve well-being, or we can take advantage of opportunities to heal. PWB is especially affected by finding opportunities to take meaningful actions. The MMO serves a key role in this pursuit for service members, units, patients, and self.

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Chapter 26

SLEEP, REST, AND RECOVERY

ANGELA M. YARNELL, PHD*; MATTHEW L. LOPRESTI, PHD†; OMOTOLA O. LANLOKUN, BS‡; AND THOMAS J. BALKIN, PHD§

INTRODUCTION

DEFINITIONS

BACKGROUND

MILITARY SERVICE AND SLEEP DEFICITS

ROLE OF MILITARY MEDICAL OFFICER

SLEEP HYGIENE AND FATIGUE MANAGEMENT TOOLS

GUIDANCE TO COMMANDING OFFICER

SUMMARY

SLEEP MANAGEMENT RESOURCES

*Major, Medical Service Corps, US Army; Research Psychologist, Behavioral Biology Branch, Center for Military Psychiatry Neuroscience Research, Walter Reed Army Institute of Research, Silver Spring, Maryland

†Major, Medical Service Corps, US Army; Deputy Director, US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, Washington

‡Research Intern, ORISE, Behavioral Biology Branch, Center for Military Psychiatry & Neuroscience, Walter Reed Army Institute of Research, Forest Glen, Maryland

§Fellow, ORISE Knowledge Preservation Program, Behavioral Biology Branch, Center for Military Psychiatry & Neuroscience, Walter Reed Army Institute of Research, Forest Glen, Maryland

INTRODUCTION

Sleep is important to every aspect of performance involving the brain. Therefore, adequate sleep, rest, and recovery (reset) are critical components of any successful military training program or operational mission. The reset process requires adequate rest and recovery time after a major physiological or psychological insult such as an intense experience or demanding work period.

Friction often exists between meeting mission requirements and obtaining adequate sleep or rest in an operational environment. Commanders naturally want to know the minimum amount of sleep or rest needed to maintain military effectiveness during missions, between missions, and for full recovery or reset.

This chapter provides military medical officers (MMOs) information needed to advise unit commanders on appropriate management of sleep and alertness in their troops. MMOs play an important role in promoting sleep health and teaching tools service members can use to maximize good sleep practices.

DEFINITIONS

Sleep represents a physiological function of the brain and is required to maintain health and performance. Exhibit 26-1 further defines sleep and provides a popular theory about sleep and wake. Rest refers to periods of time when no tasks are being performed (time off task). Performance improvement results from rest, but rest does not equal sleep. During sleep, rest occurs, but not vice versa.

EXHIBIT 26-1

TWO-PROCESS THEORY OF SLEEP

“Sleep is a dynamic behavior … a special activity of the brain controlled by precise and elaborate mechanisms.”[1] Sleep serves a homeostatic function in the body and is marked by reduced consciousness, reduced response to environmental stimuli, and dreaming. Alexander Borbély, a Swiss sleep researcher, presented a model in the early 1980s to describe the regulation of the sleep–wake cycle. He proposed that this cycle is regulated by two interacting mechanisms, or processes of sleep–wake regulation[2]:

- Process C represents circadian rhythm, or the regulation of the body’s internal processes and alertness levels, governed by the internal biological clock.

- Process S represents the accrual of the physiological need for sleep during wakefulness that manifests as a homeostatic drive for sleep.

___________________

1. Hobson JA. Sleep. New York, NY: Scientific American Library; 1989: 1.

2. Borbély AA. A two process model of sleep regulation. Hum Neurobiol. 1982;1(3):195–204.

There is broad agreement about what sleep is and how it can be identified and measured, but there is no consensus regarding the ultimate functions of sleep. In 1976, Naitoh observed that sleep deprivation studies have served only to “confirm repeatedly a truism: [sleep loss] makes animals and humans sleepy.”[1] Although this observation remains largely true today, the past 4 decades of sleep research has produced a wealth of knowledge and some compelling hypotheses regarding the functions of sleep. For example, Tononi and Cirelli[2] hypothesize that sleep serves to prune away excess, energy-depleting synaptic connections that accrue during wakefulness, making the well-slept cortex optimally efficient—a state that manifests behaviorally as optimal alertness and cognitive performance.

Sleepiness and fatigue are frequently used interchangeably, but are best considered as distinct phenomena. Sleepiness is best defined as the propensity or readiness to initiate sleep. It varies as an interactive function of sleep debt (caused by inadequate sleep) and the circadian rhythm of alertness.[3] Sleepiness is marked by deficits in alertness and cognitive performance[4] related to deactivation of brain regions associated with higher order cognitive functions (eg, prefrontal cortex).[5] Sleepiness can only be reversed by sleep.

Figure 26-1. Although sleepiness and fatigue are caused by different factors, both affect performance.

Fatigue is defined as a subjective awareness of declining abilities, due to increasing mental effort[6] that results from increasing “time on task.” Fatigue may be accompanied by observable decrements in performance[7] after prolonged or repeated tasks that vary as a result of cognitive load or task difficulty and time on task.[8] Unlike sleepiness, fatigue can be reversed by “time off task.”

Sleepiness and fatigue both result in performance decrements; however, these phenomena are physiologically different. Fatigue accrues as a function of “time on task,” whereas sleepiness accrues as an interactive function of “time awake” and the circadian rhythm of alertness,[8] as shown in Figure 26-1. Sleepiness is reversed by sleep, and fatigue is reversed with rest.

Physicians should explore patient complaints of fatigue because patients may be using it in different ways to describe tiredness or malaise (eg, as associated with depression or diabetes). When sustained performance is required, appropriate interventions should be recommended on the basis of both “time on task” and “time awake” variables.

BACKGROUND

With mounting scientific evidence suggesting its importance for health, safety, and performance, adequate sleep has increasingly become the focus of the US military’s efforts to improve and sustain the effectiveness, short-term and long-term well-being, and quality of life of service members.[9] The array of deleterious effects resulting from sleep loss is wide. One particularly important effect is impaired immune function.[10]

In the short term, acute sleep deprivation results in impaired cognitive performance including the following11–14:

- reduced vigilance and situational awareness,

- impaired critical thinking and problem solving,

- compromised decision-making, and

- deficits in motivation.

This impaired cognitive performance may increase likelihood of accidents and suboptimal task and mission completion. Psychological impacts such as enhanced symptoms of pain, fatigue, and negative moods may also affect well-being and job performance.

In the longer term, chronic sleep restriction has been shown to lead to impaired alertness and performance that accrues over days and weeks in a dose-dependent manner.15,16

In recent years, the effects of chronic sleep restriction on health and well-being have been found to include reduced resilience to stress-related disorders such as the following:

- posttraumatic stress disorder and depression,17–21

- cardiovascular disease,[22]

- type II diabetes,[23]

- metabolic syndrome and weight changes,24,25 and

- mortality.26,27

Recent epidemiological evidence also suggests that chronic reduced sleep may predict dementing illnesses such as Alzheimer disease.[28]

MILITARY SERVICE AND SLEEP DEFICITS

Sleep disturbances are common among military personnel. Problems may begin at the start of a military career and do not discriminate by rank. Recruits at basic training as well as cadets at the service academies typically obtain less than the recommended 8 hours of sleep per night. For example, at the US Military Academy, cadets obtain an average of less than 5.5 hours of sleep per night during their 4 years of training.29–31

Deployed service members are impacted even more. Because modern military operations are often characterized by high operational tempos, with 24-hour-per-day activity and austere, non-sleep-conducive environments, chronic sleep restriction is widespread among deployed troops. Deployed service members report that they average significantly less than the recommended 8 hours of sleep per night,32,33 and less than the amount of sleep obtained in garrison.[34] They report averaging less than 6 hours of sleep per night, and over half report experiencing some sleep deprivation.[35] A study of deployed US Air Force personnel revealed that 75% reported sleep that was so poor they met the diagnostic criteria for insomnia.[32] Nighttime duties and poor sleep environments are the major factors impacting sleep while deployed.[36] US Navy personnel are no strangers to poor sleep either. Submariners, for example, report poor quality and quantity of sleep while at sea (< 6 h) compared to shore duty (~7 h) or while on leave (>7 h).[37] On surface ships, sailors who work the night shift topside and are exposed to bright morning sun just prior to bedtime (in the ascending phase of the circadian rhythm) sleep less (4.7 h) than sailors who work below deck during the night shift (7.4 h) without exposure to sunlight prior to bedtime.[38]

EXHIBIT 26-2

COMPARISON OF TRAUMA-ASSOCIATED SLEEP DISORDER WITH RAPID EYE MOVEMENT SLEEP BEHAVIOR DISORDER

Trauma Associated Sleep Disorder

- Disinhibition of voluntary muscle movement during REM sleep

- Triggered by traumatic event

- 50% comorbidity with posttraumatic stress disorder

- Repetitive dream mentation

- Dreams involve reenactment of traumatic triggering event

- No evidence of association with developing other neurologic disorders later in life

- Some success in treatment with prazosin

REM Sleep Behavior Disorder

- Disinhibition of voluntary muscle movement during REM sleep

- Spontaneous onset

- Can indicate future diagnosis of Parkinson disease

___________________

REM: rapid eye movement

Data sources: (1) Mysliwiec V, O’Reilly B, Polchinski J, Kwon HP, Germain A, Roth BJ. Trauma associated sleep disorder: a proposed parasomnia encompassing disruptive nocturnal behaviors, nightmares, and REM without atonia in trauma survivors. J Clin Sleep Med. 2014;10(10):1143–1148. (2) Postuma RB, Gagnon JF, Bertrand JA, Genier Marchand D, Montplaisir JY. Parkinson risk in idiopathic REM sleep behavior disorder: Preparing for neuroprotective trials. Neurology. 2015;84(11):1104–1113.

Furthermore, it has been shown that subjective reports of sleep duration and habituation to chronic sleep restriction are not accurate and do not reflect physiological adaptation.39,40 Because subjective measures of sleepiness do not always accurately reflect the actual level of sleepiness-related impairment, objective measures of sleep such as wrist actigraphy are critical for the evaluation of both individual and unit-level readiness, especially in operational environments where performance is critical to mission success. Actigraphy has been shown to be a valuable tool to supplement fatigue risk-management systems for monitoring alertness in various high-risk and shift-work environments, including aviation,41,42 trucking,[43] and hospitals.[44] More information about using tools such as actigraphy to implement good sleep hygiene practices is detailed below.

There is emerging evidence that military personnel may be especially susceptible to a unique constellation of symptoms comprising a newly proposed syndrome called trauma-associated sleep disorder.[45] This proposed syndrome is similar to, and could easily be confused with, rapid eye movement sleep behavior disorder because both are characterized by disinhibition of voluntary muscle movement during rapid eye movement sleep (resulting in the “acting out” of dream mentation). However, there are several critical differences that may affect prognosis and treatment, which are listed in Exhibit 26-2.

ROLE OF THE MILITARY MEDICAL OFFICER

The MMO plays a vital role in the education and training of unit leadership and personnel with regard to the importance of adequate sleep and the relationship between sleep and health. The US Army Performance Triad[46] recognizes that optimal readiness, health, and performance cannot be achieved without sufficient sleep, physical activity, and proper nutrition. MMOs should become familiar with this program and be prepared to assist service members to develop and achieve their sleep, activity, and nutrition goals.

Sleep is a primary physiological need, like hunger or thirst, but the “consumption” of sleep may be more heavily influenced by social and environmental factors than eating or drinking. Unit leaders and personnel often underestimate the amount of time needed for getting good quality, restorative sleep. In military culture, sleep loss may be considered a sign of mental or physical toughness.[30] In fact, the opposite is true. MMOs must be prepared to educate unit personnel and leadership on the importance of adequate sleep to brain function and performance, and ultimately to the mission. This requires integration of good sleep hygiene practices into all relevant unit activities (eg, mission planning, work–rest cycles, shift scheduling).

Insufficient sleep threatens the mission in a number of ways. Failure to obtain adequate or restorative sleep can result in loss of energy, weariness, difficulty concentrating, and memory deficits.[47] Although service members sometimes endure periods of total sleep deprivation, chronic sleep restriction (insufficient daily sleep) is practically ubiquitous in deployed environments, which are characterized by adverse or constrained conditions.[48] Chronically sleep-restricted individuals may subjectively adapt to repeated or prolonged periods of sleep loss, but from an objective standpoint (ie, in terms of the effects of sleep loss on objectively measured performance), there is little evidence of adaptation. Figure 26-2 shows that chronic sleep restriction and total sleep deprivation both have qualitatively equivalent effects on performance; all that varies is the rate at which these deficits accrue. Even for elite service members who are highly trained and experienced, sleep loss results in significant decrements in vital cognitive abilities including vigilance, memory, and reasoning.[49] Basic guidance regarding the management of sleep and alertness is available in Army Techniques Publication 6-22.5, A Leader’s Guide to Soldier Health and Fitness.[50]

Because sleep loss impacts a wide array of cognitive abilities and performance, it constitutes a significant threat to military personnel and operations. For example, sleep loss slows psychomotor responses and results in attentional lapses.[51] These lapses and slowed performance in some cases reflect microsleep—brief (0.5–15.0 s) intrusions of sleep into periods of wakefulness.[52] In fact, sleepiness-induced performance deficits (eg, lowered reaction time and impaired judgment) can occur even in the absence of microsleep. Microsleep episodes are sufficient but not necessary to produce sleepiness-related performance deficits. Duties performed by service members are often dangerous or conducted in dangerous environments. Lapses in performance and attention are not only safety concerns, they are also threats to mission success. Additionally, insufficient sleep results in poor decision-making, especially for decisions involving risk-taking.[53] Leaders at all levels are expected to make decisions, sometimes with little time or information, and even small decrements in decision-making ability (speed or quality) can put missions and lives at risk.

Figure 26-2. Mean number of lapses on the psychomotor vigilance task (and standard error) across days as a function of time in bed group.
B: baseline; E: experimental phase; R: recovery phase; HR: hours (time in bed)
Reproduced with permission from: Belenky G, Wesensten NJ, Thorne DR, et al. Patterns of performance degradation and restoration during sleep restriction and subsequent recovery: a sleep dose-response study. J Sleep Res. 2003;12(1):12.

Figure 26-3. In the short term, effective management of sleep and alertness in the operational environment promotes safety,1 military effectiveness,2 and psychological resilience.3 In the long term, a consistent regimen of adequate sleep may have multiple health benefits, including a relatively reduced risk of developing heart disease, cancer, type II diabetes, and Alzheimer disease.4

1. Thomas MJ, Ferguson SA. Prior sleep, prior wake, and crew performance during normal flight operations. Aviat Space Environ Med. 2010;81(7):665–670.

2. Wesensten NJ, Balkin TJ. The challenge of sleep management in military operations. US Army Med Dep J. 2013;Oct-Dec:109–118.

3. Germain A. Resilience and readiness through restorative sleep. Sleep. 2015;38(2):173–175.

4. Benedict C, Byberg L, Cedernaes J, et al. Self-reported sleep disturbance is associated with Alzheimer’s disease risk in men. Alzheimers Dement. 2015;11(9):1090–1097.

Beyond its direct, short-term effects on mission accomplishment, sleep loss may have long-term deleterious effects on psychological resilience and the development of psychopathology.54,55 Conversely, regularly obtaining adequate sleep may play a positive role in enhancing resilience (ie, the ability to recover from a stressful event or to grow in the face of adversity).[56] The military is concerned with training and equipping a ready and resilient force. MMOs play a key role in assuring that this goal is achieved by promoting healthy sleep.

Riding atop the circadian rhythm that mediates alertness or sleepiness across a 24-hour cycle, there are shorter, ultradian rhythms that mediate alertness on a much shorter, even moment-to-moment basis. In the short term, excessive subjective sleepiness can also be partially and momentarily masked by high motivation, excitement, exercise, and competing needs such as hunger or thirst. Also, it has been shown that sleep-deprived or restricted individuals will often become subjectively habituated to an increased sleep debt. Because those regions of the brain that are required for accurate self-assessment are impaired by sleep loss (eg, the prefrontal cortices), sleep-deprived or restricted individuals are functionally impaired and therefore poor judges of the extent to which they have been affected by insufficient sleep. For this reason, objective measures of sleep (eg, derived from wrist actigraphy) should be employed as part of a comprehensive alertness and sleep management program. Figure 26-3 gives more information about the positive effects of managing sleep in the short term and long term.

SLEEP HYGIENE AND FATIGUE MANAGEMENT TOOLS

Several tools and technologies can be applied to facilitate the management of sleep and alertness in the field, including hardware, such as wrist actigraphy (Figure 26-4) for objective measurement of sleep duration, continuity, and timing, and enabling software. Also, pharmaceuticals such as stimulants and hypnotics may be warranted under some circumstances. Independently, each of these tools can be used effectively to consolidate sleep or enhance alertness and performance during waking hours. Sleep can be consolidated by using hypnotic medications. Stimulants such as caffeine and nicotine can enhance alertness. Performance model-informed work–rest scheduling can be adapted to support both sleep requirements and the ability to be alert and well rested during duty hours.

Figure 26-4. Shown is the Actiwatch Spectrum, used for objectively measuring sleep.
Photograph courtesy of Philips Respironics, Bend, OR.

Optimum benefit can be realized when these tools are used in concert, as components of a comprehensive sleep–alertness management system. As described in Wesensten, Killgore, and Balkin,[57] an optimal system utilizes an objective measure of sleep–wake timing and duration for each individual operator rather than (a) estimates of the likely amount of sleep obtained based on the timing and duration of scheduled off-duty hours; or (b) unreliable self-reports of timing, duration, and quality of sleep. Currently, the best technology for measuring sleep timing, duration, and continuity in field environments is wrist actigraphy.

Wrist actigraphs are relatively unobtrusive, about the size and weight of a typical wristwatch. Some commercial models incorporate typical wristwatch functions. These devices use accelerometers to measure wrist movements—data from which sleep and wakefulness can be reliably determined and scored.[58] Sleep–wake scoring of wrist movement data is often performed by the devices in real time, and these data are stored in memory. A typical wrist actigraph can collect and store approximately 6 to 8 weeks of sleep–wake data, with the limiting factor being battery life. It is anticipated that even longer periods of continuous data collection will become available over the coming years, as advances in battery technology are made.

Several commercial products are currently marketed with claims they can be used to measure sleep–wake timing and duration. Many of these products are multifunction devices that provide a measure of daytime physical activity level in addition to an estimate of nighttime sleep, but they have not been adequately validated. Commercial wrist actigraphs that are designed and marketed for the sole purpose of measuring sleep–wake timing and duration have generally been tested against polysomnography (the gold standard for sleep–wake scoring) and found to be valid and reliable.

In the optimal, comprehensive sleep–alertness management system, objective (actigraphically derived) sleep–wake data serve as inputs into an individualized mathematical model (ie, a performance prediction algorithm that “learns” an individual’s response to sleep loss and outputs a quantitative prediction of individual cognitive performance capacity). Thus, the mathematical model provides the means for interpreting the actigraph’s sleep–wake data in terms of its meaningfulness for individuals in the operational environment, the likelihood of their making errors and having accidents,[59] and the rate at which they can perform useful mental work.[60] It also allows commanders and others to predict what further decrements in cognitive performance will occur if no sleep is allowed in the next X amount of hours and the benefits that would accrue if a nap of X hours were allowed at time Y.

The 2B-Alert Web application is an open-access, predictive tool designed to optimize cognitive performance by analyzing the effects of sleep–wake patterns, time of day, and caffeine consumption.[61] This tool was developed in an ongoing, collaborative project at the Walter Reed Army Institute of Research and the Biotechnology High Performance Computing Software Applications Institute (Frederick, MD). A mobile application using this technology can predict alertness and cognitive performance for individuals, and its functionality is expandable.[62] Using such scientifically validated tools that predict performance and recommend interventions during continuous and sustained operations will actually prevent decrements in performance from reaching critical thresholds.

When operationally feasible, reversal of sleep-loss-induced alertness and performance deficits is best accomplished with recovery sleep (either natural or pharmaceutically facilitated). Although stimulants can improve alertness and at least some aspects of cognitive performance,[63] it is important to keep in mind that they do not actually replace sleep; they only help delay its onset. Sleep debt continues to accrue during stimulant-sustained wakefulness, and in the absence of recovery sleep, escalating doses of stimulants are required to maintain alertness with increasing levels of sleep debt. The relative operational utility of stimulants and hypnotics are evaluated in the literature; operationally salient points include the following57,64,65:

- Equivalent doses of many stimulants such as d-amphetamine, modafinil, and caffeine have been established,[57] but because of its relative safety, efficacy, availability, and widespread use and acceptance, caffeine in the recommended doses should at this time be considered the stimulant of choice for use in operational environments.

- Sleep inducers can be used to effectively enhance sleep when the opportunity for sleep occurs during the daytime (when the circadian rhythm of alertness is in the ascending phase and therefore mitigates against sleep onset and maintenance).

- Benzodiazepine agonists such as zolpidem are most effective for inducing and maintaining sleep, but “drug hangover effects” are possible and should be considered when these drugs are used in an operational environment.

- Melatonin and synthetic melatonin receptor agonists (such as ramelteon) are generally less effective than benzodiazepine receptor agonists, but may be useful under some circumstances (eg, when the user has a significant sleep debt but still experiences difficulty sleeping during the daytime).

In addition to informing the command about sleep management and optimization, MMOs must make decisions about the use of alertness-enhancing pharmaceuticals. It is imperative that MMOs know the effectiveness and possible side effects and hangover effects of these products and prescribe them accordingly.

GUIDANCE TO THE COMMANDING OFFICER

In military environments, the extent to which stress exposure impacts psychological functioning and military effectiveness is dependent in part on the quality of the unit leadership.[66] Chronic sleep restriction is among the most salient stressors faced by military personnel. Unit leadership plays a key role in ensuring all unit members get enough sleep. In addition to its benefits for health and well-being, adequate sleep is a personnel readiness issue and is just as important as weapon or equipment readiness. Leaders set the operational tempo for their unit, and that pace should be set to maximize individual and unit performance. Optimal performance can be achieved only when service members obtain adequate sleep. In the current conflicts, mental agility or “cognitive fitness” is essential for success. Sleep is a vital component of cognitive fitness. Commanders are urged to make sleep a priority for themselves and for their troops. Sleep should be considered an item of logistical resupply just like food, water, fuel, and ammunition, and should be addressed when planning missions.

SUMMARY

Sleep and rest, or “time off task,” provide qualitatively and physiologically distinct benefits to the soldier. In the short term, effective management of sleep in the operational environment promotes safety, military effectiveness, and resilience. In the long term, evidence is emerging that adequate sleep results in multiple health benefits later in life. Therefore, the goal should always be to maximize sleep quality and duration to the extent possible given operational realities and exigencies. This goal can best be achieved by implementing a comprehensive sleep–alertness management system that includes hardware such as wrist actigraphy (for objective measurement of sleep duration, continuity, and timing); software that provides performance predictions and guidance regarding sleep–wake interventions; and an armamentarium of pharmaceuticals (eg, caffeine) and hypnotics (eg, zolpidem) to optimize short-term control over alertness and sleep as needed.

SLEEP MANAGEMENT RESOURCES

The links below provide further details about the US military’s guidance on sleep for service members at all levels. They detail functional sleep management tools that can help ensure individual service member health and performance as well as unit operational effectiveness.

- 2B-Alert App –web-based demo (https://2balert-web.bhsai.org/2b-alert-web/login.xhtml)

- 2B-Alert App – description (https://techlinkcenter.org/technologies/2b-alert-personalized-alertness-cognitive-performance-app/)

- US Army Performance Triad website (https://p3.amedd.army.mil/)

- US Army Medicine’s Performance Triad training sessions for soldiers and leaders (http://www.armymedicine.mil/Pages/Performance-Triad-Training-Sessions.aspx)

- Army Techniques Publication 6-22.5, A Leader’s Guide to Soldier Health and Fitness (http://www.apd.army.mil/epubs/DR_pubs/DR_a/pdf/web/atp6_22x5.pdf)

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61.   Reifman J, Kumar K, Wesensten NJ, Tountas NA, Balkin TJ, Ramakrishnan S. 2B-Alert Web: An open-access tool for predicting the effects of sleep/wake schedules and caffeine consumption on neurobehavioral performance. Sleep. 2016;39(12):2157–2159.

62.   2b-alert-personalized-alertness-cognitive-performance-app. Defense TechLink Website. https://techlinkcenter.org/technologies/2b-alert-personalized-alertness-cognitive-performance-app/. Accessed July 6, 2018.

63.   Harrison Y, Horne JA. Sleep loss and temporal memory. Q J Exp Psychol A. 2000;53(1):271–279.

64.   Bonnet MH, Balkin TJ, Dinges DF, et al. The use of stimulants to modify performance during sleep loss: a review by the sleep deprivation and Stimulant Task Force of the American Academy of Sleep Medicine. Sleep. 2005;28(9):1163–1187.

65.   Vermeeren A, Coenen AM. Effects of the use of hypnotics on cognition. Prog Brain Res. 2011;190:89–103.

66.   Britt TW, Davison J, Bliese PD, Castro CA. How leaders can influence the impact that stressors have on soldiers. Mil Med. 2004;169(7):541–545.

Chapter 27

MUSCULOSKELETAL INJURY PREVENTION

TIMOTHY C. GRIBBIN, MED*; KATHRYN BEUTLER, BS†; AND SARAH J. DE LA MOTTE, PHD, MPH‡

INTRODUCTION

EPIDEMIOLOGY

CURRENT MITIGATION PROGRAMS

SMART Centers

The Sports Medicine Injury Prevention Program

Developing Efforts

RISK FACTORS FOR MUSCULOSKELETAL INJURY

PREVENTION STRATEGIES

Training Modifications

Equipment Modifications

Functional Assessments

Movement Training

Components of Successful Injury Prevention Implementation Plans

MUSCULOSKELETAL INJURY AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer

Guidance to the Commanding Officer

SUMMARY

*Research Associate, Injury Prevention Research Laboratory, Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland

†Research Assistant, Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland

‡Assistant Professor and Scientific Director, Injury Prevention Research Laboratory, Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland

INTRODUCTION

Musculoskeletal injury (MSK-I) is the number one cause of lost duty days in the US military, posing a threat to readiness and a financial burden on the fighting force. MSK-Is in military members occur during training, recreational and sporting activities, and occupational duties.[1] Many successful interventions have been implemented to reduce the burden of MSK-I in military communities by focusing on surveillance and education, supportive leadership, and training modifications. This chapter outlines the spectrum of MSK-I issues and discusses recommended steps for future prevention of MSK-I in the US military. Importantly, the unique role of the military medical officer (MMO) to help maintain MSK health is discussed. Terms relating to MSK-1 are defined in Table 27-1.

EPIDEMIOLOGY

As the largest health problem for US military service members, whether at home or abroad, MSK-I accounts for over 1.95 million physician visits each year in the Department of Defense. This is nearly three times higher than the utilization for mental disorders, which is the second most common condition.[2] During deployment, nonbattle MSK-Is are the leading cause of air evacuation from theater, and account for 24% of all evacuations; combat injuries account for only 14% of such missions.[3] Furthermore, MSK-Is are the number one reason for lost duty days and contribute to the largest proportion of service-connected disability in the Department of Veterans Affairs.4,5 Therefore, MSK-Is are a burden not only during active duty, but over the entire lifecycle of service members.

The vast majority of MSK-Is in the US military are nonbattle-related injuries, commonly occurring during recreational activity, exercise, training, and occupational events.[2] MSK-Is are also a problem during deployments, where approximately one in six service members will sustain a noncombat MSK-I sufficient to degrade or preclude their subsequent ability to perform mission duties.[3]

MSK-Is are of particular concern in training environments during the beginning of a service member’s career. Up to 27% of male recruits and 57% of female recruits sustain a training-related MSK-I during Army basic combat training (BCT),[6] with similar rates across other service branches. These injuries result in expensive medical care, training delays, and training dropouts, which can cost more than $57,000 per discharged recruit.7,8 For recruits who graduate BCT after sustaining an MSK-I, many are unable to complete their first term of enlistment. From 2007 to 2012, injuries sustained during BCT accounted for nearly 82% of all disability-related medical discharges during recruits’ first year of service.[9]

The most commonly diagnosed nonbattle injuries in both training and deployment are overuse injuries of the lower extremity and lumbar spine.3,10,11 Lower extremity stress fractures are a common overuse injury during initial basic training; prevalence during this training has been reported to be as high as 6.9% for males and 21% for females.[12] Basic training injuries cause tremendous force attrition: 25% of male recruits who sustain an injury in basic training will proceed to an early medical discharge.[13]

The burden of MSK-I described above is a driving factor in physical training and has been identified as a top priority for program and policy interventions to reduce injury rates. However, knowing that physical training, during entry-level military training and deployment, is a primary cause of MSK-I does not inform program designers and policy makers as to why service members are being injured at such high rates. Identifying risk factors that predispose to these injuries is critical to successfully implement a strategy to reduce the burden of MSK-I.

CURRENT MITIGATION PROGRAMS

SMART Centers

Traditional MSK-I treatments at military sites often consist of 15- to 20-minute booked appointments at orthopedic or primary care clinics. Such visits have two major drawbacks: (1) primary care providers may not have adequate training in the evaluation of and appropriate referral for MSK-I,[14] and (2) providers most likely do not have the requisite expertise to complete an MSK-I evaluation in 15 to 20 minutes, let alone create a comprehensive rehabilitation plan.

In 2008, Marine Corps Base Camp Lejeune began implementing Sports Medicine and Reconditioning (SMART) Teams at designated MSK-I clinics to (a) expedite return to work or duty, (b) improve healthcare satisfaction, and (c) reduce attrition of active duty service members. These goals must be achieved through targeted improved MSK-I care access, early and accurate MSK-I diagnosis, and aggressive reconditioning. Primary care sports medicine-trained physicians, athletic trainers, and physical therapists provide team-based care in an open-bay configuration at the SMART clinics. This configuration allows for a large number of patients to be seen and lends itself to better-coordinated MSK-I care. An additional benefit is a decreased number of required orthopedic consults through early diagnosis and treatment compared with the traditional model. SMART centers have improved access to care and decreased the numbers of service members referred for physical evaluation boards.[14]

TABLE 27-1

KEY DEFINITIONS

Term

Definition

Intrinsic risk factor

Aspects inherent to the individual that may predispose him or her to injury. Intrinsic risk factors may include demographic factors (eg, age, sex, education level, income level, marital status, occupation); anatomical characteristics; and physical fitness factors.

Extrinsic risk factor

Conditions imposed on the individual that may cause injury. Extrinsic risk factors may include running mileage, training techniques, footwear and other equipment, load carried, environmental conditions, and leadership.

Modifiable risk factor

An aspect of the individual that is within their ability to change, which may also be considered “intrinsic,” or environmental factors that interface with the individual.

Overtraining

The point where an individual experiences a decrease and/or a plateauing in performance due to an imbalance in training load relative to recovery capacity.

Acute injury

Injury that occurs at a definitive time point and in response to identified, often traumatic factors (eg, anterior cruciate ligament tear).

Overuse injury

Injury that occurs at an imprecise time point and in response to cumulative overload rather than a single inciting event (eg, Achilles tendinopathy).

Functional movement assessment

A test or series of tests designed to measure an individual’s ability to perform athletic or work-related physical tasks, such as squatting, lunging, or balancing on one leg. Functional movement assessments typically value movement quality (correct form) over movement quantity (how many reps or how much weight).

Dynamic balance

One’s ability to maintain stability as the body moves through space.

The Sports Medicine Injury Prevention Program

Between 1997 and 2001, approximately 1,100 Marines per year were discharged from basic training due to MSK-I, with females more than twice as likely as males to have an MSK-I-related discharge. Consequently, a program to address the problem was implemented in Marine Corps basic training, the Sports Medicine Injury Prevention (SMIP) program. First initiated at Parris Island in June 2003, SMIP focuses on MSK-I prevention, assessment, and treatment using athletic trainers integrated into the recruit-training environment at the battalion level. The program has since been added at Marine Corps Recruit Depot San Diego and secondary training level sites as well.

Central to SMIP’s success is an initiative that has been integrated into the Marine Corps Physical Training Instructor Course, in which drill instructors (who are pivotal in the physical training sessions during recruit training) are informed about injury prevention during entry-level training. SMIP has capitalized on this effort to become a seamless part of the regular training environment.

Developing Efforts

All services are trying to develop approaches to minimize and mitigate MSK-I. Within the Marine Corps, the Force Fitness Instructor initiative is moving forward. Additionally, the Army has the Master Fitness Trainer program and is piloting a holistic health and fitness program, all of which are aimed at limiting MSK-I. The recommendations for implementation are strong, but the science of best practices requires further review, once programs have been implemented.

RISK FACTORS FOR MUSCULOSKELETAL INJURY

Over the past few decades, research has consistently established risk factors such as age, sex, race, previous injury history, and poor cardiovascular fitness for MSK-I (Table 27-2). These risk factors have traditionally been categorized into intrinsic and extrinsic risk factors, as defined in Table 27-1.6,7,15 Intrinsic risk factors include demographics (eg, age, sex, race/ethnicity, genetics); anatomical characteristics (eg, knee alignment and arch height); and physical fitness (eg, cardiorespiratory endurance, muscular strength/endurance, and flexibility). Extrinsic risk factors may include running mileage, training techniques, footwear and other equipment, load carried, environmental conditions, and leadership.[16] However, MSK-I prevention strategies for training-related injuries have now begun to focus on whether intrinsic and extrinsic risk factors are “modifiable” or “nonmodifiable.” A modifiable risk factor is one that the individual is able to change, which may also be considered intrinsic factors, or extrinsic factors that interface with the individual. Categorization as modifiable or nonmodifiable allows for identifying specific risk factors amenable to change and where MSK-I prevention efforts can be focused.17,18

Although these risk factors have been consistently established in training settings, most are either not easily modifiable or account for only a small percentage of overall injury risk. For example, smoking status is considered to be modifiable, but it can take over one year for a smoker to physiologically recover from its effects after quitting.[19] Thus, current efforts to determine MSK-I risk and implement prevention strategies have shifted toward readily modifiable risk factors in the short term, such as assessing and correcting an individual’s functional movement patterns or movement strategies used to accomplish a task.

A person’s movement patterns may be key to injury prevention. Thus, primary prevention (prevention of the first injury) and secondary prevention (prevention of recurrent injury) may include optimizing movement patterns, correcting poor quality movement, and improving dynamic balance. Changing movement patterns is essentially improving “movement quality.” Shifting from a quantity mindset (how many push-ups you can do) to a quality mindset (how can you perform a push-up in a biomechanically optimal way) can be challenging, but is vital for the military setting.20,21 Programs addressing better neuromuscular control and proprioceptive and agility training have been shown to decrease anterior knee pain, stress fracture, and other lower extremity MSK-I incidence during military training.7,22,23

TABLE 27-2

INJURY-ASSOCIATED RISK FACTORS BY CATEGORY

Category

Risk Factor

Modifiable (M) or Nonmodifiable (N)

Demographic

Age > 24 years

N

Caucasian race

N

Female gender

N

Previous MSK-I

N

Tobacco use

M

Anatomical

Genu valgum

N

Q-angle > 15 degrees

N

Decreased ankle dorsiflexion

M

Rear foot hyperpronation

M

Arch extremes (pes cavus, pes planus)

M

Physical fitness

Low levels of physical activity before training

M

Low aerobic fitness

M

Extremes of flexibility

M

Low muscular strength and endurance

M

Body mass index and body composition extremes

M

MSK-I: musculoskeletal injury

Data source: de la Motte SJ, Oh R. Successful injury prevention interventions. In: Cameron KL, Owens BD, eds. Musculoskeletal Injuries in the Military. New York, NY: Springer New York; 2016: 267–286.

PREVENTION STRATEGIES

Most MSK-I prevention strategies focus on modifying the training programs, altering equipment used, applying specific anatomical correction techniques, and assessing movements. These are briefly described below.

Training Modifications

Careful monitoring of the training environment can help to decrease MSK-I risk. Excessive running volume during training has long been associated with higher rates of MSK-I in military populations,16,24,25 and improper training advancement or “doing too much, too fast” is also a common cause of MSK-I overuse injuries in particular. In basic training, up to 80% of lower extremity injuries suffered are overuse injuries, and likely attributed to low levels of baseline fitness among recruits, as well as doing too much too quickly.[1] Because many individuals entering military service have low fitness, graduated and interval training interventions have been implemented to increase baseline levels of fitness and prevent the development of overuse MSK-I.7,16,22,26 Notably, decreasing running mileage by 40% decreased stress fracture incidence across Marine Corps basic training by more than 50%,[27] with minimal effects on physical fitness test scores (Table 27-3).[16] The reduction in stress fracture rates from reducing running mileage was estimated to save $4.5 million in direct medical care costs and nearly 15,000 training days per year.[27]

In addition to total running volume, exercise frequency and duration serve a vital role in managing MSK-I risk during basic training, and likely during all physical training. Above a certain intensity, frequency, and duration of training, injury rates appear to increase markedly, whereas fitness levels change minimally within a certain training load range.

Another approach to reducing MSK-I is to standardize the amount of training mileage at the division level. Results from military training studies strongly support standardizing training mileage, volume, and intensity as an effective way to reduce MSK-I.28,29 The Army Physical Readiness Training (PRT) program for the 9-week BCT was designed to decrease overall formation running mileage, with a gradual increase in distance running. The PRT program standardized basic training warm-ups and physical training, and incorporated new evidence-based calisthenics, dumbbell drills, movement drills, interval training, and flexibility training with a progressive increase in repetitions and intensity. Compared to the traditional Army BCT physical training program, the PRT group had (a) a higher pass rate on first-time administration of the final Army physical fitness test (APFT), (b) fewer APFT failures, and (c) a 52% and 46% decrease in the overuse injury rate in males and females, respectively, without any deleterious effects on run times. This was despite running 54% fewer formation miles (17.1 miles compared to 37.2 miles). Furthermore, a significant decrease in time-loss overuse injuries was noted in the PRT group for both males (65.8%) and females (68.5%) relative to the traditional program.[29] The PRT is now an established policy (FM-7-22[30]) to standardize physical training for all soldiers across the Army.

TABLE 27-3

STRESS FRACTURE INCIDENCE BY MILEAGE AND RUN TIME

Marines (n)

Total Run Distance (km)

Stress Fracture Incidence (n/100)

Final 3-Mile Run Times (min)

1,136

89

3.7

20.3

1,117

66

2.7

20.7

1,097

53

1.7

20.9

Data source: Shaffer RA. Musculoskeletal injury project. Paper presented at: American College of Sports Medicine 43rd Annual Meeting; May 29–June 1, 1996; Cincinnati, OH.

Equipment Modifications

Although training modifications can significantly reduce the risk of injury, equipment modifications can also be important. Two approaches include footwear and ankle bracing. Footwear is one of the easiest modifications that can be made. There is limited evidence that selecting running shoes based on arch height decreases injury risk in basic training,[31] but some evidence suggests that running shoes lose their shock-absorbing capabilities after 250 to 500 miles.[32] Service members should be urged to get new running shoes sooner than the previously recommended 400 to 600 miles.[33]

A popular trend in runners is barefoot running or wearing minimalist shoes. The theory for this approach is that the runner’s gait is shorter than when wearing traditional running shoes, which leads to a midfoot or forefoot strike, rather than rear-foot strike. Whereas this should theoretically decrease the impact delivered to the shin, knee, and hips, the best evidence to date suggests that injury rates in barefoot and traditional runners are identical, but occur in different anatomic locations. Barefoot runners typically sustain injuries to the foot, ankle, and calf; heel strike runners suffer injuries to the shin, knee, and hip.[34]

Importantly, a rapid transition from traditional running shoes to barefoot or minimalist shoes places the runner at an increased risk for injury.[35] Like any new motor skill or physical activity, barefoot/minimalist running is a learned skill. Changes in running style require strengthening the supporting musculature, changing flexibility patterns of antagonist musculature, and acquiring and mastering new movement patterns. Any transition in running style or shoe type ought to be gradual and careful, and should optimally occur under qualified supervision to minimize injury risk to the individual warfighter. Exhibit 27-1 provides basic guidance on how to select running shoes.

EXHIBIT 27-1

GUIDANCE ON RUNNING SHOE SELECTION

- Replacing shoes. Buy new shoes every 3 to 6 months. After 250 to 500 miles of use, a shoe loses 60% of its shock absorption.

- Cushioning. Shoes should provide cushioning without excessive motion control.

- Fit. Allow for plenty of “wiggle room” in the toe box. Above all, the shoe should be comfortable.

- Flexibility. The shoe should allow the foot to move in its normal motion. To test this, squeeze the shoe from the toe and from the heel simultaneously to bow the sole. Check that that sole of shoe flexes easily.

- Transitioning. Transitioning from a heel-striking gait in a heavily cushioned shoe to a mid or forefoot strike with a more minimalist shoe is a high-risk situation. Transitions should be undertaken slowly and under expert supervision.

Ankle bracing is often done to minimize injuries to the ankle. Ankle sprains in the military occur at a rate of almost 35 sprains per 1,000 person-years at risk, which is five times higher than the rate reported in civilian populations.[36] Thus, ankle bracing, which has been shown to effectively prevent ankle injuries in several well-designed studies (especially in those who have had previous ankle sprains),37–39 is a high priority. In particular, there appears to be a significant benefit to prophylactic bracing to prevent ankle injuries during airborne training and operations, particularly in participants with a history of previous ankle injuries.1,38

Functional Assessments

Rapid and reliable screening procedures have been developed to screen for movement quality, and such screens have been employed in military environments. These screens include the Functional Movement Screen (FMS), the Landing Error Scoring System (LESS), and the Y-Balance Test. Although movement quality assessed by these screens has been shown to be associated with MSK-I risk in athletic populations, its role in MSK-I risk in military populations is questionable.40–45 A meta-analysis of studies that used the FMS showed the screen to have moderate to good specificity, but poor sensitivity.[46] The poor sensitivity indicates that a large percentage are incorrectly classified as “high risk” for MSK-I, despite these individuals remaining injury-free. Although these functional assessments may not be good tools for injury prediction, their ability to quantify movement quality may nonetheless be important. Movement training to improve quality remains a useful way to mitigate injury risk.

Movement Training

Recent efforts to implement neuromuscular training programs in the military are underway. The Dynamic Integrated Movement Enhancement (DIME) program was developed from prospectively identified risk factors for lower extremity injury.[47] DIME exercises require approximately 10 minutes and place a large emphasis on proper movement control and alignment during nine dynamic warm-up exercises. This program reinforces the importance of proper technique and performance of exercises.

TABLE 27-4

SEVEN STEPS FOR AN EFFECTIVE INJURY PREVENTIVE TRAINING PROGRAM

Step

Details

1. Establish administrative support.

Gain the support of leadership, and proactively address concerns. Emphasize that implementing a PTP does not detract from the organization’s mission but reduces overall costs while simultaneously improving performance. Highlight how implementing a PTP measurably increases success evaluations. For example, a well-designed PTP would improve physical fitness as measured by the Army Physical Fitness Test and decrease attrition rates caused by injury.

2. Develop an interdisciplinary implementation team.

Involve key stakeholders such as program designers, trainers, athletes, coaches, and healthcare providers to identify and suggest possible solutions for all potential logistical issues that could threaten the long-term implementation of the PTP. Decide on objective criteria for achieving high-fidelity implementation.

3. Identify logistical barriers and solutions.

Once barriers are identified, work with the interdisciplinary team to incorporate solutions into the design and strategy.

Time

Consider the time of day, duration, and frequency of the PTP as well as any opportunity costs due to lost training time.

Personnel

Consider the experience and exercise of leaders and instructors and the baseline movement quality and experience of PTP participants.

Environment

Be aware of the location in which the PTP will be performed and the equipment that will be available for use.

Organization

Consider the current warm-up (or lack of warm-up) endorsed by the organization, and be sure that the program will further, or at least not impede, the organization’s goals.

4. Develop an evidence-based PTP.

Be sure that exercises are evidence-based and solve the injury problems of the organization. Finalize exercises only after working with the administration and team to ensure a relationship of trust, collaboration, and participation. Do not simply propose the adoption of a preexisting set of exercises.

5. Train the trainers and users.

Before implementation, train the trainers well so they take ownership of the program, feel comfortable with it, and are skilled in executing it. Provide verbal training on the history, efficacy, and design of the PTP. During hands-on training, ensure that trainers can explain the rationale behind each exercise, as well as perform, critique, modify, and teach each movement. Finally, provide materials to reinforce this information, possibly including a handbook of exercises, online videos, and a worksheet of common errors.

6. Ensure fidelity control.

Throughout implementation of the PTP, continue to evaluate the trainers’ ability and the group’s execution. Provide positive feedback and key ways to improve in order to foster relationships and commitment with the organization.

7. Determine exit strategy.

Once the criteria identified in step 2 are met, begin scaling back support from daily coaching to weekly coaching and then to sporadic visits. Continue to evaluate and improve the design using feedback from the interdisciplinary team. The goal is to create a sustainable and efficient program with long-term implementation and impact.

PTP: preventive training program

Data source: Padua DA, Frank B, Donaldson A, et al. Seven Steps for developing and implementing a preventive training program: lessons learned from JUMP-ACL and beyond. Clin Sports Med. 2014;33:615–632.

Components of Successful Injury Prevention Implementation Plans

Military units and medical treatment systems have several advantages over civilian and sporting populations: they are able to implement policy changes in the top-down military structure that result in enforced adoption of new practices. However, this can also be a barrier to adoption and maintenance of such programs from the bottom up. Successful evidence-based injury prevention interventions require extensive coordination between different stakeholders and significant changes in policy to ensure both adoption of the intervention or program and continued refining and monitoring to ensure program efficacy. Common barriers to program implementation, adoption, coordination, and maintenance have been formally described by several successful intervention teams. Table 27-4 describes seven steps that can be taken for effective prevention programs.47–49

MUSCULOSKELETAL INJURY AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer

The military medical officer (MMO) is in a unique position to help maintain musculoskeletal health, but he or she has responsibility for the health and wellness of a warfighter unit and must first build trust. The MMO should be engaged in supporting primary and secondary injury prevention, human performance optimization, and enhancement of physical and psychological health. MMOs are expected to provide the highest level of prevention and treatment with respect and compassion. They must also be able to effectively communicate and translate medical and scientific knowledge into actionable plans that support ongoing training activities and military operations. Building trust-based relationships is fundamental to this mission.

The MMO must keep in mind that physical training should be progressive; it should be graduated in a slow, carefully controlled manner (usually not more than a 10 % increase per week). Also, the MMO should advocate for a 7- to 10-day period where movement quality and progression are emphasized over repetition and quantity. For example, rather than having service members (recruits and others) perform the fastest run time possible and the maximum number of sit-ups or push-ups in 90 seconds, they should be allowed to run and do sit-ups and push-ups at their own pace, always emphasizing proper form.

The importance of building strong relationships with both the unit members and the diagnostic and rehabilitative medical community cannot be overstated. The MMO must learn, observe, support, and get buy-in from senior enlisted leaders. If the MMO believes in these efforts, others will listen, and MSK-I should decrease markedly. Senior enlisted leaders must learn to view injury prevention exercises as critical to maintaining readiness and becoming more resilient, not as a sign of weakness.

Guidance to the Commanding Officer

Despite injury prevention successes, MSK-I remains the largest health problem affecting military troops today.[3] So long as the burden of MSK-I remains high, commanders will have questions for MMOs regarding implementation and adoption of emerging prevention and rehabilitation initiatives. The injury prevention principles described above can form the foundation for command recommendations. The MMO should use those principles, accompanied by current statistics in their units and facts from the literature to frame key recommendations to military line leaders. The key principles noted previously include

- training modifications (“more is not always better”);

- equipment modifications (new gadgets constantly appear on the market, so demand and rely on comprehensive data rather than testimonials or anecdotes); and

- functional movement screening (best for use when developing a treatment program, not for predicting injury).

If no good data are available, and the commander is determined to use a new device or program, contact Uniformed Services University’s CHAMP Injury Prevention Research Laboratory to help design and conduct a study to evaluate risks and benefits of the proposed device or program. More information about injury and injury prevention can be found at the Human Performance Resource Center (hprc-online.org).

SUMMARY

Injury prevention in the military has had numerous successes over the years and has benefitted from lessons learned along the way. Despite these successes, however, risk factors for MSK-I-related discharge from basic training stubbornly persists,[50] and low entry physical fitness levels are still one of the strongest predictors of MSK-I risk during all forms of training.28,50,51 MSK-I prevention interventions have primarily focused on specific strategies or systems to address the problem, with policy also aiding efforts. Through the use of secondary prevention and system approaches, successfully preventing MSK-I in the military is a known force multiplier. Prevention of overtraining, utilization of ankle bracing, and targeted neuromuscular training have all proven effective in injury prevention in several military populations. Furthermore, the military’s structure can be advantageous in the implementation of any injury-prevention intervention, but leadership support is still needed for successful integration and long-term results. Finally, for behavioral interventions to be sustainable, strategies to encourage voluntary adoption in the target population will likely be necessary.

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20.   de la Motte SJ, Gribbin TC, Lisman P, Beutler AI, Deuster P. The interrelationship of common clinical movement screens: establishing population-specific norms in a large cohort of military applicants. J Athl Train. 2016;51(11):897–904.

21.   de la Motte SJ, Lisman P, Sabatino M, Beutler AI, O’Connor FG, Deuster PA. The relationship between functional movement, balance deficits, and previous injury history in deploying marine warfighters. J Strength Cond Res. 2016;30(6):1619–1625.

22.   Brushoj C, Larsen K, Albrecht-Beste E, Nielsen MB, Loye F, Holmich P. Prevention of overuse injuries by a concurrent exercise program in subjects exposed to an increase in training load: a randomized controlled trial of 1020 army recruits. Am J Sports Med. 2008;36(4):663–670.

23.   Coppack RJ, Etherington J, Wills AK. The effects of exercise for the prevention of overuse anterior knee pain: a randomized controlled trial. Am J Sports Med. 2011;39(5):940–948.

24.   Jones BH, Cowan DN, Tomlinson JP, Robinson JR, Polly DW, Frykman PN. Epidemiology of injuries associated with physical training among young men in the army. Med Sci Sports Exerc. 1993;25(2):197–203.

25.   Jones BH, Cowan DN, Knapik JJ. Exercise, training and injuries. Sports Med. 1994;18(3):202–214.

26.   Sherrard J, Lenne M, Cassell E, Stokes M, Ozanne-Smith J. Injury prevention during physical activity in the Australian Defence Force. J Sci Med Sport. 2004;7(1):106–117.

27.   Shaffer RA. Musculoskeletal injury project. Paper presented at: American College of Sports Medicine 43rd Annual Meeting; May 29–June 1, 1996; Cincinnati, OH.

28.   Trank TV, Ryman DH, Minagawa RY, Trone DW, Shaffer RA. Running mileage, movement mileage, and fitness in male U.S. Navy recruits. Med Sci Sports Exerc. 2001;33(6):1033–1038.

29.   Knapik JJ, Hauret KG, Arnold S, et al. Injury and fitness outcomes during implementation of physical readiness training. Int J Sports Med. 2003;24(5):372–381.

30.   Department of the Army. Army Physical Readiness Training. Washington, DC: HQDA; 2012. FM 7-22.

31.   Knapik JJ, Trone DW, Tchandja J, Jones BH. Injury-reduction effectiveness of prescribing running shoes on the basis of foot arch height: summary of military investigations. J Orthop Sports Phys Ther. 2014;44(10):805–812.

32.   Cook SD, Kester MA, Brunet ME. Shock absorption characteristics of running shoes. Am J Sports Med. 1985;13(4):248–253.

33.   Teyhen DS, Thomas RM, Roberts CC, et al. Awareness and compliance with recommended running shoe guidelines among U.S. Army soldiers. Mil Med. 2010;175(11):847–854.

34.   Daoud AI, Geissler GJ, Wang F, Saretsky J, Daoud YA, Lieberman DE. Foot strike and injury rates in endurance runners: a retrospective study. Med Sci Sports Exerc. 2012;44(7):1325–1334.

35.   Cauthon DJ, Langer P, Coniglione TC. Minimalist shoe injuries: three case reports. Foot (Edinb). 2013;23(2-3):100–103.

36.   Cameron KL, Owens BD, DeBerardino TM. Incidence of ankle sprains among active-duty members of the United States Armed Services from 1998 through 2006. J Athl Train. 2010;45(1):29–38.

37.   Schumacher JT Jr, Creedon JF, Pope RW. The effectiveness of the parachutist ankle brace in reducing ankle injuries in an airborne ranger battalion. Mil Med. 2000;165(12):944–948.

38.   Knapik JJ, Spiess A, Swedler DI, Grier TL, Darakjy SS, Jones BH. Systematic review of the parachute ankle brace: injury risk reduction and cost effectiveness. Am J Prev Med. 2010;38(1 Suppl):S182–188.

39.   Sitler M, Ryan J, Wheeler B, et al. The efficacy of a semirigid ankle stabilizer to reduce acute ankle injuries in basketball. A randomized clinical study at West Point. Am J Sports Med. 1994;22(4):454–461.

40.   Kiesel K, Plisky P, Butler R. Functional movement test scores improve following a standardized off-season intervention program in professional football players. Scand J Med Sci Sports. 2011;21:287–292.

41.   Padua DA, Marshall SW, Boling MC, Thigpen CA, Garrett WE Jr, Beutler AI. The Landing Error Scoring System (LESS) is a valid and reliable clinical assessment tool of jump-landing biomechanics: The JUMP-ACL study. Am J Sports Med. 2009;37(10):1996–2002.

42.   Boling MC, Padua DA, Marshall SW, Guskiewicz K, Pyne S, Beutler A. A prospective investigation of biomechanical risk factors for patellofemoral pain syndrome: the Joint Undertaking to Monitor and Prevent ACL Injury (JUMP-ACL) cohort. Am J Sports Med. 2009;37(11):2108–2116.

43.   Shaffer SW, Teyhen DS, Lorenson CL, et al. Y-balance test: a reliability study involving multiple raters. Mil Med. 2013;178(11):1264–1270.

44.   Teyhen DS, Shaffer SW, Lorenson CL, et al. The Functional Movement Screen: a reliability study. J Orthop Sports Phys Ther. 2012;42(6):530–540.

45.   Teyhen DS, Shaffer SW, Lorenson CL, et al. Reliability of lower quarter physical performance measures in healthy service members. US Army Med Dep J. 2011(Jul-Sep):37–49.

46.   Dorrel BS, Long T, Shaffer S, Myer GD. Evaluation of the Functional Movement Screen as an injury prediction tool among active adult populations: a systematic review and meta-analysis. Sports Health. 2015;7(6):532–537.

47.   Padua DA, Frank B, Donaldson A, et al. Seven Steps for developing and implementing a preventive training program: lessons learned from JUMP-ACL and beyond. Clin Sports Med. 2014;33:615–632.

48.   Finch CF. No longer lost in translation: the art and science of sports injury prevention implementation research. Br J Sports Med. 2011;45(16):1253–1257.

49.   Donaldson A, Finch CF. Applying implementation science to sports injury prevention. Br J Sports Med. 2013;47(8):473–475.

50.   Swedler DI, Knapik JJ, Williams KW, Grier TL, Jones BH. Risk factors for medical discharge from United States Army Basic Combat Training. Mil Med. 2011;176(10):1104–1110.

51.   Trone DW, Cipriani DJ, Raman R, Wingard DL, Shaffer RA, Macera CA. The association of self-reported measures with poor training outcomes among male and female U.S. Navy recruits. Mil Med. 2013;178(1):43–49.

Chapter 28

SPIRITUAL FITNESS AND PERFORMANCE

MATTHEW T. STEVENS, MDIV,* AND JEFFREY E. RHODES, MDIV, DMIN†

INTRODUCTION

DEFINITIONS

MILITARY HISTORY OF SPIRITUALITY AND RELIGION

BACKGROUND

KEY CONCEPTS

Relationship Between Disease, Religion, and Spirituality

Spirituality and Disease

Spirituality and Health and Performance

Spiritual Care for Service Members and Patients

ROLE OF THE MILITARY MEDICAL OFFICER

Spirituality and the Military Medical Officer

Guidance to Commanding Officers

SUMMARY

SELECTED RESOURCES

*Commander, US Navy; Director, Pastoral Care Plans/Ops, Bureau of Medicine and Surgery, Falls Church, Virginia

†Commander (Retired), US Navy; VA Mental Health and Chaplaincy Department, Durham, North Carolina

INTRODUCTION

“Total force fitness” (TFF), as discussed in the opening chapter of this section, includes “spiritual fitness” as an important component and essential to overall fitness. Spiritual fitness (being spiritual) is a broader concept than being religious (practicing one’s organized religion), although the practice of one’s religion or faith may very well be considered an expression of one’s spirituality. The terms “spiritual” or “spirituality” are generally individually focused, contributing to personal identity and meaning, whereas “religion” is often more corporately focused and refers to specific traditions with more defined practices.

In the TFF initiative, it was recognized that military members have built-in stressors that affect all areas of their lives, and that eight core domains, including spiritual, needed to be discovered and developed to obtain optimal performance. Spiritual fitness in Department of Defense (DoD) settings may contribute to the development of resiliency in service members, supporting them in routine and rigorous challenges such as arduous training, deployments, and combat tours.1–3 Included in the TFF effort are attempts to realize the importance of service core values, to understand one’s identity, and to create meaning from situations that are often complex and sometimes life threatening, including health challenges. Service members must be able to apply their service core values, and recognize and appreciate the importance of a spiritually and religiously diverse force. These basic integral components provide the basis for both understanding and developing spiritual fitness in the DoD.

A 2016 Gallup poll indicates that 89% of Americans believe in God or a universal spirit.[4] Religious or spiritual beliefs and practices are common among patients seeking medical care, and even those who identify themselves as nonreligious often see themselves as being spiritual.[5] Consequently, this subject is relevant to healthcare providers. This chapter will provide a basic introduction to spirituality, review the relationship between spirituality and religion, and discuss whether healthcare providers who are not ordained clergy or chaplains should incorporate spiritual care into their overall holistic healthcare treatment plans.

DEFINITIONS

Many definitions can be offered for spirituality, and agreeing upon a common meaning is challenging because no one single definition will work for or satisfy everyone. Thus, a broad definition is provided as a starting point. Table 28-1 offers some definitions for clarity and consistency. Although spirituality includes various definitions, a broad range of practices, and a plethora of defined spiritual traditions, it is generally considered a process and path toward developing the aspect of the whole self—a basic tenet of TFF—that gives meaning to one’s life (who am I; why am I here; what is my purpose?). The spiritual path seeks to provide a sense of transcendence beyond the self and relationships with others. Spirituality can be experienced intra-personally (as a connectedness within oneself), inter-personally (in the context of others and the natural environment), and trans-personally (referring to a sense of relatedness to the unseen, God, or transcendent power greater than the self and ordinary sources.6,7

Koenig and others highlight the impact of spiritual practices on health and demonstrate the breadth and variance of the appreciation of spirituality.8,9 Some of their key findings from reviewing the literature demonstrate a clear relationship between medicine, religion, and spirituality. These relationships are important to healthcare providers.

MILITARY HISTORY OF SPIRITUALITY AND RELIGION

Military chaplaincy traces its roots to September 1775, when George Washington instructed Benedict Arnold to “protect & support the free Exercise of the Religion of the Country & the undisturbed Enjoyment of the rights of Conscience in religious Matters within your utmost Influence and Authority.”[10] From the earliest days of offering sacramental needs and comfort to military personnel ashore and at sea, to the current practice of providing comprehensive support including personal resilience and wellness, military chaplains have always served the multicultural and religiously pluralistic US military population in balance with their own religious identity. Today military chaplains provide appropriate religious and spiritually based care to military personnel and their families, often partnering with caregiving professionals from other disciplines to ensure optimum support. Beyond providing pastoral care, chaplains also advise military leaders on issues where religion, ethics, and morale may play a role in the decision-making process. Although military chaplains serve as officers in their respective branches of service, they are classified as noncombatants and restricted from participating directly in hostilities.[11] Military chaplains are supervised by their respective service’s (Army, Navy, and Air Force) chief of chaplains.

TABLE 28-1

SELECTED DEFINITIONS OF SPIRITUALITY

Religion

Involves beliefs, practices, and rituals related to the transcendent, where the transcendent is God, Allah, HaShem, or a higher power in Western religious traditions, or to Brahman, manifestations of Brahman, Buddha, Dao, or ultimate truth/reality in Eastern traditions.1

Spirituality

A process and a path people use to discover their inner selves and develop their human spirit.2

Spirituality

Propensity to make meaning through a sense of relatedness to dimensions that transcend the self in such a way that it empowers and does not devalue the individual.3

Spirituality

A connection to that which is sacred, the transcendent, which is outside of the self, and yet also within the self—and in Western traditions is called God, Allah, HaShem, or a higher power, and in Eastern traditions may be called Brahman, manifestations of Brahman, Buddha, Dao, or ultimate truth/reality.

Spiritual practices

Attendance at religious or spiritual events, meditation, prayer, mindfulness practices, yoga, mantra chanting, spending time alone in nature, recognition of rites of passage, and serving one’s community.

Spiritual traditions

Abrahamic examples: Christianity, Islam, Judaism; Eastern examples: Buddhist, Hindu, Zen.

Religious care

Helping people maintain their belief systems and organized worship practices.4

Spiritual care

Helping people to identify meaning and purpose in their lives, maintain personal relationships, and transcend a given moment.4

(1) Koenig HG. Religion, spirituality, and health: the research and clinical implications. ISRN Psychiatry. 2012:278730. (2) Sweeney PJ, Rhodes JE, Boling B. Spiritual fitness: a key component of total force fitness. J Force Q. 2012;3rd quarter(66):35–41. (3) Reed PG. An emerging paradigm for the investigation of spirituality in nursing. Res Nurs Health. 1992;15(5):349–357. (4) Emblen JD. Religion and spirituality defined according to current use in nursing literature. J Prof Nurs. 1992;8(1):41–47.

BACKGROUND

It is important to know that patients admitted to military treatment facilities are routinely asked about religious and spiritual needs or concerns during initial interviews. If the patient answers positively, a consult is automatically generated in the patient’s electronic hospital chart, and a member of the pastoral care team meets with the patient in a timely manner. If the patient does not acknowledge a spiritual need or concern to the nurse during this initial interview, chaplains at each military treatment facility have varying protocols for following up with patients throughout their stay. Chaplains remain sensitive to caring for each patient and their family regardless of spiritual or faith orientation or lack thereof (honoring diversity). The heart of clinical chaplaincy is honoring a person’s belief system and nurturing the capacity to maintain that belief system while receiving medical treatment. The military medical officer (MMO) may need to know when a formal referral is needed.

In the early 2010s, the DoD and Department of Veterans Affairs (VA) came together to implement a “learning collaborative” to integrate mental health and chaplain services as a quality improvement effort.12,13 As part of this initiative, teams of chaplains and mental health providers were encouraged to make improvements in six different areas:

1. Screening. Improve practices for screening patients for spiritual and mental health issues.

2. Referrals. Strengthen or develop clearly articulated processes for referring patients between disciplines.

3. Assessment. Develop, improve, and ensure standardized use of multidimensional spiritual and mental health assessments.

4. Communication and documentation. Establish regular communication practices as part of integrated care team meetings, and document care and consults.

5. Cross-disciplinary training. Champion various multidisciplinary and interdisciplinary training opportunities.

6. Role clarification. Develop a formal documentation of how mental health and chaplain services collaborate.

KEY CONCEPTS

Different and diverse spiritual traditions encourage social participation and mobilize members in support of the community. The DoD, which depends on social cohesion and support, is particularly interested in this aspect of spiritual fitness. Various forms of social support that arise out of spiritual and religious participation (including the family, unit, and place of worship) can provide powerful protective effects in stressful situations.[14] Additionally, studies point to positive physical and mental health outcomes and better overall coping from practicing one or several religious or spiritual activities.8,9

Relationships Among Disease, Religion, and Spirituality

Multiple studies demonstrate that practicing one’s religion or spirituality serves a positive role in treating and living with many acute and chronic diseases.15–30 Religious faith also appears to be important to many patients with serious diseases and serves as a positive coping mechanism. Religion generally influences self-care, especially in cases of severe illness; patients frequently practice religion and interact with the transcendent (God) about their disease state. This spiritual interaction may benefit the patient by providing comfort, increasing knowledge about their disease, promoting better treatment adherence, and improving quality of life.[31] Overall, the findings suggest that integrating systematic assessments of spiritual well-being into medical care is crucial, given its importance, in particular, to seriously ill patients. Care providers need to pay particular attention to whether the patient frames their identity as either “religious” or “spiritual” because this will influence the care provided.[32] Specifically, patients who describe themselves as spiritual but not religious are likely to seek support, meaning, and purpose, whereas those describing themselves as religious may be more reliant on their trust in a supporting God.33,34

Balboni et al[32] have developed three models for addressing and understanding the integration between medical concerns of patients and their religious or spiritual identification:

1. A generalist specialist model of whole-person care with the basic premise that, in a multidisciplinary, intraprofessional care team, spiritual care is a foundation of whole-person or holistic care.

2. An existential functioning model in which the care-provider, in the provision of holistic care to the patient, understands the dynamic relationships among the patient and providers and recognizes emotional, existential, and spiritual concerns.

3. An open, pluralist view that affirms the religious, spiritual, and cultural realities of both the care provider and patient and recognizes the diversity within the healthcare setting.

Each of these approaches assumes that spirituality and medicine should be integrated into the care of the patient, and affirms that spirituality must be broadly defined, embracing diverse spiritual, religious, secular, and cultural perspectives. These approaches ensure the spiritual, religious, and cultural concerns of the patient and the care provider/interdisciplinary team are addressed. Additionally, all emphasize the importance of maintaining ethical professional boundaries to protect vulnerable patients from undue influence by religious or nonreligious care providers.[32]

Spirituality and Disease

A body of evidence15,20,21,28,30,35,36 suggests that certain diseases or medical conditions may improve if the patient is engaged in religious or spiritual practices. These medical conditions range from cancer to headaches to diabetes, and more. Table 28-2 summarizes some of the medical conditions being investigated and the questions about spiritual/religious practices researchers are attempting to answer.

Spirituality and Health and Performance

In addition to disease, spirituality appears to have profound effects on well-being, which ultimately impact overall performance in a variety of venues: home, work, and life challenges. Importantly, several authors have studied the relationship between quality of life and spirituality, along with religiosity. Overall, the literature supports the idea that having both a sense of meaning and purpose in life are positively correlated to quality of life.8,6,9,26,37,38 Likewise, spiritual practices and support from a spiritual community appear to confer benefits and serve as buffers against stress. Of interest is the potential role of spirituality in cognitive function. One study found that persons 60 years or older who engaged in spiritual activities demonstrated better cognitive function than those who did not.[39] Although the exact role of spirituality in overall performance is not well documented, its potential beneficial effects on various mental health attributes and behaviors suggest it can only help. Table 28-3 summarizes the results of a review by Koenig[9] wherein high-quality studies were examined to evaluate associations among religion/spirituality and well-being and life satisfaction.

TABLE 28-2

MEDICAL CONDITIONS BEING EXPLORED IN CONNECTION WITH SPIRITUAL PRACTICES

Condition

Anticipated Questions

Cancer

Do religious and spiritual practices and beliefs increase the quality of life in cancer patients?1

Heart disease

Does loss of control of one’s physical state significantly impact purpose and meaning in living?2

Does spirituality positively influence recovery from surgery?3

Stroke

Do changes to brain function after a stroke open a door to the divine?4

Headaches

Do techniques such as cognitive-behavioral therapy and relaxation training that take the form of spiritual or religious activities influence the onset and duration of headaches?5

Does spiritual meditation have a positive effect in mitigating some of the negative impacts of migraines?6

Other chronic medical conditions

How does incorporating spirituality into self-management routines impact the health and well-being of people with chronic conditions?7

(1) Thune-Boyle IC, Stygall JA, Keshtgar MR, Newman SP. Do religious/spiritual coping strategies affect illness adjustment in patients with cancer? A systematic review of the literature. Soc Sci Med. 2006;63(1):151–164. (2) Naghi JJ, Philip KJ, Phan A, Cleenewerck L, Schwarz ER. The effects of spirituality and religion on outcomes in patients with chronic heart failure. J Relig Health. 2012;51(4):1124–1136. (3) Mouch CA, Sonnega AJ. Spirituality and recovery from cardiac surgery: a review. J Relig Health. 2012;51(4):1042–1060. (4) Mundle RG. Engaging religious experience in stroke rehabilitation. J Relig Health. 2012;51(3):986–998. (5) Banks JW. The importance of incorporating faith and spirituality issues in the care of patients with chronic daily headache. Curr Pain Headache Rep. 2006;10(1):41–46. (6) Wachholtz AB, Pargament KI. Migraines and meditation: does spirituality matter? J Behav Med. 2008;31(4):351–366. (7) Unantenne N, Warren N, Canaway R, Manderson L. The strength to cope: spirituality and faith in chronic disease. J Relig Health. 2013;52(4):1147–1161.

Spiritual Care for Service Members and Patients

Understanding spirituality within the scope of caring for service members and patients deserves consideration. Emblen[6] pointed out that nurses who practice together typically have different meanings for spirituality, which can cause difficulties. For some, spiritual care means helping patients with maintaining their religious practices, whereas the intent for others may be to help patients understand meaning in times of pain and uncertainty. Such confusion over conceptual definitions can lead to unmet patient needs due to the omission of spiritual care simply based on definitional challenges. For example, sometimes patients may indicate they have no spiritual need, meaning no religious need (because they are not members of any organized religious group), but such patients may desperately need help working through transcendent and relationship problems arising from their illness. The distinction between religious and spiritual care may be particularly helpful to providers in helping patients obtain care in connection with either religious accommodation or spiritual expression.[6] Exhibit 28-1 lists the basic elements of spiritual care that providers should consider.

In summarizing the challenges of defining spirituality, particularly within the scope of healthcare, King and Koenig[40] conclude that spirituality is a fluid concept without any single, distinct definition, and therefore difficult to measure scientifically in research. However, to help those interested in understanding spirituality, they propose four areas of focus for providers when listening to and caring for patients: consider one’s own (1) spiritual beliefs, (2) spiritual practices, (3) sense of awareness of what is going on around the patient, and (4) personal experience. These elements form a whole composite necessary for understanding and appreciating spirituality in patients receiving care for any type of medical treatment.

TABLE 28-3

ASSOCIATION BETWEEN SPIRITUALITY/RELIGIOSITY AND MENTAL HEALTH AND HEALTH BEHAVIORS

Health Attributes and Lifestyle Behaviors

Percentage of Studies Showing Positive Correlation

Well-being

82%

Meaning and purpose

100%

Hope

50%

Optimism

73%

Self-esteem

68%

Exercise

76%

Diet

70%

Data source: Koenig HG. Religion, spirituality, and health: a review and update. Adv Mind Body Med. 2015;29(3):19–26.

ROLE OF THE MILITARY MEDICAL OFFICER

Spirituality and the Military Medical Officer

The MMO, as a care provider, must appreciate the role of spirituality in healthcare as well as understanding how an individual’s spiritual framework may impact health and performance. Specifically, they need to know when to call in a chaplain. Most healthcare providers need additional training in spirituality, first to develop active listening skills and become clear about their own religious or spiritual beliefs and practices, and second to appreciate and address the importance of religion and spirituality in optimizing a service member’s plan for treatment and recovery. The MMO must also develop confidence in addressing the religious and spiritual concerns of their patients, as needed.[41]

A question currently being asked is: should training in spirituality be included as a component of medical education for optimal care of patients? Studies of medical students indicate the majority believe spirituality has a positive impact on patient health (68.2%), and although many want to address spiritual/religious concerns, nearly 48.7% report they are unprepared to do so.42,43 Lack of training on how to integrate religion and spirituality into operational and therapeutic settings results in defaulting to chaplains or religious specialists,[44] which may be fine in a military setting where chaplains are certainly trained to do this. Thus, whether spiritual training should be a part of medical school curricula remains a discussion point. Certainly the MMO must be aware of their patient’s needs and know when to call in a person specifically trained in this area. Moreover, all MMOs should acknowledge how their own spiritual and religious beliefs and practices influence the way in which they practice their healthcare profession, whatever that may be.[2]

EXHIBIT 28-1

FOUR BASIC SPIRITUAL ELEMENTS TO CONSIDER IN PROVIDER–SERVICE MEMBER/PATIENT RELATIONSHIPS

- Spirit/spirituality (process or sacred journey)

- Spiritual dimension (transcending one’s self; meaning-making)

- Spiritual well-being (process of being and self-understanding)

- Spiritual needs (deep inner requirements especially in times of distress)

Guidance to Commanding Officers

Commanding officers (COs) of military units, medical treatment facilities, and installations must be aware they are responsible for the religious and spiritual care of service members, patients, and staff through the command religious program. Generally, the CO has a team—a military chaplain and their staff—to ensure that religious services and spiritual care are available to and provided for all. However, COs also strongly influence the level of collaboration within and across units and within the entire healthcare team of providers. The MMO must work with the CO to promote the multidisciplinary or interdisciplinary collaboration of their teams with other healthcare providers and various leaders. This model of collaboration is supported by Gordon and Mitchell,[45] who conceived of four competency levels in the delivery of spiritually based care:

1. All staff and volunteers who have casual contact with patients and their families should understand that all people have distinguishable spiritual needs.

2. All staff and volunteers whose duties require contact with patients and families and caregivers should be aware of spiritual and religious needs and how to identify and respond to them.

3. All staff and volunteers who are members of multi/interdisciplinary care teams need to be trained to assess spiritual/religious needs and develop plans for care.

4. All staff and volunteers whose primary responsibility is for the spiritual and religious care of patients, visitors, and staff are expected to manage and facilitate complex religious and spiritual support for patients, families, caregivers, staff, and volunteers.

Collaborative competency models place religious and spiritual provision of care squarely in the multidisciplinary community of care providers rather than in the care of the chaplain only. Chaplains do not own religious and spiritual care in DoD or VA settings; rather, the MMO and CO can serve key support roles by viewing this care as a shared collaborative ownership responsibility for all in leadership positions and the healthcare professions.[3]

SUMMARY

Definitions of spirituality and religion are challenging and diverse, but it is commonly acknowledged that the understanding and practice of spirituality is individually based. In contrast, the understanding and practice of religion is more of an organized—even doctrinal—attempt to connect to others and have an understanding of a transcendent being. The overlap in this area is large, with some practicing spirituality by using a religious framework, and some in organized religion viewing that as their spiritual expression. The literature supporting the health benefits of practicing religion, spirituality, or both, and the role of spirituality and religion in the treatment of common existing chronic diseases, have been discussed. It is becoming increasingly important for all leaders and healthcare providers working in multidisciplinary and interdisciplinary teams to develop active listening skills and remain cognizant of their own religious or spiritual beliefs and practices. MMOs should be attuned to the spiritual concerns of those they care for (as well as their own), and not automatically pass this imperative off to the chaplain on the team. All professionals on an interdisciplinary team “own” the provision of care for the religious and spiritual concerns of their patients. And finally, medical treatment facilities and clinics that promote interdisciplinary models involving chaplains—including multidisciplinary training—must promote more holistic care for the patients and their families, which will lead to greater opportunity for religious and spiritual fitness.

SELECTED RESOURCES

- Chairman of the Joint Chiefs of Staff. Chairman’s Total Force Fitness Framework. Washington, DC: Department of Defense; September 1, 2011. CJCSI 3405.01. https://www.hprc-online.org/page/total-force-fitness/about-total-force-fitness. Accessed June 20, 2018.

- The Uniformed Services University’s Human Performance Resource Center has further information on the spiritual domain as part of the TFF effort: http://hprc-online.org/.

- Koenig HG. Religion, spirituality, and health: a review and update. Adv Mind Body Med. 2015;29(3):19–26.

- Navy Spiritual Fitness Guide: http://www.navy.mil/docs/SpiritualFitnessGuide.pdf.

- Pargament KI, Sweeney PJ. Building spiritual fitness in the Army: an innovative approach to a vital aspect of human development. Am Psychol. 2011;66(1):58-64.

- Realwarriors.net’s spiritual fitness in the military: http://www.realwarriors.net/active/treatment/spirituality.php.

- Sweeney PJ, Rhodes JE, Boling B. Spiritual fitness: a key component of total force fitness. J Force Q. 2012;3rd quarter(66):35–41.

ACKNOWLEDGMENTS

The authors would like to thank colleagues Jason Nieuwsma, PhD; Robert Julian Irvine, MDiv; and Shelia O’Mara, MDiv, from the VA Mental Health and Chaplaincy Department in Durham, North Carolina, for assistance in reference material and editing.

REFERENCES

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2.   Nieuwsma JA, Jackson GL, DeKraai MB, et al. Collaborating across the Departments of Veterans Affairs and Defense to integrate mental health and chaplaincy services. J Gen Intern Med. 2014;29(Suppl 4):885–894.

3.   Sweeney PJ, Rhodes JE, Boling B. Spiritual fitness: a key component of total force fitness. J Force Q. 2012;3rd quarter(66):35–41.

4.   Newport F. Five key findings on religion in the U.S. Gallup Inc website. https://news.gallup.com/poll/200186/five-key-findings-religion.aspx. Published December 23, 2016. Accessed June 19, 2018.

5.   Koenig HG. Religion, spirituality, and medicine: research findings and implications for clinical practice. South Med J. 2004;97(12):1194–1200.

6.   Emblen JD. Religion and spirituality defined according to current use in nursing literature. J Prof Nurs. 1992;8(1):41–47.

7.   Reed PG. An emerging paradigm for the investigation of spirituality in nursing. Res Nurs Health. 1992;15(5):349–357.

8.   Koenig HG. Religion, spirituality, and health: the research and clinical implications. ISRN Psychiatry. 2012:278730.

9.   Koenig HG. Religion, spirituality, and health: a review and update. Adv Mind Body Med. 2015;29(3):19–26.

10.   Guilday P. The Life and Times of John Carroll, Archbishop of Baltimore, 1735–1815. New York, NY: Encyclopedia Press; 1922.

11.   Additional Protocol I to the Geneva Conventions of 1949. https://treaties.un.org/doc/publication/unts/volume 1125/volume-1125-i-17512-english.pdf. Accessed April 16, 2017.

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14.   Hobfoll SE. The Ecology of Stress. New York, NY: Hemisphere Publishing; 1988.

15.   Banks JW. The importance of incorporating faith and spirituality issues in the care of patients with chronic daily headache. Curr Pain Headache Rep. 2006;10(1):41–46.

16.   Gupta PS, Anandarajah G. The role of spirituality in diabetes self-management in an urban, underserved population: a qualitative exploratory study. R I Med J (2013). 2014;97(3):31–35.

17.   Gutierrez J, Devia C, Weiss L, et al. Health, community, and spirituality: evaluation of a multicultural faith-based diabetes prevention program. Diabetes Educ. 2014;40(2):214–222.

18.   Jim HS, Pustejovsky JE, Park CL, et al. Religion, spirituality, and physical health in cancer patients: A meta-analysis. Cancer. 2015;121(21):3760–3768.

19.   Moreira-Almeida A, Koenig HG. Religiousness and spirituality in fibromyalgia and chronic pain patients. Curr Pain Headache Rep. 2008;12(5):327–332.

20.   Mouch CA, Sonnega AJ. Spirituality and recovery from cardiac surgery: a review. J Relig Health. 2012;51(4):1042–1060.

21.   Mundle RG. Engaging religious experience in stroke rehabilitation. J Relig Health. 2012;51(3):986–998.

22.   Namageyo-Funa A, Muilenburg J, Wilson M. The role of religion and spirituality in coping with type 2 diabetes: a qualitative study among Black men. J Relig Health. 2015;54(1):242–252.

23.   Park CL, Sherman AC, Jim HS, Salsman JM. Religion/spirituality and health in the context of cancer: Cross-domain integration, unresolved issues, and future directions. Cancer. 2015;121(21):3789–3794.

24.   Polzer R, Miles MS. Spirituality and self-management of diabetes in African Americans. J Holist Nurs. 2005;23(2):230–250.

25.   Salsman JM, Fitchett G, Merluzzi TV, Sherman AC, Park CL. Religion, spirituality, and health outcomes in cancer: A case for a meta-analytic investigation. Cancer. 2015;121(21):3754–3759.

26.   Salsman JM, Pustejovsky JE, Jim HS, et al. A meta-analytic approach to examining the correlation between religion/spirituality and mental health in cancer. Cancer. 2015;121(21):3769–3778.

27.   Sherman AC, Merluzzi TV, Pustejovsky JE, et al. A meta-analytic review of religious or spiritual involvement and social health among cancer patients. Cancer. 2015;121(21):3779–3788.

28.   Unantenne N, Warren N, Canaway R, Manderson L. The strength to cope: spirituality and faith in chronic disease. J Relig Health. 2013;52(4):1147–1161.

29.   Vermandere M, Lepeleire JD, Van Mechelen W, Warmenhoven F, Thoonsen B, Aertgeerts B. Spirituality in palliative home care: a framework for the clinician. Support Care Cancer. 2013;21(4):1061–1069.

30.   Wachholtz AB, Pargament KI. Migraines and meditation: does spirituality matter? J Behav Med. 2008;31(4):351–366.

31.   Stewart WC, Adams MP, Stewart JA, Nelson LA. Review of clinical medicine and religious practice. J Relig Health. 2013;52(1):91–106.

32.   Balboni MJ, Puchalski CM, Peteet JR. The relationship between medicine, spirituality and religion: three models for integration. J Relig Health. 2014;53(5):1586–1598.

33.   Bussing A, Matthiessen PF, Ostermann T. Engagement of patients in religious and spiritual practices: confirmatory results with the SpREUK-P 1.1 questionnaire as a tool of quality of life research. Health Qual Life Outcomes. 2005;3:53.

34.   Bussing A, Ostermann T, Matthiessen PF. Role of religion and spirituality in medical patients: confirmatory results with the SpREUK questionnaire. Health Qual Life Outcomes. 2005;3:10.

35.   Thune-Boyle IC, Stygall JA, Keshtgar MR, Newman SP. Do religious/spiritual coping strategies affect illness adjustment in patients with cancer? A systematic review of the literature. Soc Sci Med. 2006;63(1):151–164.

36.   Naghi JJ, Philip KJ, Phan A, Cleenewerck L, Schwarz ER. The effects of spirituality and religion on outcomes in patients with chronic heart failure. J Relig Health. 2012;51(4):1124–1136.

37.   Pargament KI, Sweeney PJ. Building spiritual fitness in the Army: an innovative approach to a vital aspect of human development. Am Psychol. 2011;66(1):58–64.

38.   Yeung D, Martin MT. Spiritual Fitness and Resilience: A Review of Relevant Constructs, Measures, and Links to Well-Being. Santa Monica, CA: RAND Corporation; 2013.

39.   Fung AW, Lam LC. Spiritual activity is associated with better cognitive function in old age. East Asian Arch Psychiatry. 2013;23(3):102–107.

40.   King MB, Koenig HG. Conceptualising spirituality for medical research and health service provision. BMC Health Serv Res. 2009;9:116.

41.   Meredith P, Murray J, Wilson T, Mitchell G, Hutch R. Can spirituality be taught to health care professionals? J Relig Health. 2012;51(3):879–889.

42.   Lucchetti G, de Oliveira LR, Koenig HG, Leite JR, Lucchetti AL. Medical students, spirituality and religiosity—results from the multicenter study SBRAME. BMC Med Educ. 2013;13:162.

43.   Lucchetti G, de Oliveira LR, Leite JR, Lucchetti AL. Medical students and controversial ethical issues: results from the multicenter study SBRAME. BMC Med Educ. 2014;15:85.

44.   Elkonin D, Brown O, Naicker S. Religion, spirituality and therapy: implications for training. J Relig Health. 2014;53(1):119–134.

45.   Gordon T, Mitchell D. A competency model for the assessment and delivery of spiritual care. Palliat Med. 2004;18(7):646–651.

Chapter 29

FAMILY READINESS

ADAM K. SAPERSTEIN, MD*; TERESA COMBS, PHD†; RYAN LANDOLL, PHD‡; AND REGINA P. OWEN, DNP§

INTRODUCTION

DEFINITIONS

Family

Family Readiness

Familiy Resilience

COMMON STRESSORS THAT INFLUENCE FAMILY READINESS

Geographic Separation

Permanent Change of Station Moves

Role Conflict

Career Obstacles

Families with Dual or Single Military Parents

IMPACT ON MILITARY CHILDREN

Young Children

Adolescent Children

Children With Special Needs

STRATEGIES FOR ENHANCING FAMILY READINESS

Preventive Strategies

Reactive Strategies

FAMILY READINESS—THE ROLE OF THE MILITARY MEDICAL OFFICER

Direct Support for Military Families

Coordinating Care

Educating Military Unit Leadership

FAMILY READINESS RESOURCES

SUMMARY

*Commander, Medical Corps, US Navy; Associate Professor, Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Assistant Professor, Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland

‡Major, United States Air Force, Biomedical Sciences Corps and Assistant Professor, Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

§Major, United States Air Force, Medical Corps and Mental Health Clinic OIC, 436 MDG/Dover Air Force Base, Delaware

INTRODUCTION

Consider the phrase “military family.” What does this mean to you? Create a mental image—the people in the family, their ages, genders, where they live, what they do, etc. Now imagine that a service member in that family is about to deploy for 12 months and one or more members of the family has come to you for advice on how to cope with this deployment. What resources would you offer? How would you counsel this family? In what ways would you wish you had counseled them well before they learned of the deployment? Do you have preconceived notions that affect your answers? Assisting families to prepare for challenges is an important role for military healthcare providers. Working to gain that skill is the most important first step in building competence and confidence. This chapter defines family and family readiness, identifies common stressors that can erode family readiness, and shares strategies and resources that are likely to help families improve resilience.

DEFINITIONS

Family

The definition of family has changed in a variety of ways over time.1,2 Consequently, the discussion of the topic of family readiness is inherently tied to a consideration and awareness of these varied definitions. Without such an analysis, any effort to provide comprehensive care for military families, including supporting family readiness, would be fruitless.

In the United States in 1950, the word “family” would most often refer to a husband, wife, and their children. The use of such a limited definition was based on many factors, including cultural norms and the assumptions and biases of the individual who elected to use it. This brings up a critical point—the only way to understand what someone else means when they say family (or anything else for that matter) is to ask. The greatest two tools a provider has are questions and engaged listening. Helpful questions to keep in mind include, “Who makes up your family?” or “Who is in your family?” These questions are effective because they are open ended and specific, a combination that allows patients to help healthcare providers understand them and their needs. By contrast, a question such as, “Who lives at home with you?” is open-ended but does not specifically ask about a patient’s definition of family. A closed-ended question such as, “How is your wife doing?” is specific but makes assumptions about the marital status of a patient and the gender of a patient’s spouse, both of which may impede providers’ ability to develop rapport, limiting a patient’s opportunity to help providers better understand their situation.

When working to learn about someone’s family, consider the following guidance.

Do:

- Ask open-ended questions about who is in their family.

- Keep an open mind because the patient’s family may include people (and even pets) that you had not previously considered as being part of a family.

- Be aware of and account for personal biases and assumptions about what constitutes a family.

- Ask about a patient’s sense of safety (physical as well as emotional) in the context of their family.

Don’t:

- Ask leading questions such as, “Things are going well at home, right?”

- Assume you understand the relationship between the patient and members of their family.

- Assume that the patient’s outward appearance (affect) correlates to their internal feelings (mood) when talking about their family.

Following these recommendations will allow medical officers to provide compassionate and comprehensive care that is tailored to the unique needs of the patient.

Family Readiness

Military units were once considered to include only the military members of that unit. Over the past decades, the concept of a military unit has changed and now includes the military members and their families.[3] This change is a result of the recognition that family factors can have a significant impact on a unit’s ability to achieve its mission and the well-being of the military as an enterprise.[4] Consequently, helping families to better cope with the stressors of military life is important for any military unit.

Each of the military services recognizes family readiness as an important goal. It is defined by the Department of Defense as “the state of being prepared to effectively navigate the challenges of daily living experienced in the unique context of military service, to include: mobility and financial readiness, mobilization and deployment readiness, and personal and family life readiness.”[4] Some challenges are unique to military family life (eg, deployments and permanent changes of duty station) and others are not (eg, having family members with special needs or living remotely from one’s extended family). All have the potential to impact the family, the service member, and the military service. Whether or not the challenges faced by a family are military unique, military healthcare providers play an active role in helping enhance that family’s readiness. At the core of this endeavor is the concept of family resilience.

Family Resilience

Family resilience comprises the ability to withstand and rebound from disruptive life challenges and relies on positive adaptation within the context of substantial adversity.[5] Although resilience was initially viewed as an innate trait, subsequent research has demonstrated this to be incorrect.[6] Resilience is now viewed as a function of the interplay between multiple risk factors and protective processes over time.[7] The following vignette illustrates this concept.

A family composed of a husband, wife, and three children ages 11, 7, and 2 are stationed in rural North Carolina. The mother, an active duty service member, deployed to a war zone where she stepped on an improvised explosive device and lost most of her right lower leg. She was medically evacuated to Maryland, where her injuries required a below-the-knee amputation. Her family moved to be with her in Maryland. The two oldest children were enrolled in a new school and the 2-year-old was placed in daycare on base. The husband spends most of each day helping his wife with her recovery while also trying to rent the house in North Carolina, tend to his elderly parents in Alaska, and manage the family’s finances.

It is easy to identify multiple risk factors that could degrade this family’s resilience, including the following:

- decreased time the service member spent with the family during pre-deployment,

- training in the months and weeks preceding deployment,

- geographical separation of the family’s active duty service member,

- a period of single parenthood during the deployment,

- geographic separation from extended family with healthcare needs,

- financial challenges,

- changes in school,

- loss of friendship support networks,

- possible loss of primary means of income if the service member is separated from the service,

- possible loss in income if the husband was employed before moving to Maryland,

- potential change in self-perception of all members of the family, and

- uncertainty concerning the current situation.

Just as understanding the factors that could impact a family’s resilience in the midst of a crisis is important in order to care for them, so too is understanding a family’s past experiences coping with stressors. To do this requires:

- identifying the stressors they have faced in the past,

- learning how they coped with these stressors,

- understanding how they perceive their experience coping with these stressors,

- determining what support they received and whether that support was helpful,

- inquiring about how members of the family interacted with each other during these times, and

- identifying whether coping with these stressors heightened their sense of vulnerability or enhanced their resilience and family readiness.

In the example above, the family is in the midst of a crisis. Ideally, families have the requisite support and skills to build resilience and avert such crises before they develop. The strategies used to achieve this outcome are called “preventive strategies.” Given that not all crises can be averted, we also need strategies that help families cope in the midst of a crisis. These are called “reactive strategies.” In this context, answers to the following questions are likely to help you best care for families and enhance their resilience and readiness:

- What are the common factors that affect military family readiness?

- What are the “preventive strategies” known to enhance readiness before a crisis?

- What are the “reactive strategies” known to be effective in the midst of a crisis?

- What is the role of the military healthcare provider in implementing these strategies?

COMMON STRESSORS THAT INFLUENCE FAMILY READINESS

Military families are faced with a host of stressors that can challenge the stability and fluidity of the family structure; affect the family’s function and dynamic; create disruptions in the family unit; and potentially compromise the family as a whole. Over time, these stressors can begin to exert a significant toll on the well-being of each family member and the relationships within a military family.

The Holmes and Rahe Social Readjustment Rating Scale for adults[8] and the Coddington Life Change Unit Value Scale for Children[9] serve as helpful references for identifying and understanding stressors. Each identifies life events that are associated with significant stress (eg, death of a family member, marriage, or change in financial state), ranked from most to least stressful. While the order of stressfulness of these events will vary from person to person, having background knowledge about factors that more commonly impact stress, resilience, and readiness can facilitate military healthcare providers’ attunement to the needs of the individual patients and the community they serve. Among the stressors included in these scales, the following are unique to and/or more commonly encountered in military families as compared with their civilian counterparts.

Geographic Separation

Military families may be geographically separated for a variety of reasons. Some of the most common are the following[10]:

- deployment of the active duty service member;

- assignment of the active duty service member to a location where, for a variety of reasons (including the medical needs of a family member), the rest of the family cannot go; or

- a family decision to remain in place when the active duty service member is assigned to a new duty station (including marital separations or divorce).

This geographic separation, especially when prolonged, has a negative impact on family homeostasis, is associated with an increase in marital discord, and is associated with an increase in anxiety in both the service member and the family.[11] Common sources of anxiety for spouses and children include fear that their loved one may not return; fear that their loved one may return with physical and/or mental injuries; worry about an inability to cope in the absence of the service member; and fear that relationships and intimacy will be negatively impacted by the lack of proximity, among others.[12] Among service members who are geographically separated from their family, common sources of anxiety include worry about missing important milestones in their children’s and spouses’ life and guilt that they have left a heavy burden on their spouse.[12]

When a service member leaves their family for a prolonged period of time, and when they return, family dynamics adjust to that change. Both of these events create stress. While filling the void left by departure of the service member is often assumed to be a negative event and their return a positive one, there are a number of scenarios in which this may not be the case. First, the service member’s interaction with one or more members of the family may be stress-inducing, and their departure may be seen as a positive. Second, the stress of the service member’s geographic separation may result in family member roles and responsibilities being more thoughtfully considered than in the past, resulting in a new family dynamic that members appreciate. Third, family members who are a part of the intentional development of this new dynamic may feel more satisfied due to their participation in its development. Fourth, family members’ new roles often involve greater responsibility and autonomy, enhancing their sense of motivation and satisfaction.[13]

Family members’ appreciation of the new family dynamic may be misinterpreted to be a lack of appreciation for the returning service member. For those service members who deployed and view themselves as returning heroes, feeling more appreciated by strangers than by family members can be especially painful. Helping all members of the family understand common challenges during reintegration, and working with them to develop effective coping strategies, requires a thoughtful and intentional approach. One helpful resource with an excellent section on reintegration is the Military One Source deployment page (http://www.militaryonesource.mil/deployment).[14]

Permanent Change of Station Moves

On average, military members move every 2 to 3 years.10,15 These moves are usually to a different state, and sometimes to a different country. Moves by civilian families are (on average) less than 20 times as common[16] and are less likely to be followed by subsequent moves in the ensuing years.

In addition to the increased frequency of moves, military families have far less control over a number of factors related to the move, including the location to which they move, the timing of that move, and the frequency of subsequent moves. Moves are often to locations where the family has not previously lived and where the military member, their spouse, and their children lack social connections.[17] Moves can occur in the middle of the school year, which can be particularly challenging for school-age children because it adds another transition with which they must cope. Curriculum misalignment between their old and new schools can also cause stress because children may be behind (and overwhelmed) or ahead (and bored) when starting in the new school.[17] These factors may in part explain why military families opt to homeschool their children twice as frequently as their civilian counterparts.[18]

Subsequent moves can occur just 1 year after arrival, bringing into focus the fallacy of the use of the word “permanent” in the term “permanent change of station.” In addition, moves rarely bring a family back to a previous duty station, and even when they do, the community at that duty station has typically changed markedly due to other families’ moves. Another significant difference between civilian and military family moves is that military families are responsible for completing myriad mandated checklists before, during, and after relocation.

Frequent permanent change of station moves typically have economic implications beyond the simple costs of the move. While many moving costs are borne by the military service, some are not. These costs may include: new items that cannot be shipped from one’s prior location (eg, household items, food, liquids in open containers), new clothes based on differences in climate, selling vehicles at one’s old duty station and purchasing new vehicles at the new duty station, and loss of money from one’s security deposit if renting, among others. In addition, loss of income earned by civilian family members can be substantial. Perhaps the biggest economic issue related to a permanent change of station move is that of home ownership. While there are some good reasons to consider purchasing a home, military members and their families face a significant disincentive to build equity in the housing market. This disincentive stems from many factors, including lack of control over the timing of a subsequent move and the potential need to sell the house at an inopportune time; the potential need to rent the house at a loss; and perhaps most significantly, the potential loss of a security clearance as a result of an inability to pay one’s debts (including a mortgage). Many military families choose to buy homes and benefit economically from that decision, but the uncertainly of that outcome causes it to remain a significant stressor for military families, even when the outcome is a good one.

The stress caused by permanent change of station moves can negatively affect family members and result in physical, social, and psychological disturbances including depression, headaches, and an increased incidence of allergic rhinitis and heart disease.19,20 The stress of a move, as well as the discordant ways in which individual family members may cope, sometimes contributes to interpersonal conflict resulting in frequent arguments and family rancor. Children are impacted as well, and respond to the way their parents talk about and react to the move.

Sadly, even when such symptoms are recognized, there are a number of potential barriers to family members’ getting needed medical attention. These hurdles may include:

- Transportation. The family may only have one vehicle with them on arrival to their new duty station, which the active duty member uses to get to work, causing difficulty in getting to appointments.

- In-processing. There may be a perception of pressure from the command to prioritize administrative check-in responsibilities before seeking healthcare.

- Mental health stigma. Family members may feel uncomfortable about seeking care for mental health concerns.

- Medical providers. It may take some time to find a new primary care manager and establish new relationships with healthcare providers.

The last issue can be particularly stressful for those with complex and chronic health conditions, including children with special needs, for whom continuity of care and timely access to care can be particularly important.

Role Conflict

American views on roles in families are changing. Traditional views of family included a presumption that the husband served as “breadwinner” and the wife as “homemaker.” More modern views recognize diversity in family composition and respect the value of shared roles and egalitarianism.[21] In a military family context, military members and their spouses may be in situations in which their actual role is not well aligned with the role they believe is their responsibility. This conflict is often related to one’s perceived gender role and can cause internal turmoil and degrade resilience.

Men comprise approximately 8% of the total number of military spouses,[22] a 3.5-fold increase over the past 30 years.22,23 Consequently, there has been a significant increase in the number of stay-at-home husbands and fathers, consistent with the national trend.[15] For a male stay-at-home military spouse with traditional attitudes about gender roles, not being the breadwinner can be difficult. This may be more problematic when living in a military community in which there are relatively few stay-at-home fathers. In addition to the social stigma against the idea of a stay-at-home father, most military spouse support organizations were designed for supporting the needs of women.[22]

It may be equally challenging for female military spouses who have modern views about their role to cope with not being a breadwinner for the family. This can be exacerbated when living within a larger military community that they perceive to have traditional views of gender roles.

The stress associated with incongruity between one’s perceived gender role and one’s actual role is not limited to military spouses. Service members, regardless of sex, also must cope with these challenges, including a potential sense of guilt for not playing a more active role in the care of children.

Career Obstacles

Military spouse employment is a unique stressor that can cause a ripple effect within the family system. For the employed spouse, geographic moves result in their transferring within the same company (if possible) or quitting their job and seeking new employment. This can be far more difficult than it might seem. First, moves are based on the needs of the military and may place the military spouse in a location where their skill set is not in demand. Second, even if their skill set is in demand, competition for open jobs can limit employment opportunities and result in spouses accepting positions at a lower level than the one they left, impeding their career progression.[24] Third, even when offered a new job, the military family with children must find a childcare facility with openings, and the military spouse may have to wait for an opening for a new job. Even when a new job is identified, the military spouse may discover that the cost of childcare at their new location is greater than their income. Due to these and other factors, military spouses are employed less frequently, have lower income, and work fewer hours when compared with their civilian counterparts with similar education levels.[24]-[26] This can be quite frustrating and negatively impact individual and family resilience and readiness.

Young military families are particularly susceptible to anxiety and stress related to spouse career obstacles. The junior military member’s income may be inadequate to ensure family financial stability. As a result, dual incomes are often necessary. As noted above, frequent relocations make continuity of employment and career progression difficult.[27] In addition, completing a college degree (something strongly associated with economic success[28]) can be quite challenging. Although online college programs have made it easier for those who move frequently to complete their degree, spouses who attended brick-and-mortar universities may struggle to find a college or university that accepts the previous credits attained.

Even those with advanced degrees face challenges. First, there may be a limited number of job opportunities in the vicinity of one’s new duty station. Second, spouses whose professional practice requires state licensure (such as social workers, doctors, nurses, lawyers, and teachers) may find that the governing regulations and professional requirements of the state or country to which they have moved require additional certifications. These additional requirements, in addition to administrative hurdles and costs, may delay a military spouse’s ability to gain employment in their new location.

All of these barriers to spouse career development can impact the family as a unit. This may negatively impact the service member’s job performance and career progression, creating an additional hurdle to families trying to develop financial stability. In addition, it is likely to result in decreased family resilience and readiness; decreased sense of self-worth on the part of the spouse[29]; and increased levels of anxiety in all family members. The issue may contribute to a decision to separate from military service prior to the attainment of military retirement benefits.[25]

Families with Dual or Single Military Parents

Families with dual military parents face unique challenges. These can include:

- the need to rely on outside agencies for child care and transportation;

- the possibility of both parents being geographically separated from the family, occasionally at the same time;

- the possibility of parents receiving assignments at different locations, thus forcing a separation of the family unit; and

- conflict that can arise in situations where a desire for career progression comes into conflict with the needs of the family, one’s partner, or a desire to keep the family unit together.

In the face of these challenges, families typically seek to develop and sustain support structures to buoy them in times of need, but developing such a structure, especially when living a nomadic life, requires effort. Grandparents or other extended family members serve as a potential source for such support, but can face challenges in accessing military services on behalf of the family, particularly if serving as alternative caregivers while parents are deployed.[30] Additionally, frequent relocations can make it difficult for military families to develop and maintain close relationships, which can exacerbate feelings of isolation. Fortunately, fellow military families tend to have an understanding of these challenges and support one another. However, when living in a predominately civilian community, where a military family can be perceived as transient, finding such support can be more challenging.

Families with a single military parent face challenges of their own. One of these is the need to balance childcare responsibilities with a responsibility to the military organization.[31] These two responsibilities are inherently intermeshed. Focusing on work responsibilities usually leads to career progression, which improves the ability to care (economically) for children, and may also offer the opportunity to assume positions with greater work hour flexibility. At the same time, having a sense that one’s children are well cared for allows one to focus more effectively at work. Another challenge is coordinating childcare and transportation, including finding care options that are conveniently located and affordable on a single income.[32] Deployments can place extreme hardship on families with a single military parent even if extended family members are available and willing to provide relief.33,34 These hardships can impact both parents’ and children’s well-being before, during, and after the deployment.

IMPACT ON MILITARY CHILDREN

Children are inherently affected by the realities of military family life. Relocations, deployments, and other factors create stressors that civilian families rarely, if ever, experience. Among the cohort of military children, young children, adolescents, and children with special needs are three subsets that may be especially impacted by the stressors of military life.

Young Children

Children under 6 years old are especially vulnerable when it comes to geographic separation. Young children are often confused about the cause of their parent’s absence and where they have gone; have challenges with trust; and often have an increase in cognitive, mood, and behavioral problems.[34] On return of the absent parent, young children often demonstrate increased attachment behaviors, developmental regression, and other distressed behavior.[35] With deployment, young children often fear for their parent’s safety. Although they may not fully understand the risks of deployment, the ubiquitous, sensationalized media coverage of today’s military conflicts can exacerbate this sense of fear.

Adolescent Children

For adolescents, geographic separation and relocation are both major stressors. Adolescents, as compared with younger children, have a greater awareness of the risks posed when their parent is deployed, and less comfort sharing fears related to this awareness. This dichotomy can lead to feelings of loss, depression, anxiety, and thoughts of suicide.36,37 Adolescents may have both concern for their deployed parents and a sense of increased responsibility for family members.[37] Relocation can be especially stressful for adolescents because they are in a period of intense identity formation, which can be disrupted by geographic moves. Consequently, adolescents who have experienced a geographic move in the past year have a higher incidence of hyperactivity, mental illness, mood lability, substance use concerns, suicidality, and poor academic performance.19,38 While this highlights the many short-term challenges faced by adolescents in military families who move, studies demonstrate that multiple moves over time, especially when military families are given the resources to support these moves, may promote resilience and not undermine development.[38]

Children with Special Needs

Children with special needs may have particular difficulty with the frequent transitions that occur in military families. Consequently, some families elect to stay in one location while the military member takes orders to another location, trading the positives of geographic stability of the non-military spouse and children for the negatives of geographic separation. Those families who move with their military service member must ensure that the new duty station will be able to meet the needs of their child with special needs. The Exceptional Family Member Program (http://efmp.amedd.army.mil)[39] is a critical program designed to ensure that family members are stationed in locations where their special needs can be met.

Even when relocating to a location where their family member’s special needs can be met, families face a number of challenges. First, many family members with special needs have a more difficult time adapting to a new environment. Second, there may be a delay between arrival and initiation of special needs services. Even when those services are initiated, they may be different from those received in the past due to differences in programs and services from state to state. These setbacks can be harmful to the child and create additional stressors for the family.[40]

STRATEGIES FOR ENHANCING FAMILY READINESS

When considering various strategies to help families enhance their readiness, it is important to recognize that there is no “one size fits all” approach. What works for one person in a given situation may or may not work for another person in a similar situation, even if those two people are in the same family. The reason is that each individual has their perspective, borne out of their own personal context, defined as the interwoven fabric of one’s unique and diverse life experiences.[41]

The fact that one approach may not work for everyone in a given family can be frustrating, both for the healthcare provider and for family members. The common belief that the family member is not “trying hard enough” if they do not respond well to a strategy that works for others in the family is erroneous. This can compound the distress that patients experience. In addition to being faced with a significant life stressor, they also receive the message that they are not putting forth the effort needed to overcome it. This may cause feelings of worthlessness and shame in addition to what they may already be feeling, most commonly feelings of sadness and being overwhelmed. Explaining to members of a family that each individual copes in their own way and at their own pace normalizes this reality, can facilitate mutual support, and can enhance family readiness.

One way to organize approaches to enhancing family readiness is to divide them into preventive strategies (those that enhance family readiness in advance of a stressor) and reactive strategies (those that enhance family readiness in the face of a stressor).

Preventive Strategies

Facilitating Dialogue

In most cases, the best preventive strategy is to encourage family members to openly talk about anticipated challenges. As a military healthcare provider, starting with open-ended questions that ask about perceived family roles may help identify incongruence between individual family members’ perceptions and help identify anticipated difficulties.

Often, family members will be hesitant to discuss upcoming stressors, for several reasons. One is the simple fact that these conversations can be difficult and uncomfortable. Another is the potential concern of parents who may feel that talking about a stressor in advance will only increase the anxiety of their children about that stressor. These challenges are further complicated by the fact that for military families, some stressors (such as geographic separation) may be unanticipated. These situations can be highly variable and leave little time to proactively plan informed family discussions.

Understanding family members’ reticence to discuss anticipated or upcoming stressors is an important first step toward encouraging positive prevention efforts. Consequently, healthcare providers may need to prompt this discussion, rather than assuming that family members will proactively have conversations with one another in advance. Helping to normalize the discomfort and emphasize the importance of these conversations is key. Additionally, providing developmentally appropriate language for all family members is usually very helpful and may allay anxieties. For example, explaining a deployment using phrases like “mommy’s going to war” or “dad’s got to fight for the country” can be especially anxiety provoking. Instead, an “ask–clarify–ask–answer” approach is recommended in the following four steps:

1. Ask what the family members understand about the upcoming stressor.

2. Clarify their thoughts and concerns about this stressor, using age-appropriate language.

3. Ask what questions they have about this stressor.

4. Answer those questions, again using age-appropriate language.

Managing Uncertainty

Handling uncertainty can also be difficult. Parents may be hesitant to discuss with children a potential move or deployment that may be canceled or changed, sometimes with unexpected time frame shifts. These are regular occurrences in a military community. For example, one family in which the father deployed and who had two young children, decided to create a paper chain that they hung around their living room. Each link in the chain represented one day that their father would be gone and each day they removed one link. One week before the anticipated end of the deployment, the father learned his deployment was being extended by 2 months. The children were devastated. The concept was a noble one—trying to help the children to make sense of the situation and have a better understanding that the deployment was not indefinite. Unfortunately, the discordance between expectations and reality in such a situation can easily push a family into a crisis. How can providers help parents find a balance between offering reassurance without making promises that they may not be able to keep? Some approaches include:

- Tell children the season, rather than specific dates the parent may return.

- Find an object of consistency—something that always moves with them from house to house, or an object that a parent and child can both share while being geographically separated.

- Find a positive activity to look forward to as a family. Be careful to validate negative emotions and provide opportunity for family members to share concerns. Additionally, it is important to remain sensitive to the uncertainty that may be associated with the anticipated stressor. Identifying smaller but positive activities to engage in and look forward to (eg, writing letters, video chats, and one-on-one time with the parent at home), as opposed to bigger activities may be more effective.

Expectation Management

Frustration within families often arises when there is incongruity between family members’ perceptions of the roles each family member plays and family members’ perceptions of how static or flexible those roles should be. For children and adults alike, divergent views of the roles of family members can be disorienting, especially in the context of geographic moves and geographic separation. As a military healthcare provider, the goal of facilitating a discussion about roles and role flexibility is not to encourage members to conform to a single view, but to help them understand others’ perspectives.

In addition, it may be helpful to explain to patients that while consistency in roles can be reassuring, the ability to adapt to change through flexible family roles is often positively adaptive. For example, an adolescent who takes on additional responsibilities during a deployment may initially feel challenged by the need to adapt to a new role, but will often develop pride in their contributions and greater self confidence that helps them adapt to challenges in the future. When the deployed service member returns, however, their adolescent may be conflicted between being happy about their reunion, while struggling with frustration regarding reduction in autonomy and a decreased sense of contribution. Consciously acknowledging this as family is important. Having parents highlight the positive qualities developed and additional responsibilities demonstrated, while also acknowledging the loss of this expanded role, can go a long way to normalizing and mitigating the challenges of this adjustment period.

Military healthcare providers should have discussions about family and family roles at a time when families are not in crisis. This offers a great opportunity for the family to anticipate how various stressors may affect each of them. Perhaps most importantly it allows each of them to manage their expectations, thus decreasing stress and enhancing resilience. These same strategies can be very helpful during times of service member reintegration. In addition, the following tips for facilitating reintegration may be helpful:

- Have discussions without distractions (television, phones, etc).

- Engage in closed-loop communication—state what you understand others to be saying to ensure mutual understanding and demonstrate respect.

- Set aside dedicated one-on-one time with each member of the family.

Younger children may regress or display behaviors that are developmentally less mature than normal for them in an attempt to cope with challenges. Understanding this behavior as normal can allow a family to respond affirmatively rather than critically. However, given that military challenges such as deployment have been associated with mental health difficulties and developmental delays in children,[42] it is important for healthcare providers to routinely assess and be aware of these risks. In this way, a strengths-based approach to early intervention can be developed.

Psychological First Aid

Psychological first aid is a concept that that emphasizes meeting basic needs (eg, food, shelter, security) in the midst of a disaster,[41] but also offers an opportunity for preventive interventions. Asking individuals what healthy eating and regular physical activity means to them is a respectful way to open the discussion about leading a healthy lifestyle without seeming condescending. In addition, asking patients what they do for stress reduction is recommended. Such questioning facilitates a dialogue regarding various physiological stress reduction mechanisms (eg, deep breathing, progressive muscle relaxation, and mindful meditation) that have been demonstrated to result in decreases in perceived stress reduction as well as cortisol levels.43,44

Reactive Strategies

When a family is in crisis, consider whether it is feasible for a family to incorporate any of the above preventive strategies. It can be difficult to establish new patterns of behavior during times of crisis. Consequently, developing a clear understanding of family roles and rapport with family members usually becomes the top priority. Next, incorporating psychological first aid is often quite helpful. The eight core actions of psychological first aid are as follows[45]:

1. contact and engagement,

2. safety and comfort,

3. stabilization,

4. information gathering,

5. practical assistance,

6. connection with social supports,

7. information on coping, and

8. linkage with collaborative services.

In the midst of a crisis, it is critical to ensure that a family’s basic psychological needs are met and that social supports are put in place. This typically requires engagement with other healthcare providers to offer the family the interprofessional and interdisciplinary care they need. Within the Military Health System, most outpatient settings have embedded behavioral health professionals who can connect with family members. Additionally, outside resources are available for helping children and families to cope with trauma. A list of suggested resources is available in Table 29-1. For the military medical officer at a remote duty station where there are no on-site mental health professionals, the best option may be to establish a method in advance (such as video chat) to connect a family struggling with a crisis with the care they need.

TABLE 29-1

ONLINE FAMILY READINESS RESOURCES

Organization

Website

Synopsis

Military Family Resources

After Deployment

https://www.afterdeployment.dcoe.mil

Health and wellness resources for the military community.

Blue Star Families

https://www.bluestarfam.org

Resources, programs, and special opportunities for military families.

Everyone Serves

https://www.everyoneservesbook.com/

Handbook for family and friends of service members during Pre-Deployment, Deployment and Reintegration

Military Family Books

https://www.militaryfamilybooks.com

Books about the military and deployment for all family members.

Military One Source

https://www.militaryonesource.mil

Information on nearly every aspect of military life including deployment, reunion, relationships, grief, spouse employment & education, parenting and childhood services.

Military.com Military Deployment Center

https://www.military.com/deployment

Service-specific deployment resources

National Military Family Association

www.militaryfamily.org

A wide range of robust and relevant resources for military families.

The American Military Partner Association

www.militarypartners.org

Resources for partners, spouses, families, and allies of LGBT service members/veterans.

Military Spouse Resources

Military Spouse Employment Authority

https://www.fedshirevets.gov

Laws regarding military spouse employment benefits.

Military SOS

www.militarysos.com

Support and information resource for military spouses and significant others of all branches, around the world.

My Career Advancement Account

https://mycaa.militaryonesource.mil/mycaa/

A $4,000 tuition assistance program provided by the DoD for spouses of service members E1-E5, O1-O2, and W1-W2.

Pat Tillman Foundation

www.pattillmanfoundation.org

Foundation that invests in military veterans and spouses through educational scholarships.

Military Children’s Resources

Military Child Education Coalition

www.militarychild.org

Tools and resources to ensure quality educational opportunities for all military-connected children affected by mobility, family separation, and transition.

Military Kids Connect

www.militarykidsconnect.dcoe.mil

Online community for military children; includes age-appropriate resources to support children dealing with the unique psychological challenges of military life.

Mental Health Resources

Military Crisis Line

https://www.veteranscrisisline.net

Confidential help for service members and their families.

National Child Traumatic Stress Network

www.nctsn.org

Resources for parents, teachers, caregivers, and professionals for helping children cope with a wide range of stressors.

National Suicide Prevention Lifeline

https://suicidepreventionlifeline.org/

Confidential suicide prevention hotline available to anyone in suicidal crisis or emotional distress.

The Soldiers Project

https://www.thesoldiersproject.org

Free, confidential psychological services to US military veterans and their loved ones who have served at any time after September 11, 2001.

In the midst of and immediately following a crisis, there is likely to be variation in the emotions felt and the speed with which those emotions are processed by different family members. Explaining that this variation is likely to occur and is normal can go a long way toward mitigating frustration and helping families work together and offer mutual support. Encouraging family members to share emotions with each other (without forcing sharing) will usually build resilience. Before starting this process, be mindful that family members may have grown up in an environment in which they never gained comfort with or learned the language needed to express emotions. In this situation, discussing how to discuss emotions is a critical first step. Care should be taken not to unduly categorize reactions as pathologic during and after a crisis event. However, it is important to remain vigilant about early identification of a maladaptive stress response such as suicidal ideation or dissociation.

FAMILY READINESS—THE ROLE OF THE MILITARY MEDICAL OFFICER

As described above, supporting military family readiness is a team endeavor. This team includes the family, members of the active duty member’s command, and members of the healthcare team, among others. Military medical officers can best help by (a) directly supporting military families, (b) coordinating the care delivered when needed, (c) staying up to date regarding evolving professional recommendations, and (d) educating the command about helpful resources for preventive and reactive strategies.

Direct Support for Military Families

Direct support for military families includes much more than ensuring that the military member has been medically evaluated and is fit for duty. It also includes ensuring that the family’s medical needs are addressed and that they understand their care plan. In some situations, the medical officer will be able to care for the family, but in others, they may need to be seen by another provider. Playing an active role in ensuring that family members get the care they need is important. Navigating the healthcare system can be challenging, especially for individuals with limited experience accessing healthcare. Checking in to ensure that the families receive excellent care reassures military members and their families that their well-being is important. This is likely to contribute to family readiness. One simple strategy is to schedule “walk around” time to check in with the members of the unit. During that time, asking specific questions about families’ needs from the healthcare team is recommended. If concerns are mentioned, healthcare providers should investigate the concerns, act when possible, and reach back within 48 hours to provide information or plans of action.

Coordinating Care

As noted above, healthcare providers may not be able to provide all the care required by service members or members of their family. In these situations, the most important first step is to listen. Play close attention to concerns and what has been done to seek help to date. Once it is determined that the healthcare needs exceed the provider’s capability to provide direct care, a plan of action and timeline should be discussed so the service member and their family members know what to expect.

The next step will be to engage colleagues to coordinate the care military families need. Excellence in coordinating care depends on relationships—both with the patient and with members of the healthcare team who are in a position to help. To this end, developing relationships with key members of the healthcare team, in advance of crises, is essential. Members of the healthcare team who often play a key role in helping facilitate care include the following:

- social workers,

- primary care providers and nurses,

- mental health providers and nurses,

- chaplains, and

- referral managers.

Educating Military Unit Leadership

Informing command leadership about the importance of family readiness, how it contributes to mission readiness at the individual and unit levels, and educating them about strategies known to be effective in preventing and managing crises are some of the most important military healthcare provider tasks. When possible, initiate these conversations early in the military assignment and at times when the command leadership has the time to listen. Providing specific personal examples in which preventive strategies to help enhance family resilience and readiness had an impact on command readiness can be a particularly poignant way to convey the point.

FAMILY READINESS RESOURCES

Many resources are available to military families and the military healthcare providers who support them. Because family readiness is not a one-size-fits-all endeavor, it may take some effort to find the most effective resources and techniques to enhance readiness for each family. See Table 29-1 for representative resources designed to strengthen military family readiness.

SUMMARY

Family readiness in the context of a military community is influenced by each family’s unique makeup and situation, but there are many common stressors faced by military families that could affect their readiness. Both preventive and reactive strategies help support the families’ readiness, and in turn, their units. Just as not all strategies will work for every individual, neither will all approaches work for every command. Understanding a variety of strategies, being comfortable with identifying alternative strategies if one is not effective, and maintaining willingness to work collaboratively with patients to find (through shared decision-making) the best solution will improve and reinforce military family readiness.

REFERENCES

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2.   Clever M, Segal DR. The demographics of military children and families. Future Child. 2013;23(2):13–39.

3.   Bowles SV, Pollock LD, Moore M, et al. Total force fitness: the military family fitness model. Mil Med. 2015;180(3):246–258.

4.   U.S. Department of Defense. Military Family Readiness (DoD Instruction 1342.22). Washington, DC: U.S. Department of Defense. July 3, 2012. Updated April 11, 2017.

5.   Luthar SS, Cicchetti D, Becker B. The construct of resilience: a critical evaluation and guidelines for future work. Child Dev. 2000;71(3):543–562.

6.   Anthony EJ. Risk, vulnerability, and resilience: an overview. In: Anthony EJ, Cohler J, eds. The Guilford Psychiatry Series. The Invulnerable Child. New York, NY: Guilford Press; 1987: 3–48.

7.   Patterson JM. Understanding family resilience. J Clin Psychol. 2002;58(3):233–246.

8.   Holmes TH, Rahe RH. The social readjustment rating scale. J Psychosom Res. 1967;11(2):213–218.

9.   Coddington RD. The significance of life events as etiologic factors in the diseases of children. J Psychosom Res. 1972;16:7-18.

10.   Comptroller General of the United States. Longer Time Between Moves Related to Higher Satisfaction and Retention. Washington, DC: US General Accounting Office; 2001. Report to Congress. GAO-01-841 Military Personnel.

11.   Asbury ET, Martin D. Military deployment and the spouse left behind. Fam J. 2012;20(1):45–50.

12.   Drummet AR, Coleman M, Cable S. Military families under stress: implications for family life education. Fam Relations. 2003;52(3):279–287.

13.   Ryan RM, Deci EL. Intrinsic and extrinsic motivations: classic definitions and new directions. Contemp Educ Psychol. 2000;25(1):54–67.

14.   Deployment. Military One Source Web site. http://www.militaryonesource.mil/deployment. Accessed May 22, 2018.

15.   Hix WM, Shukiar HJ, Hanley JM, et al. Personnel Turbulence: The Policy Determinants of Permanent Change of Station Moves. Santa Monica, CA: RAND Corporation; 1998.

16.   US Department of Commerce, Economic and Statistics Administration. Statistical Abstract of the United States: 2012. 131st ed. Washington, DC: US Census Bureau; 2013.

17.   Ruff SB, Keim MA. Revolving doors: the impact of multiple school transitions on military children. Prof Couns. 2014;4(2):103–113.

18.   Anderson JR. ABCs of home schooling. Why more military families are skipping school in favor of this sweeping trend. Military Times. March 14, 2013.

19.   Bowen GL. Family Adaptation to Relocation: An Empirical Analysis of Family Stressors, Adaptive Resources, and Sense of Coherence. Alexandria, VA: US Army Research Institute for the Behavioral and Social Sciences; 1989. ARI Technical Report 856.

20.   Matthiesen JK, Tissington PA. The four-factor taxonomy of relocation outcomes. Hum Resource Dev Rev. 2008 7(2):142–164.

21.   Amato PR, Booth A. Changes in gender role attitudes and perceived marital quality. Am Sociol Rev. 1995;60(1):58–66.

22.   Center, Defense Manpower Data. 2015 Demographics: Profile of the Military Community. Washington, DC: Office of the Deputy Assistant Secretary of Defense for Military Community and Family Policy; 2015.

23.   Carr C, Orthner DK, Brown III RJ. Living and family patterns in the Air Force. Air Univ Rev. 1980;31(2):75–96.

24.   Maury R, Stone B. Military Spouse Employment Report. Institute for Veterans and Military Families; 2014.

25.   Cooke TJ, Speirs K. Migration and employment among the civilian spouses of military personnel. Soc Sci Q. 2005;86:343–355.

26.   Harrell MC, Lim N, Castaneda LW, Golinelli D. Working Around the Military: Challenges to Military Spouse Employment and Education. Santa Monica, CA: RAND National Defense Research Institute; 2004.

27.   Castaneda LW, Harrell MC, Varda DM, Hall KC, Beckett MK, Stern S. Deployment Experiences of Guard and Reserve Families: Implications for Support and Retention. Santa Monica, CA: RAND Corporation; 2008.

28.   Pascarella ET, Terenzini PT. How College Affects Students: Findings and Insights from Twenty Years of Research. Vol 2. San Francisco, CA: Jossey-Bass; 2005.

29.   Goldsmith AH, Veum JR, Darity W. Unemployment, joblessness, psychological well-being and self-esteem: theory and evidence. J Socio Econ. 1997;26(2):133-158.

30.   Bunch SG, Eastman BJ, Moore RR. A profile of grandparents raising grandchildren as a result of parental military deployment. J Hum Behav Soc Environ. 2007;15(4):1–12.

31.   Vuga J, Juvan J. Work–family conflict between two greedy institutions—the family and the military. Curr Sociol. 2013;61(7):1058–1077.

32.   Kimmel J. Child care costs as a barrier to employment for single and married mothers. Rev Econ Stat. 1998;80(2):287–299.

33.   Kelley ML, Doane AN, Pearson MR. Single Military mothers in the new millennium: stresses, supports, and effects of deployment. In: Wadsworth SM, ed. Risk and Resilience in U.S. Military Families. New York, NY: Springer-Verlag New York; 2011:343-363.

34.   Kelley ML. Single military parents in the new millennium. In: Castro CA, Adler AB, Britt TW, eds. Military Life: The Psychology of Serving in Peace and Combat. Westport, CT: Praeger Security International; 2006: 93–103.

35.   Barker LH, Berry KD. Developmental issues impacting military families with young children during single and multiple deployments. Mil Med. 2009;174(10):1033–1040.

36.   Cederbaum JA, Gilreath TD, Benbenishty R, et al. Well-being and suicidal ideation of secondary school students from military families. J Adolesc Health. 2014;54(6):672–677.

37.   Milburn NG, Lightfoot M. Adolescents in wartime US military families: a developmental perspective on challenges and resources. Clin Child Fam Psychol Rev. 2013;16(3):266–277.

38.   Millegan J, McLay R, Engel C. The effect of geographic moves on mental healthcare utilization in children. J Adolesc Health. 2014;55(2):276–280.

39.   Exceptional family member program. US Army Medical Department Web site. http://efmp.amedd.army.mil. Updated September 9, 2015. Accessed May 5, 2018.

40.   Russo TJ, Fallon MA. Helping military families who have a child with disability cope with stress. Early Child Educ J. 2001;29(1):3–8.

41.   Saperstein AK, Lilje T, Seibert D. A model for teaching reflective practice. Mil Med. 2015;180(4 Suppl):142–146.

42.   Nguyen DR, Ee J, Berry-Caban CS, Hoedebecke K. The effects of military deployment on early child development. US Army Med Dep J. Oct-Dec 2014:81–86.

43.   Hoge EA, Guidos BM, Mete M, et al. Effects of mindfulness meditation on occupational functioning and health care utilization in individuals with anxiety. J Psychosom Res. 2017;95:7–11.

44.   Phillips KM, Antoni MH, Lechner SC, et al. Stress management intervention reduces serum cortisol and increases relaxation during treatment for nonmetastatic breast cancer. Psychosom Med. 2008;70(9):1044–1049.

45.   Network NCTS. Psychological First Aid Field Operations Guide, 2nd Edition. Washington, DC: National Center for PTSD; 2006.

Chapter 30

MEDICAL READINESS

CHRISTOPHER W. BUNT, MD,* AND BONNIE SANCHEZ†

INTRODUCTION

ROLE OF THE MILITARY MEDICAL OFFICER

Predeployment

Deployment

Postdeployment

GUIDANCE TO THE COMMANDING OFFICER

SUMMARY

*Lieutenant Colonel, US Air Force Reserves, Medical Corps; Associate Professor, Department of Family Medicine, Medical University of South Carolina, Charleston, South Carolina

†Senior Master Sergeant, US Air Force; Air Force District of Washington Functional Manager, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, Maryland

INTRODUCTION

Medical readiness involves a series of assessments to ensure that uniformed service members (USMs) are free of health-related conditions that endanger others or limit their ability to achieve their assigned mission. Medical readiness also refers to the ability of medical units in each service to prepare their medical personnel to provide healthcare to military members at home and abroad. The role of the military medical officer (MMO) is to both support and advise the commanding officer (CO). While the CO is ultimately responsible for military and medical readiness accountability, it is the MMO’s duty to lead the team that will screen, evaluate, and treat members as needed per mission requirements and the CO’s directives. This chapter will examine the physical conditions and procedures essential to medical readiness for the USM.

In 2008, the Institute for Healthcare Improvement introduced three critical objectives in healthcare provision. Labeled the “Triple Aim,” the three objectives are (1) better health, (2) better patient care, and (3) lower costs.1,2 In 2009, the Department of Defense (DoD) added a fourth objective, medical readiness, and renamed the concept the “Quadruple Aim.”[3] DoD healthcare directives and instructions now must always consider their impact on the Quadruple Aim.

Medical readiness is an essential component in the preparation of the USM for deployment. In general, the deployed environment is more taxing to the individual USM and does not have the same medical capabilities as the continental United States (CONUS). This chapter is divided into sections focusing on the aspects of medical readiness that are handled before, during, and after deployment. The term “deployment” encompasses contingency deployments in support of military operations (eg, Operation Enduring Freedom); overseas assignments (outside CONUS); and military operations other than war (eg, humanitarian missions). Multiple areas of readiness overlap, and this chapter presents a framework to assist with information retention. While every aspect of a medical encounter can be essential for the USM’s readiness, this chapter’s focus will be on the military-unique readiness items. Exhibit 30-1 provides a quick reference checklist for the MMO.

ROLE OF THE MILITARY MEDICAL OFFICER

Predeployment

Predeployment includes the period of time from the USM’s entry into military service up through their first deployment. By definition, this period overlaps with the postdeployment period leading up to the USM’s second and subsequent deployments. Reviewing the USM’s medical history and medical record is the first step in determining their individual medical readiness. From this initial review, recommendations are made about next steps, including prevention, evaluation, and treatment.

Prevention

The first step in ensuring optimal health for all USMs is preventing illness and disability. Prevention is divided into four discrete areas: (1) screening, (2) immunizations, (3) behavioral modifications, and (4) chemoprophylaxis (prophylactic use of medications to prevent illness). Table 30-1 provides examples of each. Of these areas, immunizations and chemoprophylaxis are currently the most evidence-based.[4]

Screening. Screening is the most comprehensive of the four areas of prevention, and includes mental health history, neuropsychological testing, disease surveillance, dental examinations, annual preventive health assessments (PHAs), and occupation-specific examinations (eg, for aviators).

EXHIBIT 30-1

MILITARY MEDICAL OFFICER QUICK REFERENCE MEDICAL FITNESS CHECKLIST

- Periodic health assessment (PHA)

- Disease surveillance (laboratory testing, eg, HIV, TB)

- Routine immunizations

- Chemoprophylaxis (eg, anti-malarials)

- Dental readiness

- Vision readiness

- Hearing readiness

- Baseline neurocognitive assessment (eg, ANAM)

___________________

ANAM: Automated Neuropsychological Assessment Metrics

HIV: human immunodeficiency virus

TB: tuberculosis

Adapted from: O’Connor FG, Deuster PA, DeGroot DW, White DW. Medical and environmental fitness. Mil Med. 2010;175(8:57):57-64.

TABLE 30-1

PREDEPLOYMENT PREVENTION

Form of Prevention

Examples

Screening

Mental health history: Patient Health Questionnaire-2 (PHQ-2)

Neuropsychological testing, eg, baseline TBI screens: Automated Neuropsychological Assessment Metrics (ANAM)

Disease Surveillance, eg, laboratory testing: USPSTF recommendations, HIV, cholesterol, cancer screening (colon, cervical)

Dental examinations: at least annual exams and subsequent classification assigned (1–4)

Preventive Health Assessments (PHA): at least annually.

Occupation-specific examinations: aviators, Personnel Reliability Program (nuclear weapons handling and support), Presidential Support Program

Immunizations

CDC-required and recommended immunizations (http://www.cdc.gov/vaccines/schedules/)

Host-nation-specific immunizations, eg, yellow fever for Far East countries

Behavioral modifications

Substance use/abuse evaluation

Exercise habits

Dietary practices

Medical therapy compliance

Chemoprophylaxis

Anti-malarials

CDC: Centers for Disease Control and Prevention; HIV: human immunodeficiency virus; TBI: traumatic brain injury; USPSTF: US Preventive Services Task Force

Mental health history and testing is done during the annual PHA and subsequently with each medical encounter. Given potential impacts on the mission, depression screening is done at the beginning of each encounter. The most frequently used “first-step” method for screening for depression is the Patient Health Questionnaire-2 (PHQ-2).[5] This survey instrument asks the USM to quantify his or her level of (1) anhedonia (lack of interest in activities) and (2) depressed mood over the most recent 2 weeks. Each question is graded on a 4-point Likert scale, with 0 equal to “not at all” and 3 corresponding to “nearly every day.” Those patients who have a two question-combined answer score of 3 or higher are referred for additional evaluation.[5]

It is extremely important to detect and treat traumatic brain injury (TBI), including mild-TBI (concussions), yet these injuries remain hard to detect. Screening USMs for TBI involves baseline testing of neurological status during predeployment, and then follow-up testing after actual or possible TBI events. Baseline and post-event testing in the military are performed using tools such as the Automated Neuropsychological Assessment Metrics (ANAM).6,7 Another option for testing at the point of care (in the field or clinic) after an event is the Military Acute Concussion Evaluation (MACE).[8]

Disease surveillance, including laboratory testing, is most often based on service-specific regulations and DoD instructions.[4] These regulations, in turn, are often based on the recommendations of the US Preventive Services Task Force (USPSTF). The USPSTF makes recommendations after an exhaustive objective review of all available evidence about a diagnostic test, therapeutic procedure, or other treatment. Its recommendation statements fall into one of three categories: recommended, uncertain, or not recommended.[9] Other disease surveillance testing currently in place for USMs includes human immunodeficiency virus (HIV), which is recommended every 18 to 24 months in the DoD, and non-fasting lipids (cholesterol), recommended every 5 years.

Disease surveillance screening is not limited to laboratory studies, however. Cancer screening is another aspect of prevention, and can include laboratory testing (for cervical and colon cancer) as well as imaging (for breast and colon cancer) or other procedures (for colon cancer). Current recommendations for cervical cancer screening in average-risk women include a cervical Papanicolaou (pap) smear every 3 years in females ages 21 to 29, and either a pap smear every 3 years or a high-risk human papillomavirus (HPV) test every 5 years in females ages 30 to 65. The current recommendation for breast cancer screening is that average risk women (those without a first-degree relative family history of breast/ovarian cancer) should be screened with mammography every 2 years starting at age 50. Colon cancer screening recommendations include options for fecal occult blood testing (a laboratory study), computed tomography colonography (radiographic imaging), or colonoscopy (a procedure). The frequency for these tests vary with risk level, findings, age, and ethnicity.[9]

Dental readiness is a key component of medical readiness. All USMs need at least annual dental visits that include an exam and cleaning, and consequently they are grouped into four dental classes: those in class 1 do not require dental treatment for 12 months; those in class 2 require treatment within 12 months; those in class 3 require immediate treatment to avoid a dental emergency; and those in class 4 have not had a dental exam in the past 13 months. Classes 2 through 4 require limited mobility and duties due to urgency or gravity of the dental situation, and make the USM not medically ready.

The annual PHA is a required screening medical encounter for all USMs. All services rely on the member to report concerns in a pre-encounter survey and the provider to review the member’s responses, previous encounters, and medical record. Screening items include routine vital signs, visual acuity, and member-reported mental and physical health concerns. This is often the only opportunity for the majority of USMs to update their information, specifically capturing any medical encounters from the civilian sector (the military’s electronic medical record does not currently communicate with the civilian side) and new changes to their health. For specific USMs (eg, aviators, age > 50) hearing screening may also be done during or in association with the PHA.[4]

Some DoD units have additional requirements for medical readiness. These units include aviation (each medical decision or recommendation must be reviewed and approved by a flight surgeon prior to approving flight status) and those involved in the Presidential Support Program (PSP) and the Personnel Reliability Program (PRP). PSP personnel support the US president and presidential activities. PRP personnel either support activities involving or directly work with nuclear weapons. Given the high stakes involved with these activities, the healthcare of these personnel is monitored closely, with each medical interaction and decision requiring review and evaluation by the PSP/PRP medical team prior to the USM’s return to full duties.[10]

Immunizations. While immunizations protect the individuals who receive them, immunizations also provide “herd” or community immunity, whereby community members who cannot receive a vaccine (infants, pregnant women, immunocompromised individuals) are still protected from a contagious disease outbreak because critical members are immunized.[11] Immunizations are one of the most significant medical breakthroughs in history, and have helped the developed world eradicate contagious diseases such as polio. The DoD requires all vaccinations recommended by the Centers for Disease Control and Prevention (CDC) for each USM.[12] All of the current recommended immunizations can be found on the CDC website (http://www.cdc.gov/vaccines/schedules/). MMOs should be familiar with the various databases used by the DoD to track USMs’ immunizations status (see Data Management, below).

Behavioral modification. One of the most important aspects of prevention involves behavior change. Areas of behavior that should be addressed include substance use or abuse (tobacco and alcohol most commonly), poor diet, poor exercise habits, and medical therapy noncompliance. Changing these behaviors by assessing the patient’s willingness to change and then moving forward with specific, achievable goals is a powerful tool that can improve health and medical readiness for that individual and the military unit. Motivational interviewing is an effective technique that MMOs can use in behavior change counseling. This is a collaborative effort (usually initiated as a conversation) between the patient and provider to facilitate behavior change.[13]

Chemoprophylaxis. Prophylactic use of certain medications can also provide protection against illness and disability. For instance, pregnant USMs will receive prophylactic antibiotics during labor and delivery when they test positive for Group Beta Streptococcus (GBS). The most commonly used chemoprophylaxis method in the USM is anti-malarials. Other examples include taking aspirin for primary prevention of cardiovascular disease (CVD) and colon cancer in adults 50 to 59 with a greater than 10% 10-year CVD risk.

Evaluation

If the screening process, or a USM, raises a concern, further evaluation is required. Evaluation can include a focused history, physical examination, and diagnostic testing (laboratory and radiologic imaging). It may also involve referral from a primary care provider to a secondary care (specialist or subspecialist) provider. The MMO must work efficiently and effectively to evaluate any complaint or issue, with a keen focus on patient safety and health while minimizing mission disruptions.

TABLE 30-2

SERVICE-SPECIFIC PROFILING BASICS

Army

Temporary or “T”

- Definite endpoint with expectation of improving or resolving condition

- May complete “diagnostic” APFT but no recorded APFT

- If for less than 7 days, is entered on a “sick call slip,” form DD689

- If more than 7 days, entered as e-Profile into MEDPROS as a DLC

- Does not lead directly to an MEB

- Recurrent T profiles may warrant a formal FFRE which may lead to MEB

Permanent or “P”

- Indefinite endpoint, with no expectation of improvement or resolution to RTD or 1 year has elapsed from date of injury/disease

- Indicated when soldier has met MRDP for at least one condition

- Alternate APFT is authorized when any APFT event is medically contraindicated or unsafe

- Requires approval authority

- If PULHES 3 or 4, referral to MEB is mandatory

Navy

Temporary Limited Duty (TLD)

- Appropriate for sailors who will likely return to an unrestricted duty status

- If expected RTD is <30 days, use light duty form, NAVMED 6310-1; may be extended in 30-day increments, max 90 days

- If expected RTD is > 90 days, documented on LIMDU form, NAVMED 6100/5, and authorize in 6-month increments (12-month max)

- Enlisted: MTF convening authority may authorize up to 12 months of TLD; additional TLD must be approved by Navy Personnel Command (PERS-82)

- Officers: TLD requests must be approved by PERS-82

- Members referred to PEB for disability adjudication are placed on TLD pending PEB outcome

Permanent Limited Duty (PLD)

- Allows USMs to continue on active duty in a limited assignment when there is a need for their skill or experience

- Each case individually considered, member’s length of service is not controlling factor in PLD decisions

- Through referral to PEB process and processed on NAVMED form 6100/5

- Upon USM’s request, PERS-82 may retain an “unfit to continue naval service” member in a PLD status when the retention is in the best interest of the service and consistent with guidance in paragraph 6003 of SECNAVINST 1850.4E

- PLD will not be approved when retention in PLD status would jeopardize USM’s or other’s health or safety

Air Force

Duty-Limiting Condition (DLC)

- Definite endpoint, resolution expected in 31–365 days

- Completed on AF Form 469 in ASIMS

- 469 must define duty restrictions including what member cannot do (templates available)

- 469 must also include applicable FRs (cardio – run or walk, push-ups, sit-ups, abdominal circumference, height, weight)

- Completed 469 requires commander’s signature

- Does not lead directly to MEB

- 365 cumulative days for same condition warrants referral to DAWG at local MTF

Mobility-Limiting Condition (MLC)

- Definite or indefinite endpoint

- Also completed on AF Form 469 in ASIMS with MR box checked

- Condition may not improve or resolve

- Associated with specific diagnoses

- Members are not worldwide qualified and may not PCS or do TDY (see Medical Standards Directory* for a list of current medical standards for retention, flying classes, and special operational duty)

- Will likely lead directly to MEB (pregnancy is mobility restricting, but does not lead to an MEB)

*Air Force Medical Service Knowledge Exchange (https://kx.afms.mil)

APFT: Army Physical Fitness Test

ASIMS: Aeromedical Services Information Management System

DAWG: Deployment Availability Working Group

DLC: duty-limiting condition

FFRE: fit-for-retention evaluation

FR: fitness restriction

LIMDU: limited duty

MEB: medical evaluation board

MEDPROS: Medical Protection System

MLC: mobility-limiting condition

MR: mobility restriction

MRDP: medical retention determination point

MTF: medical treatment facility

PCS: permanent change of station

PEB: physical evaluation board

RTD: return to duty

TDY/TAD: temporary duty

USM: uniformed service member

Data sources: (1) Sloan D, Garner K. Cross service communications: writing profiles for an increasingly joint environment. Uniformed Fam Physician. 2015;Winter:29–32. (2) US Department of the Army. Standards of Medical Fitness. Washington, DC: DA; 2011. Army Regulation 40-501. (3) US Department of the Air Force. Duty-Limiting Conditions. Washington, DC: DAF; 2013. Air Force Instruction 10-203. (4) US Department of the Air Force. Medical Examinations and Standards. Washington, DC: DAF; 2014. Air Force Instruction 48-123. (5) US Navy Personnel Command. Limited Duty (LIMDU). Washington, DC: DN; 2004. MILPERSMAN 1306-1200. (6) US Navy Bureau of Medicine and Surgery. Medical evaluation boards. In: Manual of the Medical Department. Washington, DC: BUMED; 2005: Chap 18.

TABLE 30-3

PHYSICAL PROFILE SERIAL CHART (PULHES) AND HEARING PROFILE

Reproduced from: US Department of the Air Force. Medical Examinations and Standards. Washington, DC: DAF; 2018. Air Force Instruction 48-123. Attachment 3, Tables A3.1 and A3.2.

Treatment

Once a condition has been evaluated and diagnosed, treatment is the logical next step. While not all conditions or patient complaints can be diagnosed, the MMO must determine whether there is potential harm for the individual, society, the unit, or the mission. If the possibility of harm exists, treatment must be completed at the recommended interval, and the MMO must be in communication with the member’s CO as well as their own medical CO about the issue. Communication of medically necessary information among all parties facilitates decision-making and is an example of the crucial advisory role the MMO plays for the military CO.

Physical Profiles and Medical Evaluation Boards

The main tool for communicating medical limitations for a USM is the physical profile. While each service has unique ways of handling light duty, profiles, and subsequent referrals to medical evaluation boards (MEBs), each requires the MMO to communicate a USM’s medical readiness status to their respective CO (Table 30-2). All services use (to varying degrees) the physical profile serial system to analyze and “grade” the functions of various organs, systems, and integral body parts. This grading system has six factors, designated as “P-U-L-H-E-S,” in which each letter delineates a specific medical area (Table 30-3). All potential restrictions can impact promotion and the mission, and therefore must be used appropriately and judiciously.

Physical profiles can convey medically directed and recommended restrictions on duties, mobility status, and fitness participation and testing. Duty activities that are restricted are generally occupation-specific (lifting, carrying, jumping, etc) but can be general in nature because fitness is considered a core USM duty. Duty restrictions are usually attached to conditions that will resolve within 31 to 365 days (eg, ankle sprain, fractured bone). Mobility restrictions can impact deployments, permanent change of station moves, and temporary duty assignments. Mobility restrictions are generally recommended when specific diagnoses are made (eg, cancer, suicidal ideation, diabetes) and the workup of the condition is ongoing. Fitness restrictions can directly impact the USM’s ability to complete required physical fitness testing. Fitness restrictions may occur in conjunction with either a duty or mobility limitation (eg, a postoperative procedure). For each stated restriction in the written profile, the USM’s CO has ultimate authority for determining whether to accept or reject the recommendation.

MEBs are convened when a military member is diagnosed with a specific medical condition that could have a permanent or long-term impact on their ability to perform mission or duty requirements. MEBs can be initiated for either duty or mobility limitations, and must be considered with each limitation or recommended restriction. Each service has a separate process and threshold for carrying out an MEB, although each requires that the patient’s primary care manager complete a narrative summary that details all of the current medical issues and delineates their potential mission/duty impact. The USM’s CO is also required to write a letter determining the mission impact of the USM’s condition. The entire package is reviewed by an objective team of multidisciplinary professionals, who render the final decision. The decision results in one of three outcomes for the USM: (1) return to duty without restriction, (2) return to duty with defined restrictions, or (3) separate or medically retire from military service. Table 30-4 lists MEB and physical profile resources for each service.

Data Management

The DoD maintains multiple databases that track USM medical readiness. The Air Force currently uses the Aeromedical Services Information Management System (ASIMS), the Army uses the Medical Protection System (MEDPROS), and the Navy and Marine Corps utilize the Medical Readiness and Reporting System (MRRS). Table 30-5 lists the URL for each. All have the common goal of providing a CO a quick snapshot of the unit’s medical readiness. It is important for the MMO to be facile with entry and review of data in these repositories.

EXHIBIT 30-2

MILITARY MEDICAL OFFICER DEPLOYMENT CONCERNS FOR INDIVIDUAL DEPLOYERS

Immunization status

- Review and update all CDC-required immunizations

- Consider/give: smallpox and anthrax

- Consider other location-specific immunizations (eg, yellow fever)

Personal protection

- Appropriately-sized gas mask

- Two pairs of corrective lenses and gas mask inserts (if applicable)

- Consider anti-malarials

Location-specific occupational health issues

- Consider climate

- Consider specific health needs (electrical outlet, refrigeration, etc)

- Consider medications/immunizations

TABLE 30-4

MEDICAL EVALUATION BOARD AND PHYSICAL PROFILE REFERENCES

Service

Document

URL

Army

AR 40-501

https://armypubs.army.mil/epubs/DR_pubs/DR_a/
pdf/web/ARN3801_AR40-501_Web_FINAL.pdf

Navy

MANMED, Chapter 18

https://www.med.navy.mil/directives/Documents/NAVMED%
20P-117%20%28MANMED%29/MMDChapter18pdf

SECNAVINST 1850.4E

http://www.secnav.navy.mil/mra/CORB/Documents/
SECNAVINST-1850-4E.PDF

Air Force

AFI 10-203

https://www.afpc.af.mil/Portals/70/documents/
06_CAREER%20MANAGEMENT/03_Fitness%20Program/
Air%20Force%20Instruction%2010-203.pdf?ver=2018-08-22-115744-620

AFI 48-123

http://static.e-publishing.af.mil/production/1/af_sg/
publication/afi48-123/afi48-123.pdf

TABLE 30-5

MEDICAL READINESS DATABASES

Service

Database

Acronym

URL

Army

Medical Protection System

MEDPROS

https://medpros.mods.army.mil/MEDPROSNew/

Navy

Medical Readiness and Reporting System

MRRS

https://mrrs.sscno.nmci.navy.mil/mrrs/

Air Force

Aeromedical Services Information Management System

ASIMS

https://asims.afms.mil/webapp/Login.aspx

Deployment

Upon receipt of orders for a contingency deployment, the USM’s full record must be evaluated for medical readiness. All of the predeployment requirements listed above must be reviewed and completed in a timely and efficient manner, which will depend on how well the MMO has maintained an appropriate and correct database of information for each member of the unit. Ultimately, the MMO must medically “clear” each individual for deployment. Several key concerns for the MMO once deployment orders have been received are the USM’s immunization status, personal protection, and location-specific occupational health issues (Exhibit 30-2).

Required immunizations should be updated for each USM before deployment orders arrive, but current requirements for the deployment’s determined area of responsibility (AOR) should be reviewed. Two common immunizations in the current AOR that play a role in deployment preparation are smallpox and anthrax. Each USM must complete screening forms to determine medical eligibility for these immunizations, and the MMO is ultimately responsible for determining whether the member should be issued these critical immunizations predeployment or in the AOR. Additional immunizations may be necessary based on the specific AOR.

Personal protection is another key component of medical readiness. Anti-malarials are an example of chemoprophylaxis personal protection. In addition, all deploying members must be fitted for and then issued an appropriately sized gas mask prior to their departure for the AOR. This often is completed under the guidance of the MMO or the MMO’s designee. Dovetailing with gas mask fitting, the MMO must ensure that each member who requires vision correction has two pairs of corrective lenses (ie, eyeglasses; contact lenses are not allowed in the AOR) and gas mask inserts with the same prescription.

The MMO must also consider occupation-specific information about the AOR to enhance environmental medical readiness. While predeployment medical readiness covers many different aspects, specific AORs have unique prevention needs. Targets of prevention may include medications (anti-malarials) and immunizations (yellow fever). A USM’s individual health needs may also play a role. Certain health conditions may limit the USM’s ability to perform (including the need for electrical outlets for medical equipment, refrigeration of medications, etc). Additionally, understanding and preparing for the AOR’s climate can reduce climate-induced morbidity (heat or cold injuries).

Postdeployment

Postdeployment time focuses on reunion and readjustment for the USM. While many areas begin to overlap with the subsequent predeployment period, a major focus for the MMO after deployment is the Post-Deployment Health Re-Assessment Program (PDHRA). This program involves a sequenced process including member survey completion and face-to-face encounters immediately and at later intervals after redeployment home. The program’s main goal is determining whether any medical conditions or concerns developed during, or are related to, the deployment. The program also specifically targets significant concerns such as posttraumatic stress disorder (PTSD), TBI, and other environmental exposure issues. With appropriate evaluation, USMs can be rapidly and appropriately referred for further evaluation and treatment of any concerning condition.[14]

GUIDANCE TO COMMANDING OFFICER

The MMO should provide regularly scheduled updates about the unit’s medical readiness to the CO. Any deficiencies should be remedied, or at the very least, solutions provided as potential fixes. Expect the CO to demand 100% accountability for all medical readiness items, and anticipate that the CO will prevent USMs from taking leave or holiday time if the requirements are not met. Expectations are best managed with constant communication between the MMO and the CO.

SUMMARY

The MMO plays a crucial role in maintaining the medical readiness of each USM. It is imperative that the MMO work closely with the CO to facilitate rapid and efficient screening, evaluation, and treatment of each USM to ensure mission completion. Maintaining knowledge of the service-specific guidelines will enhance the USM’s medical readiness and help the DoD achieve the “Quadruple Aim.”

REFERENCES

1.   Institute for Healthcare Improvement. The Triple Aim: Optimizing health, care and cost. Healthc Exec. 2009;24:64–66.

2.   Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff. 2008;27(3):759–769. doi: 10.1377/hlthaff.27.3.759. PubMed PMID: 18474969.

3.   Office of the Under Secretary of Defense (Comptroller) Chief Financial Officer. Managing the Military Health System. In: United States Department of Defense Fiscal Year 2015 Budget Request Overview. Washington, DC: DoD; 2014: 5-8.

4.   O’Connor FG, Deuster PA, DeGroot DW, White DW. Medical and environmental fitness. Mil Med. 2010;175(8):57–64.

5.   STABLE National Coordinating Council Resource Toolkit Workgroup. Patient Health Questionnaire-2 (PHQ-2) overview. In: STABLE Resource Toolkit. Washington, DC: US Department of Health and Human Services; 2007. http://www.cqaimh.org/pdf/tool_phq2.pdf. Accessed March 8, 2018.

6.   Kane RL, Roebuck-Spencer T, Short P, Kabat M, Wilken J. Identifying and monitoring cognitive deficits in clinical populations using Automated Neuropsychological Assessment Metrics (ANAM) tests. Arch Clin Neuropsychol. 2007;22:115–126. doi: 10.1016/j.acn.2006.10.006.

7.   Rice V, Lindsay G, Overby C, et al. Automated Neuropsychological Assessment Metrics (ANAM) Traumatic Brain Injury (TBI): Human Factors Assessment. Aberdeen Proving Ground, MD: Army Research Laboratory; 2011.

8.   Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Military Acute Concussion Evaluation (MACE) pocket card. Defense and Veterans Brain Injury Center: Silver Spring, Maryland; 2012. https://dvbic.dcoe.mil/files/resources/DVBIC_Military-Acute-Concussion-Evaluation_Pocket-Card. Accessed January 16, 2018.

9.   US Preventive Services Task Force. Recommendations for primary care practice. Updated September 2017. http://www.uspreventiveservicestaskforce.org/Page/Name/recommendations. Accessed September 28, 2017.

10.   US Department of Defense. DoD Nuclear Weapons Personnel Reliability Assurance. Washington, DC: DoD; 2016. DoD Instruction 5210.42.

11.   US Department of Health and Human Services. Community immunity (“herd immunity”). Vaccines.gov. http://www.vaccines.gov/basics/protection/. Updated May 11, 2017. Accessed September 28, 2017.

12.   US Centers for Disease Control and Prevention. Immunization schedules. http://www.cdc.gov/vaccines/schedules/. Updated February 6, 2017. Accessed September 28, 2017.

13.   Motivational Interviewing Network of Trainers website. http://www.motivationalinterviewing.org/. Published 2017. Accessed September 28, 2017.

14.   US Department of Defense Post-Deployment Health Reassessment. DoD Deployment Health Clinical Center website. http://www.pdhealth.mil/dcs/pdhra.asp. Accessed September 29, 2017.

Chapter 31

REHABILITATION AND REINTEGRATION

OLUWASEYI GBADE-ALABI, MD,* AND PAUL PASQUINA, MD†

INTRODUCTION

HISTORY OF REHABILITATION IN THE MILITARY

RECENT CHALLENGES IN COMBAT CASUALTY REHABILTIATION

ELEMENTS OF MILITARY REHABILITATION

Acute Care

Home Care

Sports and Recreation

Nonprofit Organizations

ROLE OF THE MILITARY MEDICAL OFFICER

REHABILITATION TEAM MEMBERS AND ROLES

GUIDANCE TO THE COMMANDING OFFICER

SUMMARY

*Major, Medical Corps, US Army; Chief, Inpatient Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland

†Professor and Chair, Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Chief, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland

INTRODUCTION

Military medical officers (MMOs) must not only recognize the importance of optimizing human performance in preparing service members for deployment and mission success, but they must also be prepared to provide high quality of care for those injured in the line of duty. Combat casualty care and maintaining military readiness are fundamental functions of the Military Healthcare System (MHS) and are uniquely interconnected. Providing life- and limb-saving care on the battlefield directly impacts a unit’s combat effectiveness. Service members who are confident they will receive the best medical care in the event of an injury are far more likely to be willing to put their lives in harm’s way. The same holds true for their families and the American public who support them back home. They trust that if a service member is injured in the line of duty, they will receive state-of-the-art comprehensive care, ranging from life-saving procedures to advanced rehabilitation. MMOs must not only recognize and respect this trust, but be committed to dedicating their professional careers to honor this trust through activities such as life-long learning and skills acquisition; promoting injury prevention and wellness; and improving access and efficiency of care delivery.

While significant emphasis in military medicine is centered on acute combat casualty care, saving lives is only the first step to “restoring” life after severe injury. To provide comprehensive care across the spectrum of care within the MHS, the military has generally divided its medical support of combat missions into five levels of care (Table 31-1).[1] Rehabilitation practices typically occur from Role 3 through Role 5.

This chapter provides an overview of rehabilitative and reintegration practices utilized within the MHS to care for combat casualties. The reader should come to understand the complicated course of recovery that faces the modern military casualty; the terms and definitions commonly used within the field of rehabilitation (Table 31-2); the roles and responsibilities of the specialists who commonly make up the interdisciplinary rehabilitative treatment team; and the role of the MMO in the successful rehabilitation and reintegration of the modern combat casualty.

TABLE 31-1

MILITARY ROLES OF CARE

Role

Location

Medical Assets

Goals

Roles 1 and 2

Mobile medical assets deployed within the military theater of operation

1. Immediate first-responder care: self-aid, buddy aid, combat lifesaver

2. Combat medic/corpsman (trained in combat casualty care)

1. Resuscitation

2. Stabilization

3. Coordination of rapid air or ground evacuation to Role 3 facility

Role 3 (combat support hospital)

Mobile facility; highest level of medical and surgical care available within the military theater of operations

1. Mobile surgical teams

2. Lab

3. Radiology

1. Perform life- and limb-saving interventions

2. Further stabilization

3. Transfer to a Role 4 facility

Role 4

Fixed medical facility outside the continental United States (OCONUS)

Advanced surgical and medical intensive care interventions

Further stabilization prior to evacuation to Role 5 for definitive care

Role 5

Fixed medical facility within the continental United States (CONUS)

1. Interdisciplinary team of medical and surgical specialists

2. Greater capacity for more protracted and comprehensive care

1. Provide definitive medical and surgical interventions

2. Address behavioral health needs

3. Comprehensive rehabilitative care

TABLE 31-2

COMMONLY USED REHABILITATION DEFINITIONS

Term

Definition

Activities of daily living (ADLs)

Activities required for personal care including feeding, dressing, grooming, bathing, and toileting.

Assistive technology

Any item, piece of equipment, or product, whether it is acquired commercially, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of individuals with disabilities. Common examples are crutches, prosthetics, orthotics, wheelchairs, hearing aids, canes, magnifiers, communication boards, speech synthesizers, and talking books.

Disability

According to the World Health Organization, the term “disability” relates more to one’s functional status within society than to any specific diagnosis or physical, cognitive, or emotional impairment. The ICF defines disability within a bio-psycho-social model in which disability arises from the interaction of health conditions with contextual factors—environment and personal factors. Therefore, disability is a complex, dynamic, multidimensional state that depends on both an individual’s capacity and their performance within a contextual environment. For example, an individual with an ankle fracture who cannot bear their weight and does not have crutches, a wheelchair, or other means of supporting independent mobility, may be more “disabled” than an individual with bilateral lower limb amputations who is independent in community ambulation using lower limb prosthetics.

Handicap

A disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfillment of a role that is normal for that individual.

Impairment

Problems in body function or alterations in body structure, for example, paralysis or blindness. Impairments may be static or dynamic in a progressive or diminishing manner (eg, cognitive functional impairment may improve over time after a brain injury, or may decline with various forms of dementia).

Instrumental activities of daily living (IADLs)

Complex tasks required for independent living in the immediate environment such as care of others in the household, telephone use, meal preparation, house cleaning, laundry, and in some cases use of public transportation.

Orthotics

Externally applied devices to restrict movement, enhance function, or protect a body part. Commonly referred to as braces or splints, orthotics are more accurately defined by the body parts they support (eg, knee orthotics, foot orthotics, spine orthotics, wrist-hand orthotics, ankle-foot orthotics).

Participation

An individual’s capacity and performance in interacting with society, whether that be within a family, work environment, or community. According to the ICF, participation restrictions are problems that may involve any area of life, for example, facing discrimination in employment, barriers to transportation, or even lack of awareness or access to programs.

Prosthetics

An artificial body part, to replace a missing extremity or other body part. Prosthetic limbs are generally composed of a socket (interface between the residual limb and device); joint (knee, elbow, wrist, etc); terminal device (hand, foot); control system; and suspension. Numerous prosthetic devices currently exist. Common devices include microprocessor knees, which have built-in sensors that automatically adjust knee flexion/extension resistance depending on the user’s speed of walking; energy-storing feet, which are composed of deformable materials that, when compressed through weight bearing, recoil to provide simulated “push-off” during walking or running; myoelectric prosthetics, which are externally powered, motorized (robotic-like) upper limb devices controlled by skin sensors that pick up electrical activity from the contraction of the residual limb muscles below them; body-powered prosthetics, which are upper limb prosthetics with cable systems attached to a harness around the user’s shoulders, so that excursion of the cable causes a terminal hand or hook device to open or close.

Rehabilitation

Programs or processes for returning an individual to health after an injury, illness, or addiction.

Rehabilitative medicine

Field of medicine focused on the evaluation, diagnosis, and management of individuals of all ages with a physical and/or cognitive impairment to maximize recovery and quality of life.

ICF: International Classification of Functioning, Disability and Health

HISTORY OF REHABILITATION IN THE MILITARY

Although the medical specialty of physical medicine and rehabilitation (PM&R) is relatively young, the principles of rehabilitation date back to ancient Chinese medicine, when physical movement training called “Cong fu” was used to relieve pain, and to 5th century BCE Greece, where physicians described an elaborate system of gymnastic exercises for the treatment of disease.[2] In the United States, rehabilitation centers grew significantly during the polio epidemic during the early 1900s, and gained international attention when president Franklin Delano Roosevelt, after suffering from lower limb paralysis as a result of polio, spent time learning how to walk at a unique facility in Warm Springs, Georgia. His personal success inspired him to purchase and expand the facility, which is believed to be the first such place in the country to specifically provide rehabilitative care.[3]

Military conflict has also provided a catalyst for the advancement for rehabilitative care. This was especially true during World War II, when improved lifesaving medical and surgical care resulted in a significant number of soldiers surviving wounds that would previously have been fatal. Their return home with loss of limb, paralysis, and other physical impairments necessitated more comprehensive rehabilitative care. In response, the US military established the US Army Air Forces Convalescent Training program in 1942, which was headed by Dr Howard Rusk (considered the “father of comprehensive rehabilitative care”). These programs began to incorporate individualized physical, neuropsychological, and occupational-social therapies.[4] With the success of these programs and their ability to help severely wounded soldiers return to active participants in society, Congress provided additional funding to the Army for further training and research in the field of PM&R.

Following the conflict in Vietnam, “rehabilitative” care was largely considered the function of the Department of Veterans Affairs; however, lessons learned during Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn indicated a continued need for the Department of Defense and MHS to maintain competence and capacity in providing comprehensive rehabilitative care.

RECENT CHALLENGES IN COMBAT CASUALTY REHABILTIATION

Over the past decade, significant advances have been made in the acute resuscitative trauma care of combat casualties, resulting in historically high survival rates.5,6 Mortality rates have decreased from approximately 24% in the Vietnam conflict to less than 20% in OIF/OEF.[7] Survival on the battlefield, however, is just the first step. The MHS must remain committed not just to helping service members “survive” after injury, but also to “thrive” during their recovery and return to active participation in society. These goals have been especially challenging in recent years, especially for combat casualties with complex blast-related injuries, which are frequently associated with severe physical, emotional, and cognitive impairment. Injuries such as extremity trauma, limb loss, paralysis, traumatic brain injury (TBI), and vision and hearing impairment are frequently associated with blast, and are often complicated by complex pain, infection, and psychological injury, including depression, anxiety, and posttraumatic stress disorder (PTSD). Whether these injuries occur in isolation or in combination, they require not only specialized acute medical, surgical, and behavioral health interventions, but also a well-coordinated and integrated holistic rehabilitation plan.

The distinct injury patterns associated with high-energy weaponry and blast are not commonly seen in the civilian medical world; therefore, MMOs must understand the unique challenges they present when caring for today’s wounded warrior. Although a discussion of the various degrees of blast injury (primary, secondary, tertiary, quaternary) and comprehensive polytrauma care is beyond the scope of this chapter, it is important to recognize that because of the advances in body armor, rapid medical support, and improved resuscitation techniques, service members are now surviving wounds that in the past would have been fatal. This has increased the demands for and complexity of the rehabilitative care required by this unique patient population.8,9

ELEMENTS OF MILITARY REHABILITATION

Rehabilitative efforts are largely accomplished through the work of an interdisciplinary team of specialists, representing a multitude of disciplines and employing an array of interventions, modalities, and assistive technologies to help maximize functional independence and successful reintegration or participation in society. Fundamental to the rehabilitative team are the patient and their family, who help the clinical team establish meaningful short-term and long-term goals, which are incorporated into an individualized treatment plan that accommodates the unique challenges and characteristics of each patient. While these principles are commonly practiced by physicians who specialize in PM&R (physiatrists), as well as other rehabilitation specialties (physical therapy, occupational therapy, etc), all MMOs must be familiar with these concepts and implement them as early and aggressively as possible when caring for combat casualties.

It is through rehabilitation and the restoration of functional independence that many individuals regain dignity and even discover personal growth, which can often propel them to discover new meaning and purpose in their lives. Ultimately, rehabilitative efforts are not limited to achieving independence or providing adaptive strategies to promote daily functional activities; these efforts also promote the patients’ highest quality of life, successful reintegration, and active participation in their families and society.

Acute Care

In addition to acute life- and limb-saving surgical and medical interventions, rehabilitation principles must also be applied as early as possible in the care of service members with combat injuries to ensure optimal outcomes. Failure to aggressively initiate comprehensive rehabilitative practices in the acute stage of caring for combat casualties leads to worsening secondary complications and poorer outcomes. The negative consequences of immobility, poor skin care, lack of appropriate bowel and bladder management, and delay in teaching independence in feeding, bathing, dressing, and communicating, may not only lead to multiple setbacks during the recovery process, but also have devastating negative effects on the physical and emotional well-being of service members, especially those with devastating wounds. Furthermore, the appropriate prescription of prosthetics (eg, artificial legs, arms, hands), assistive technology (eg, wheelchairs, communication tools, environmental control devices), and other rehabilitative interventions will likely help decrease pain, reduce anxiety, and promote earlier mobility and independence. Early rehabilitation practices typically start with patient and family education, as well as mitigation practices to reduce the risk of pressure sores, venous thromboses, joint contractures, osteopenia, muscle atrophy, urinary tract infections, bowel dysfunction, and cardiovascular deconditioning.10,11

Immobility during the acute phase of care is likely to lead to multiple secondary complications. Muscle disuse atrophy, osteopenia and osteoporosis, contractures and decubitus ulcers, significant fluid/volume shunting and orthostatic hypotension, decreased respiratory capacity, and increased risk for infection may result from prolonged bed rest and immobility.12–14 (A further description of some of these conditions is provided in Table 31-3.) Promoting early bed mobility, frequent skin pressure reliefs, passive and assistive range-of-motion exercises, and early weight-bearing and ambulation with or without a prosthesis, orthosis, or assistive device can help prevent contractures, bone loss, skin breakdown, and significant muscle atrophy or cardiovascular deconditioning.

A comprehensive discussion of all the complications associated with blast trauma is beyond the scope of this chapter, but certain conditions, such as heterotopic ossification, venous thromboembolic events, pain, sleep disturbance, and behavioral health problems warrant recognition by all MMOs because of the frequency of their occurrence as well as their implications for successful rehabilitation and reintegration. Table 31-4 provides a brief discussion of these unique complications and methods to mitigate and treat them.

Home Care

After discharge from the hospital, the injured service member will transition to outpatient care, either at home or utilizing base lodging associated with the nearest military medical treatment facility. Rehabilitation care continues to play a significant role during this period, as patients continue to recover from their wounds. Outpatient physical and occupational therapists, along with speech language pathologists and neuropsychologists, continue to challenge patients with new therapeutic interventions, such as targeted stretching, strengthening, and conditioning; dexterity skills training; proper utilization of assistive technology; and advanced cognitive and communication skills to achieve new goals for improved independence and higher functioning. Specialized providers in orthotics and prosthetics also refine the design and fit of these devices to maximize individual functional use. Throughout the outpatient rehabilitation process, patient and family education remains critically important not only to help modulate realistic expectations, but also to reinforce independent strategies and therapeutic training at home.

In-home therapeutic care (eg, nursing, therapies, case management), as well as home modifications, should also be considered for patients with persistent functional impairments. Architectural home modifications, such as enlarging doorways or installing ramps to accommodate wheelchair use, handrails to prevent falls, and benches in showers or elevated toilet seats, are some examples of common modifications. The installment and cost of making such modifications are often provided with support from sources such as the Department of Veterans Affairs grant programs and nonprofit organizations (NPOs).[15]

TABLE 31-3

COMPLICATIONS ASSOCIATED WITH IMOBILITY

Complications

Background

Assessment/Treatment

Muscle atrophy

Muscle loss, also called disuse atrophy, occurs at a rate of 1%–3% per day with prolonged immobility, and is more severe in patients with concurrent spinal cord injury. It affects all skeletal muscle, including the diaphragm, which may lead to hypoventilation and other respiratory concerns.

Early involvement by the PT/OT and rehabilitation team to assess. Encourage out-of-bed activity, assisted moves from bed to chair, and utilization of support modalities. Minimization of pain and ability for weight-bearing may require consultation with primary surgical/inpatient team.

Osteopenia/osteoporosis

Decreased mechanical and muscle stress on bones causes a decrease in bone formation and an increase in bone reabsorption.

Radiographic evidence of bone loss, coupled with a bone mineral density scan, can support the diagnosis of osteopenia/osteoporosis. Prevention is preferred; early activity to prevent muscle atrophy can also help prevent osteopenia/osteoporosis due to increased mechanical stress on bones. Supplementation with bisphosphonates, oral calcium, and vitamin D may also help.

Contractures

Decreased movement may alter the physical architecture of muscles and connective tissue around joints, leading to arthrogenic or myogenic contractures. These significantly limit range of motion, function, and mobility.

Frequent range-of-motion activities and functional movements can prevent their formation. Treatment includes heat therapy, passive stretching and range-of-motion exercise, casting or splinting of limbs, or in extreme cases, surgical intervention.

Fluid shifts/orthostatic hypotension

Passive fluid shift from the lower extremities to the heart increases the preload on the heart, stimulating release of atrial natriuretic peptide and increased net water and salt loss. A lower total body volume causes a reduction in heart load and blood volume (causing secondary cardiomyocyte atrophy). Coupled with an autonomic dysfunction, patients may be more prone to orthostatic hypotension.

Monitor daily patient fluid volume intake and losses. Encourage out-of-bed activity and upright positioning. Use special care to prevent falls when patients are performing transfers and moving from a supine position.

Decubitus (pressure) ulcers

Excessive, unrelieved pressure causes capillary compression and ischemia, which promote skin breakdown and ulceration. This generally occurs in paralyzed, insensate, or cognitively impaired patients. Risk of ulceration is increased with wet or macerated skin and friction injuries. Bony prominences, including at the heels, elbow, sacrum, and occiput, are most at risk while patients are supine; ischial tuberosities are at greater risk with prolonged unprotected seating.

Appropriate staging of the ulcer is important because it guides appropriate treatment and prevention procedures. The National Pressure Ulcer Advisory Panel, among others, provides staging and treatment guidelines. Preventing infection is important because pressure ulcers can be a nidus for bacterial colonization. Padding at risk areas is insufficient. Frequent turning while in bed or pressure relief while seating are fundamental to appropriate prevention and care. Specialized beds should be considered for all patients requiring prolonged bedrest.

PT/OT: physical therapy and occupational therapy

Driving rehabilitation and motor vehicle adaptions should also be considered as part of the comprehensive rehabilitation program, because driving independence is also very important for the quality of life of most wounded warriors. For complex injury patients with TBI, driving independence may present significant challenges because it requires complex cognitive effort, while also performing multiple other simultaneous tasks. Because of the inherent risks in driving, driving simulators may be used to help assess a patient’s capabilities, while also providing a meaningful and engaging activity to supplement cognitive rehabilitation.[16] Demonstration of successful use of a driving simulation platform may then lead to progression to on-road training with greater confidence.

Sports and Recreation

Participation in sports and physical activity has also been shown to significantly improve multiple aspects of the patient’s health; in addition to the physical benefits, patient outlook, social interactions, self-perception, and goal-oriented behaviors are also improved.[17] Sports and activity can also help patients cope with the stresses of dealing with their new disabilities. A measure of control over their own health and well-being is gained by actively participating in these activities. Additionally, these activities may boost self-confidence, demonstrate what the patients can still accomplish despite their disability, and improve overall quality of life.[18] Studies of recreational and leisure activities have shown specific reduction in symptoms of PTSD—hyperarousal, avoidance, and perseverance of thoughts surrounding traumatic events.[19]

Recreational/motivational therapists are particularly well suited to developing safe, interactive experiences for the rehabilitating patient and can provide an important ongoing link between hospital ward care and the transition home. In addition to organizing and executing group and individual sports and recreational activities, these therapists develop strong rapport with their patients and provide psychological support for the recovering combat casualty.

Expressive arts can also play an important role in the recovery of the wounded warrior. In addition to the positive effects of engagement with a self-driven task that can provide a level of personal achievement and encourage creative methods of expression, the arts can serve to positively affect the recovery of the patient and serve as a contribution to their community—an effective route of reintegration.[20] There is some evidence that self-expression through art may help patients better cope with symptoms of PTSD, depression, and TBI.[21]

Nonprofit Organizations

In recent years, a multitude of NPOs have mobilized to assist wounded warriors and their families. These organizations offer services ranging from exclusive retreats, recreational outings, and athletic events, to helping retrofit or build custom disability-friendly homes. Some NPOs purchase and customize adaptive vehicles, while others provide much needed assistance with vocational internships, peer mentoring, or coaching. Finally, some NPOs provide financial assistance to families for lodging, travel, or equipment. Not only do these organizations provide direct assistance to wounded veterans, but they also greatly increase public awareness of many of the challenges wounded warriors face when reintegrating back into society after injury. Their impact on the public, public officials, and the media all help boost community support for veterans, and should therefore be generally embraced by the rehabilitation community.

ROLE OF THE MILITARY MEDICAL OFFICER

The MMO is the primary medical resource for the unit commander. The MMO provides recommendations regarding in-garrison medical care and maintenance of a capable and healthy unit; identifies and provides preventative medical care for deploying units based on anticipated and actual medical and environmental threats in the deploying location; supports the training of assigned medical resources; and provides medical care to the members of the unit and their families. In regard to rehabilitation, the MMO is responsible for maximizing the functionality of the unit through effective and well-planned medical care that accounts for effective pain management, functional therapies, and supportive methods to reintegrate the injured service member back into their community. Rehabilitation specialists represent a wealth of knowledge and expertise; therefore, MMOs must be aware of their presence and experience in order to maximize their mission success.

REHABILITATION TEAM MEMBERS AND ROLES

Rehabilitative medicine takes a team approach that starts during the acute phases of combat casualty care, as previously described. Inpatient teams most frequently include physiatry, physical, occupational, and recreational therapists; dietitians; social workers; rehabilitation counselors; and speech language pathologists, case managers, prosthetists, and orthotists. After discharge, patient care continues with outpatient physical and occupational therapy, driving rehabilitation, recreational/motivational therapy, and music/art therapy. Continued medical care and follow-up, even after the patient has returned to duty or to their community, is key to successful reintegration. The various team members who play prominent roles in rehabilitation are listed in Table 31-5.

TABLE 31-4

UNIQUE SECONDARY COMPLICATIONS FROM HIGH-ENERGY TRAUMA

Complication

Functional Assessment

Treatment

Heterotopic ossification (HO): the inappropriate growth of bone within soft tissue

Most often found in hip, elbow, shoulder, and knee. Up to 80% of traumatic amputations may develop HO in the residual limb. Clinical signs include decreased ROM of the involved limb, erythema, and local swelling. HO may take weeks to be detected by traditional radiograph^1; appropriate diagnosis requires the exclusion of other conditions such as infection, deep venous thrombosis, or hematoma. Bone scans and serum alkaline phosphatase levels may aid diagnosis.

ROM exercises are the principal means of prevention and treatment. NSAIDs have been shown to reduce the incidence of HO by two- to three-fold.2 Another option includes the use of etidronate, which blocks the formation of the bone matrix. Surgical excision of HO is generally advised only for fully mature HO.3 Early surgical excision may also be successful, although if performed too early, HO is likely to recur, especially without initiating prophylactic measures after excision.4

Venous thromboembolic events (VTE): includes deep venous thrombosis (DVT) and pulmonary embolism (PE)

Symptoms of DVT include swelling, localized pain, erythema, and warmth; symptoms of PE include tachycardia, dyspnea, and chest pain. Diagnosis of VTE may be challenging for patients with impaired consciousness, lack of sensation, or paralysis, and may be aided by a D-dimer blood test or lung ventilation-perfusion scan; confirmatory diagnosis is achieved through duplex ultrasound or computed tomography scan with pulmonary angiography.

Treatment of VTE begins with prevention. Typical guidelines call for pharmacological anticoagulation within 72 hours of injury; appropriate agents are low molecular weight heparin or adjusted dose unfractionated heparin. Sequential compressive devices or compression hose may also reduce risk. Surgical placement of an intravena cava filter may also be effective. Ultimately, early mobility and return to regular function are paramount to reducing the risk of VTE formation.

Behavioral/mental health: includes posttraumatic stress disorder, depression, and anxiety

Symptoms may manifest as sleep disturbance, poor nutrition, decreased interest, and feelings of depression. A variety of questionnaires have been developed to better detect these injuries and diseases.5,6

Treatment ranges from counseling to peer support groups, cognitive behavioral therapy, and pharmacological treatments. The behavioral therapy team should be involved early in the care of the patient to identify concerns as soon as possible.

Delirium: acute mental status change over a period of hours to a few days

Significant for trauma patients, who may resume consciousness in an unfamiliar hospital setting with little to no recall of events. Causative factors, including urinary tract infection, occult infection, drug interactions, inadequate pain control, dehydration, electrolyte abnormalities, and impaired glycemic control, should be identified.

Maintain a consistent treatment team, decorate room with familiar items, and minimize loud noises and bright lights. In acute cases, a 24-hour sitter may be needed to prevent self-harm, such as accidental extubation, inappropriate removal of IV lines, and accidental falls. Use of prophylactic antipsychotic medications for delirium has shown mixed results; these medications, along with physical restraints for agitated patients, should be used as last resort.7

Pain

Recent reports suggest that even with newly published TCCC guidelines, fewer than half of casualties are adequately treated for their pain.8 Multiple sources of pain may exist for a polytrauma patient. For comatose patients, who are unable to express their pain verbally, providers should monitor for surrogate signs of pain, such as tachycardia, tachypnea, hypertension, and facial grimaces.

Common medications for pain management include NSAIDs, opioids (IV, IO, IM, and oral transmucosal “lollipop” forms), and ketamine.9 Multimodal forms of pain management include adjuvant pharmacological agents, such as antidepressant and anticonvulsive medications, as well as PCA systems and regional blocks with peripheral catheters. Alternative methods include music therapy, self-hypnosis, acupuncture, thermal modalities, and TENS. Emerging evidence supports immersion virtual reality for chronic and acute pain.10,11

IM: intramuscular; IO: intraosseous; IV: intravenous; NSAID: nonsteroidal antiinflammatory drug; PCA: patient-controlled analgesia; ROM: range of motion; TCCC: Tactical Combat Casualty Care; TENS: transcutaneous electrical stimulation

(1) Perosky J, Peterson J, Eboda O, Morris M, Wang S, Levi B et al. Early detection of heterotopic ossification using near-infrared optical imaging reveals dynamic turnover and progression of mineralization following Achilles tenotomy and burn injury. J Orthop Res. 2014;32(11):1416-1423. (2) Banovac K, Sherman A, Estores I, Banovac F. Prevention and treatment of heterotopic ossification after spinal cord injury. J Spinal Cord Med. 2004;27(4):376–382. (3) Potter BK, Forsberg JA, Davis TA, et al. Heterotopic ossification following combat-related trauma. J Bone Joint Surg Am. 2010;92(Suppl 2):74–89. (4) Teasell R, Mehta S, Aubut J, et al. A systematic review of the therapeutic interventions for heterotopic ossification after spinal cord injury. Spinal Cord. 2010;48(7):512–521. (5) McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-item short-form health survey (SF-36): II, psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993;31(3):247–263. (6) US Department of Veterans Affairs. PTSD: National Center for PTSD: PTSD screening instruments. VA website. https://www.ptsd.va.gov/professional/assessment/screens/index.asp. Accessed June 14, 2018. (7) Friese RS, Diaz-Arrastia R, McBride D, Frankel H, Gentilello LM. Quantity and quality of sleep in the surgical intensive care unit: are our patients sleeping? J Trauma. 2007;63(3):1210–1214. (8) Schauer SG, Robinson JB, Mabry RL, Howard JT. Battlefield analgesia: TCCC guidelines are not being followed. J Spec Oper Med. 2015;15(1):85–89. (9) Kotwal R, Butler F, Edgar E, Shackelford S, Bennett D, Bailey J. Saving lives on the battlefield: a Joint Trauma System review of pre-hospital trauma care in combined joint operating area Afghanistan (CJOA-A) executive summary. J Spec Oper Med. 2013;13(1):77–85. (10) Hoffman HG, Richards TL, Coda B, A et al. Modulation of thermal pain-related brain activity with virtual reality: evidence from fMRI. Neuroreport. 2004;15(8):1245–1248. (11) Wiederhold B, Soomro A, Riva G, Wiederhold Md. Future directions: advances and implications of virtual environments designed for pain management. Cyberpsychol Behav Soc Netw. 2014;17(6):414–422.

After injury, regardless of the severity, the MMO serves as a guide to help prepare the recovering service member to return to duty, reintegrate back into their community, or both. While many team members with important roles contribute significantly to the service member’s recovery (see Table 31-5), it is the MMO who is responsible for coordinating the collective efforts of the team.

The MMO must also balance medical care and recovery with the needs of the unit and the goals of the unit commanding officer (CO). If the service member intends to return to duty, the MMO should provide a reasonable timetable for their return. The MMO must make it clear to the CO that continued therapy and rehabilitative activities may be necessary even after the service member has returned to the unit. Continued pain management may also be required, and reasonable expectations of the person’s capabilities should be given to the CO.

A unique consideration in military service is the regular participation in physical training (PT). Unlike most civilian occupations, all military members are expected to participate in PT regularly and complete biannual physical fitness testing to demonstrate their continued physical fitness. After injury, the returning service member should be careful in their reintroduction to PT and may require modifications to their training schedules. The MMO serves as a primary liaison between the command staff and service member, balancing the recovery and rehabilitation needs of the patient and encouraging a reasonable timetable for return to duty and personal responsibilities.

As a physician, the goal is to treat the patient in their entirety. In the civilian world, this often means the inclusion of family, educating and encouraging the active participation of family members in supporting and helping the patient adjust to their new reality as they heal. In the military, particularly in combat units that have deployed together, unit members are often akin to family. With patient permission (whenever possible), unit members should be encouraged to visit the patient and provide another source of support. Additionally, peer support groups with other injured service members can be useful in early resocialization and aid the mental aspect of the healing process.

GUIDANCE TO THE COMMANDING OFFICER

The CO, and combat/line staff in general, are tasked with achieving their missions as successfully as possible. While in an ideal world this includes maximal damage to the enemy and no loss of life or limb to their own troops, reality dictates that more often than not, one or more of their soldiers will be injured in the line of duty. The dangers and mishaps of life do not stop at the operation, however; injuries may also occur while in garrison and during training, and even during leave.

It is the MMO’s duty to make the CO aware of the possibility of injury, recommend steps to minimize risk of injury and medical problems, and treat those that arise and return the patients to duty as soon as possible. Some injured service members may never be able to return to duty in the same way as before their injury; this must also be communicated to the CO. The MMO should be realistic in recommending times for patient recovery, but also keep in mind the needs of the unit. Even after the service member returns to the unit, further therapy may be needed; the MMO should make those expectations known to the CO as soon as possible, clearly outline the plans for rehabilitation and therapy, and convey the possible limitations that might delay return to duty.

TABLE 31-5

MEMBERS OF THE REHABILITATION TEAM

Team Member

Role

Physiatrist

Board certified in physical medicine and rehabilitation. Physiatrists provide physician leadership to interdisciplinary rehabilitation teams focused on functional restoration, adaptive interventions, goal-directed therapy, and improved quality of life.

Physical therapist (PT)

Credentialed providers trained in the evaluation of the patient’s physical limitations. PTs develop and apply therapeutic interventions to enhance mobility and function. PTs are trained in the appropriate use of specialized assistive technology and equipment, such as bedside commodes, crutches, canes, walkers, prosthetics.

Occupational therapist (OT)

Credentialed providers trained to assess patients for functional and cognitive deficits, particularly those related to performing ADLs and IADLs. OTs design upper limb prosthetics and orthotics; conduct driving rehabilitation, recreational therapy, and return to vocation training; also work with patients on problem-solving as well as fine-motor skill development.

Speech language pathologist (SLP)

Credentialed providers trained in the assessment and treatment of speech and communicative dysfunction and swallowing impairments; therapy sessions include breaking down the elements of speech and cognition, language processing, and listening; also assess need for special communication assistive devices.

Certified prosthetist and orthotist (CPO)

Non-credentialed but certified specialists who fabricate and fit artificial limbs (prosthetics) or braces/splints (orthotics).

Assistive technology professional (ATP)

Non-credentialed providers/consultants with specialized certification in the assessment of individuals with disabilities to help identify, fit, train, and modify various assistive devices to support independence and function (eg, manual and motorized wheelchairs; high- or low-tech devices to support visual, hearing, cognitive, or communicative impairments).

Case manager (CM)

Credentialed nurses or social workers who coordinate comprehensive care plans for patients receiving services from a variety of providers. Case managers also serve as critical liaisons between the patient and treatment team as well as third parties (eg, insurance companies, healthcare administrators, equipment companies). Frequently knowledgeable about various nonprofit organizations or other veteran service organizations that help service members and families in need.

Rehabilitation psychologist

Credentialed providers who provide specialized assessments and counseling to patients and families in support of adjustment to hospitalization and disability.

Neuropsychologist

Credentialed providers trained in assessing all parameters of cognitive function (eg, attention, memory, problem-solving skills, language skills, executive function) as well as the links between brain injury, brain functioning, and behavior; especially qualified to engage patients in cognitive rehabilitation.

Vocational rehabilitation specialist

Noncredentialed providers trained in assessing and counseling patients on return to education or employment; help develop reasonable goals and trouble-shoot potential barriers in the school or workplace.

Driving rehabilitation specialist

May be credentialed or non-credentialed. Skilled in training and testing individuals with disabilities in an “on-road” training environment and assessing for appropriate adaptive vehicle mechanisms.

Recreational/motivational specialist

May be credentialed or non-credentialed. Assist patients and families in applying skills learned in rehabilitation to activities that support personal growth and active community participation; promote development of self-confidence and comfort in social situations both at home and in the community, organize group and individual activities to practice skills and develop strategies to nurture friendships and social networks, and assist patients in finding new areas of interest as well as new ways to pursue old interests through adaptations.

Music/art therapist

Frequently non-credentialed but have specialized training in facilitating recovery through the application of music and art modalities. Art of all forms (visual, performance, writing, music, etc) may have a therapeutic effect on many neurological and psychological conditions.

Social worker

Credentialed providers who work with the patient and their family, assisting them in identifying care and transition needs to ensure a smooth and safe discharge; evaluate their support system and home needs; access community resources such as financial entitlements, home care, and transportation; provide information about other types of care.

Registered dietitian nutritionist (RDN)

Credentialed specialists in patient diet and nutrition. Support the care team by diagnosing and prescribing an individualized diet to meet the patient’s needs based on their medical problems and goals. RDNs contribute a critical part in the patient’s recovery and reintegration by supporting a healthy lifestyle and diet.

ADLs: activities of daily living; IADLs: instrumental activities of daily living

The MMO should also recommend to the CO that other unit members be encouraged (as operational tempo allows) to visit with injured unit members when possible in order to provide support and encouragement. Keeping an injured member who is healing connected with their unit can be another way of providing motivation in their rehabilitative process and keep them feeling like a part of their squad.

SUMMARY

Rehabilitation plays an important role in the return to duty and social reintegration of service members following injury, particularly blast-related trauma. While acute life- and limb-saving techniques may preserve the life of an individual, it is rehabilitation that preserves the function of that individual. When the entire rehabilitation team is utilized by the well-informed MMO, the chances of successful reintegration as a contributing member of society, including the possible return to duty, are significantly increased. MMOs can take advantage of the resources and structure present in the MHS to maximize the care rendered. They also serve as a unique and important liaison between the patient and their CO. MMOs must be clear and concise in their communication, promote a healthy balance between the mission and individual health and well-being, and always stand as an advocate for their patients.

REFERENCES

1.   Clarke JE, Davis PR. Medical evacuation and triage of combat casualties in Helmand Province, Afghanistan: October 2010–April 2011. Mil Med. 2012;177(11):1261–1266.

2.   Atanelov L, Stiens SA, Young MA. History of physical medicine and rehabilitation and its ethical dimensions. AMA J Ethics. 2015;17:568–574.

3.   Verville RE, Ditunno JF Jr. Franklin Delano Roosevelt, polio, and the Warm Springs experiment: its impact on physical medicine and rehabilitation. PM R. 2013;5(1):3–8.

4.   Conti AA. Western medical rehabilitation through time: a historical and epistemological review. Sci World J. 2014;Jan:1–5. doi: 10.1155/2014/432506.

5.   Gerhardt RT, De Lorenzo RA, Oliver J, Holcomb JB, Pfaff JA. Out-of-hospital combat casualty care in the current war in Iraq. Ann Emerg Med. 2009;53(2):169–174.

6.   Ling GS, Rhee P, Ecklund JM. Surgical innovations arising from the Iraq and Afghanistan wars. Annu Rev Med. 2010;61(1):457–468.

7.   Reiber GE, McFarland LV, Hubbard S, et al. Service members and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: Survey methods, participants, and summary findings. J Rehabil Res Dev. 2010;47(4):275–297.

8.   Scott SG, Belanger HG, Vanderploeg RD, Massengale J, Scholten J. Mechanism-of-injury approach to evaluating patients with blast-related polytrauma. J Am Osteopath Assoc. 2015;106:265–270.

9.   Dismounted Complex Blast Injury Task Force. Dismounted Complex Blast Injury. Fort Sam Houston, TX: DCBI Task Force; June 18, 2011. http://armymedicine.mil/Documents/DCBI-Task-Force-Report-Redacted-Final.pdf. Accessed September 29, 2017.

10.   Pezzin LE, Dillingham TR, MacKenzie EJ, Ephraim P, Rossbach P. Use and satisfaction with prosthetic limb devices and related services. Arch Phys Med Rehabil. 2004;85(5):723–729.

11.   McFarland LV, Hubbard Winkler SL, Heinemann AW, Jones M, Esquenazi A. Unilateral upper-limb loss: Satisfaction and prosthetic-device use in veterans and servicemembers from Vietnam and OIF/OEF conflicts. J Rehabil Res Dev. 2010;47(4):299–316.

12.   Giangregorio L, McCartney N. Bone loss and muscle atrophy in spinal cord injury: epidemiology, fracture prediction, and rehabilitation strategies. J Spinal Cord Med. 2006;29:489–500.

13.   Galeiras Vázquez R, Rascado Sedes P, Mourelo Fariña M, Montoto Marqué A, Ferreiro Velasco M. Respiratory management in the patient with spinal cord injury. Biomed Res Int. 2013;2013:1–12.

14.   Stekelenburg A, Gawlitta D, Bader DL, Oomens CW. Deep tissue injury: how deep is our understanding? Arch Phys Med Rehabil. 2008;89(7):1410–1413.

15.   HomeAdvisor.com. Grants for home modifications: 16 resources for homeowners with disabilities. https://www.homeadvisor.com/r/grants-for-home-modification/. Accessed June 14, 2018.

16.   Lew HL, Rosen PN, Thomander D, Poole JH. The potential utility of driving simulators in the cognitive rehabilitation of combat-returnees with traumatic brain injury. J Head Trauma Rehabil. 2009;24(1):51–56.

17.   Caddick N, Smith B. The impact of sport and physical activity on the well-being of combat veterans: A systematic review. Psychol Sport Exerc. 2014;15(1):9–18.

18.   Laferrier J, Teodorski E, Cooper R. Investigation of the impact of sports, exercise, and recreation participation on psychosocial outcomes in a population of veterans with disabilities: a cross-sectional study. Am J Phys Med Rehabil. 2015;94:1026–1034.

19.   Vella EJ, Milligan B, Bennett JL. Participation in outdoor recreation program predicts improved psychosocial well-being among veterans with post-traumatic stress disorder: a pilot study. Mil Med. 2013;178(3):254–260.

20.   National Initiative for Arts & Health in the Military. Arts, Health and Well-Being Across the Military Continuum. Washington, DC: Americans for the Arts; 2013. http://www.americansforthearts.org/sites/default/files/pdf/2013/by_program/legislation_and_policy/art_and_military/ArtsHealthwellbeingWhitePaper.pdf. Accessed September 29, 2017.

21.   Smyth J. Creative, Artistic, and Expressive Therapies for PTSD. Brookline, MA: Foundation for Art and Healing; 2012.

Section IV

TACTICAL MILITARY MEDICINE IN THE OPERATIONAL ENVIRONMENT

Section Editors:

JAMES PALMA, MD, MPH, AND CRAIG GOOLSBY, MD, MED

US Army Reserve medics from the 396th Combat Support Hospital, headquartered at Fairchild Air Force Base, Washington, perform a litter carry during a promotional photo shoot for Army Reserve marketing and recruiting at Fort Hunter Liggett, California, July 18, 2018. (US Army Reserve photo by Master Sgt. Michel Sauret)
Reproduced from: https://www.dvidshub.net/image/4799355/us-army-reserve-medical-soldiers-photo-shoot.

Chapter 32

APPROACH TO THE EMERGENCY PATIENT

TRESS GOODWIN, MD*; KATHERINE ELLIS, MD†; AND CRAIG GOOLSBY, MD, MED‡

INTRODUCTION

WHY EMERGENCY MEDICINE IS DIFFERENT

EMERGENCY DEPARTMENT CONCEPTS AND PROCEDURES

Prehospital Arrivals

The Initial Assessment

Sick Versus “Not Sick”

The Safety Net

The Emergency Department Workup

PATIENT ISSUES AND CHALLENGES SPECIFIC TO THE EMERGENCY DEPARTMENT

CHALLENGES IN DEPLOYED EMERGENCY MEDICINE

SPECIFIC CHIEF COMPLAINTS AND RED FLAGS

Abdominal Pain

Chest Pain

Headache

Trauma

Shock

Poisoning

Cardiac Arrest

Case-Based Approach Summary

DISPOSITION

SUMMARY

*Assistant Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Attending Physician, Children’s National Health System, Washington, DC

†Major, Medical Corps, US Air Force; Medical Director, Malcolm Grow Medical Clinic Emergent Care Center, Joint Base Andrews, Maryland

‡Associate Professor and Vice Chair, Education, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

Military medical providers (MMPs) face numerous challenges in both stateside and deployed medical practice. One of the most daunting and time-sensitive challenges is managing a patient with an acute life-threatening illness or injury. Patients with anaphylaxis, severe hemorrhage, unstable cardiac dysrhythmias, or intractable seizures need the right care, right away. Many practitioners do not encounter these types of patients in their normal practice, and therefore lack a conceptual framework and organized approach to handle an unexpected emergency. Regardless of their medical background, a practitioner can apply fundamental concepts that will benefit patients in these types of high-pressure situations. For students and providers of all levels, this chapter will provide the approach of a specialty-trained emergency physician (EP) to the fundamentals of assessing and treating severely ill and injured patients.[1]

This chapter will introduce readers to the concepts of simultaneous diagnosis and treatment, working with imperfect or limited information, and operating in resource-constrained environments. This approach is critically important to the MMP who confronts the challenges of a deployed environment with limited access to specialty consultants, including EPs. The chapter also touches on a variety of core emergency patient presentations. While it is not intended to be a definitive clinical reference, it will inform readers about “red flags” and key features of assessing and managing these patients.

Beyond the normal challenges of civilian emergency medical practice, in which patients are primarily treated in designated emergency departments (EDs), military practitioners may find themselves in hostile locations with scarce resources. Mental preparation for emergency practice in these settings is essential for all MMPs.

WHY EMERGENCY MEDICINE IS DIFFERENT

Emergency medicine is complaint driven. When a patient presents to an outpatient orthopedics department, for example, the patient’s issue is often focused and within a limited subset of diagnoses, such as fractures or joint pain. The same applies to many other fields in medicine, where presenting problems are often diagnoses rather than symptoms. For example, a patient visits their primary care doctor for diabetes management, and the goals of the visit and expected outcomes are anticipated and often predictable. Emergency patients typically present with symptoms or a chief complaint. These symptoms could represent a benign or life-threatening condition, and the EP must rapidly and efficiently make this distinction. Thus, practitioners must shift their mindset to “complaint-based” or “symptom-driven” evaluations of patients. Not all evaluations will lead to a definitive diagnosis, and providers working in an emergency setting may end up “diagnosing” their patient with “chest pain” or “abdominal pain” after having excluded life-threatening conditions during their workup process.[2]

Emergency patients are often scared. There have been numerous poorly informed popular media reports about patients using EDs for non-urgent issues and EDs primarily serving the uninsured. However, multiple studies have shown that nonacute issues do not constitute the majority of ED visits, and that many ED users are indeed insured and have a primary care provider.3–6 When a patient presents to the ED, they are concerned enough about their symptoms to seek emergency care, and their complaints are often high risk. Emergency patients often believe their symptoms are life threatening or warrant immediate evaluation. An emergency practitioner must recognize and acknowledge this worry. Sometimes patients only need reassurance and education, and then they can be safely discharged to their home or returned to duty. It is important to remember that even patients with benign conditions require respect and a thorough evaluation of their complaint by an experienced provider.

EPs have unique doctor-patient relationships. EPs face the need to form an immediate rapport with patients, with whom they have no prior patient-doctor relationships, in a high-stress environment. The EP must rapidly earn the patient’s trust so he or she will feel comfortable disclosing personal details. In a deployed setting, EPs also care for unique populations, such as local nationals and enemy prisoners of war, which makes establishing rapid rapport and an effective treatment relationship even more complex.

EPs operate in an environment of uncertainty. Test results are often not available in time to make crucial treatment information. Patients can arrive obtunded and unable to provide a history. EPs often cannot follow up with patients after discharge. These are just a few examples of uncertainty emergency providers will face. These situations can be uncomfortable, but mental preparation for these realities can help non-emergency specialists succeed.

EMERGENCY DEPARTMENT CONCEPTS AND PROCEDURES

Prehospital Arrivals

Few non-EPs interact routinely with prehospital providers. Prehospital crews transport most emergently ill or injured patients, whether deployed or stateside, for emergency care. In the United States, patient transport is done by a combination of paramedics and emergency medical technicians in ambulances and helicopters. In a deployed setting, transport is done by military medics with varying skill sets and in a multitude of platforms, such as helicopters, armored vehicles, or vehicles of opportunity. Depending on the training and equipment of these providers, the arriving patient may already have had interventions and diagnostics performed, such as venous access, an electrocardiogram, or a blood glucose measurement. Most often, the prehospital providers will call and report to the EP, allowing the ED to prepare for the patient’s arrival. For example, if an urgent surgical patient is inbound, the EP can prepare and gather all necessary equipment, have blood prepared to transfuse, and summon any needed help or consultants prior to the patient’s arrival. Preparation is even more important in mass casualty events when a large number of patients arrive at the same time.

The Initial Assessment

MMPs caring for emergency patients should hone their ability to perform a “doorway assessment” for a quick evaluation of the patient’s condition. Simple observations by a well-trained eye are crucial to gathering information and starting rapid treatment. Here are questions to consider when evaluating a patient on arrival:

- Did the patient arrive via ambulance or come into the waiting room?

- Did the patient walk into the room or arrive via wheelchair or stretcher?

- Does the patient walk without assistance? With a steady gait?

- What is the patient doing? Writhing in pain? Lying motionless? Talking on a cell phone?

- What is the patient’s work of breathing? Are they gasping for air, wheezing, or breathing comfortably?

- What is the patient’s level of pain? Are they holding a particular area, grimacing, or moaning?

- Is the patient actively vomiting?

- What is the patient’s mental status? Do they acknowledge you walking in the room and make appropriate eye contact, or is their mental status altered?

- Is the patient morbidly obese, normal, or cachectic?

- What about the skin: does the patient appear pale, mottled, cyanotic, jaundiced, burned, or covered in a rash? Do you see hemodialysis access in their arm?

- What is the patient’s hygiene? Clean? Disheveled? Neglected?

- What does the room smell like? Alcohol? Gangrene?

- Is family, battle buddy, or a caretaker at the bedside, or did the patient arrive alone?

All the above questions, and many more, can be answered in seconds. Practitioners should be mindful of all available information when seeing emergently ill or injured patients. This review, combined with vital signs, and very brief historical information can yield important information needed to begin an emergency assessment and stabilization.

Sick Versus “Not Sick”

EPs use the term “sick” to refer to seriously ill or injured patients. While the vast majority of ED patients have some degree of illness or injury, most will not be critically ill. Determining “sick” from “not sick” sounds simple, but is in reality a challenging skill that must be developed by anyone providing emergency care. Some patients’ situations are fairly obvious—in clear respiratory distress, unconscious, or with hemorrhaging wounds. These conditions should be immediately stabilized. The more challenging patients are the ones who are not overtly sick, but have characteristics that make them high risk and more likely to decompensate.

A blunt trauma patient (eg, someone who had a fall) can initially appear well with no significant overt signs of trauma, a fairly benign exam, and stable vitals. However, they may decompensate as internal injuries, such as a lacerated spleen, worsen. Knowing that this patient has a high-risk history should prompt the emergency practitioner to continue to monitor and reevaluate the patient (see below for a list of key chief complaints and tips for spotting “sick” patients).

The Safety Net

EPs use the term “safety net” in one of two ways. A civilian ED is the safety net of the medical community. An ED is the only medical facility open 24 hours a day, 7 days a week, 365 days a year. When a patient’s primary care physician’s office is closed, or if they do not have a primary care doctor or are visiting from out of town, the emergency room may be the only option. The ED may be the only option for the uninsured, under-insured, homeless, and mentally ill. In a policy statement, the American College of Emergency Physicians wrote:

Having the only universal mandate for providing health care—the Emergency Medical Treatment and Labor Act (EMTALA)—the nation’s more than 4,000 hospital emergency departments are a portal for as many of three out of four uninsured patients admitted to US hospitals, making them a vital, although often unrecognized, component of the safety net.[3]

The safety net concept also refers to an initial series of steps designed to stabilize patients. Once a sick patient is identified, emergency providers must rapidly establish the safety net. While most emergency patients will not rapidly decompensate during their initial ED course, sick patients might. A mantra often cited by medics and EPs alike is, “IV, O_2, monitor, advanced airway equipment.” These procedures—establishing intravenous (IV) access, placing the patient on oxygen and a cardiac monitor, and ensuring advanced airway equipment is readily available at the bedside—are the foundation of the safety net.

The safety net should be started immediately. On entering the room of a sick patient, emergency providers should order the team to initiate safety net procedures while rapidly anticipating next steps. Will the patient require fluids (blood or crystalloid)? Should antibiotics be started? Does the patient require intubation or additional venous or intraosseous access? The key to establishing the safety net is preparedness, and becoming comfortable starting treatment while performing diagnostic studies. An elderly, hypotensive, tachycardic patient with altered mental status is sick. If the provider waits for all imaging and lab tests to return, the patient may not survive. Additionally, a patient may need immediate fluid resuscitation, antibiotics, or cardioversion prior to performance of any labs or additional diagnostic testing. These rapid steps may be uncomfortable for many MMPs but may save an emergency patient’s life.

The Emergency Department Workup

The focus of an emergency patient’s workup and care is based on the chief complaint. Patients may have many ongoing medical issues at a given time and present with multiple complaints. However, one acute issue typically prompts the ED visit, and it should be the focus of the provider’s history, physical exam, and diagnostic testing. As in other areas of medicine, patient history and physical examination provide most of the needed information to drive any necessary testing to diagnose and indicate appropriate disposition the patient.

Unlike in some other areas of medicine, emergency providers need to think in a worst first mentality. Medical students are typically trained to take a history and perform a physical exam, generate a differential diagnosis, and then consider which diagnosis is most likely. Emergency providers follow these steps as well; however, instead of considering which diagnosis is most likely, they must consider which is most lethal—the worst first. As described above, patients presenting for emergency care often have emergency problems and are at higher risk than those seen in outpatient clinics. This does not mean that all patients require exhaustive testing to exclude emergency diagnoses; rather, it is imperative that an emergency provider consider these diagnoses and exclude them by history, physical examination, or testing if indicated.

For example, when a 30-year-old asthmatic patient presents to an ED with a chief complaint of “shortness of breath,” the diagnosis is most likely an asthma exacerbation. However, a pulmonary embolus is a more lethal diagnosis. If the provider does not consider and at least mentally address this possibility, he or she might miss an important emergency condition. Knowing the potentially fatal diagnoses for each patient complaint and focusing a workup to exclude them are key knowledge and skills for emergency providers.

Again, testing should be focused on the patient’s chief complaint. MMPs should consider available resources and choose tests that will change management of their patient. An example of a widely available test that can rapidly change management is a pregnancy test in a woman of childbearing age with an abdominal or pelvic complaint. This one simple qualitative answer can drastically change the direction of diagnostics and treatment. On the other hand, an example of an often unnecessary test is a rib x-ray series. For a patient with mild chest trauma who is suspected of having either a rib fracture or rib contusion, rib x-rays are usually not indicated. Rib fractures and contusions are treated with the same conservative care; there is no difference in the treatment. A chest x-ray may be indicated to exclude pneumothorax or another abnormality, but identifying specific rib fractures will likely not change emergency management or patient disposition or follow-up. Management is the same—pain management and prevention of atelectasis or pneumonia with incentive spirometry.

PATIENT ISSUES AND CHALLENGES SPECIFIC TO THE EMERGENCY DEPARTMENT

Most EDs have individual patients who frequently use the ED for care. Sometimes derogatorily called “frequent fliers,” these patients use the ED repeatedly and often for similar presentations. They are usually older, have chronic medical conditions such as coronary artery disease or asthma, and can be a source of frustration to the staff. Some assume that these patients use the ED as their only source of care, but studies have shown that they are also likely to utilize outpatient clinics and have high rates of hospital admission.4–6 As with other patients, the challenge is to know when their issues are acute and life threatening. They must be evaluated during each encounter with the same thoughtful approach as any other patient. Additional resources, such as social worker consultations, should also be considered to help address other factors of their frequent ED utilization.

EPs play a crucial role in detecting signs of abuse in patients—ranging from infant/child abuse, to intimate partner violence, to elder abuse and neglect.[7] Patients presenting with multiple visits and various injuries, along with stories inconsistent with injury patterns, should raise suspicion of abuse. In addition, concern should be raised if the patient seems evasive or inappropriately frightened, or if an overbearing and perhaps defensive partner or family member is in the room.[8] In children, bruises in various stages of healing as well as fractures or injuries not consistent with their age or mobility should all be red flags for the EP.[9] Often the ED may be the only healthcare setting these victims visit, and having reasonable suspicion with at-risk patients with concerning injuries could be the intervention that saves their life.

CHALLENGES IN DEPLOYED EMERGENCY MEDICINE

Deployed MMPs face additional challenges in the operational environment. Depending on the setting, personal safety can be a concern. During deployment, MMPs are far from loved ones and may have limited ability to communicate with them. Additionally, practitioners may be working outside their normal comfort zone in their patient care duties. Several challenges for emergency providers follow.

Caring for unique populations. MMPs will almost certainly care for more than American troops when deployed. They may treat contractors, local nationals, third-country nationals, enemy prisoners of war, and a host of other individuals. Caring for these populations may involve certain rules and unique challenges, but the basic principle remains that MMPs provide a baseline standard of care to every patient, regardless of background. Department of Defense Directive 2310.01E, which covers the Defense detainee program, mandates “humane treatment,” which includes “appropriate medical care and attention required by the detainee’s condition, to the extent practicable.”[10] As in caring for diverse patients stateside, this may require a language interpreter and adaptation to cultural concerns. It is important that each MMP is aware of the unique populations in their deployed setting, the resources available to help care for these patients, and the specific guidelines directing care at each facility.

Mass casualty care. Military emergency providers will likely see mass casualties that are more significant in scope than those typically seen during stateside duty. This book covers mass casualty in a separate chapter (Chapter 34, Mass Casualty Preparedness and Response), but it is important for emergency providers to develop or understand their facility’s contingency plan during a mass casualty event.

Resource availability and utilization. The resources available will vary dramatically depending upon the practice environment. Section II of this book, Operational Health Service Support, covers this topic in more detail. The military designates various levels of care based on availability of resources, ranging from first responder care to large stateside medical treatment facilities. MMPs at a Role 1 setting, such as a battalion aid station, do not have the ability to admit patients or perform advanced diagnostics. Those at a Role 3 facility, such as an Air Force theater hospital, will likely have computed tomography (CT) scanners, a host of medications, and access to operative care with surgical subspecialists. While MMPs should still consider tests that would change patient management, their options may be significantly different than when practicing at home.

SPECIFIC CHIEF COMPLAINTS AND RED FLAGS

This section consists of case scenarios focusing on several common patient complaints. It is not meant to be a complete list of chief complaints seen in the ED; rather, it is designed to help MMPs learn the process of evaluating a patient from an emergency medicine perspective. The scenarios and workups described include some repetition, partly because emergency medicine providers approach many patients in a similar way. As discussed previously, the EP will ask, “is the patient sick or not sick?” and then proceed to a more thorough history and exam as appropriate. For any given complaint, specific “red flags” indicate a more serious problem. These flags might be something the patient reports in the history, a physical exam finding, a vital sign, a lab result, or an imaging study. Some may seem obvious, such as a patient who is unconscious, but others are subtler. The scenarios that follow also take into account some of the unique challenges of military medicine: austere locations, limited resources, long transport times, and a diverse patient population.

Abdominal Pain

You are working sick call at a remote forward operating base. Your next patient is a 22-year-old female active duty soldier with a chief complaint of abdominal pain. Your medical technician provides a set of vital signs: blood pressure (BP) 90/60, heart rate (HR) 110, respiratory rate (RR) 18, temperature (T) 98°, oxygen saturation (Spo_2) 98% on room air. You walk into the exam room and see the patient sitting on the exam table, awake and alert, and in mild distress secondary to pain. In the 10 to 15 minutes that you have with the patient, what are your priorities? What important questions do you need to ask? What will you look for on physical exam? What is the most important test you need to order for this patient?

Abdominal pain can be a complex and frustrating chief complaint for the EP. A recent study showed that 6.5% of ED patients have abdominal pain as their presenting complaint, and of these, 21% were not discharged with a specific diagnosis, and were instead recorded as having undifferentiated “abdominal pain.”[11] A focused history and physical exam can narrow the differential diagnosis and quickly identify those patients who need further testing.

Even before the EP sees the patient, her vital signs indicate she has tachycardia and borderline hypotension, and is potentially sick. The patient should be asked more history about her abdominal pain: When did it start? Where is it located? What makes it better or worse? Are there associated symptoms such as nausea, vomiting, changes in bowel movements, changes in urination, anorexia, or vaginal bleeding? Does she have a history of chronic abdominal problems such as gastrointestinal reflux, gallstones, or inflammatory bowel disease? Has she had prior abdominal surgeries? When was her last menstrual period?

All women and girls of childbearing age, even in the deployed setting, should be assessed for pregnancy. A pregnancy test is the most important test to order for this patient because the results will direct further imaging studies and disposition. A pelvic exam can be considered if there is concern for pelvic pathology. Abnormal vital signs must be addressed. If the patient is dehydrated, she should receive oral (PO) or IV fluids. If she is in pain, she may need either PO or IV pain medication. Most abdominal pain patients should initially be kept NPO (nil per os, or nothing by mouth) until a surgical emergency is excluded.

The patient is initially reluctant to talk to you, but eventually confides that her last menstrual period was 6 weeks ago. Her pain started last night, is located in her right lower quadrant, and is steadily worsening. She has also had a small amount of vaginal bleeding. On physical exam, she is tender in the right lower quadrant with voluntary guarding but no rebound tenderness. Pelvic examination shows a closed cervix with a small amount of dark red blood in the vaginal vault and right adnexal tenderness. Her urine pregnancy test comes back positive. What are your next steps in management?

This patient must be worked up for ectopic pregnancy, a potentially life-threatening condition in which the fetus implants outside of the uterus, usually in the ovarian tube. The patient should be kept NPO. Appropriate labs to consider include complete blood count to evaluate for anemia given her history of vaginal bleeding, basic metabolic panel, quantitative human chorionic gonadotropin (HCG), and blood type and screen. She should be started on IV fluids and given IV pain medications. A pelvic ultrasound should be performed, which can be used not only to identify an ectopic pregnancy, but also to evaluate other serious causes of abdominal pain such as an ovarian torsion or tuboovarian abscess (Exhibit 32-1). A skilled EP may be able to perform this test at the bedside. Depending on the facility’s resources, ultrasound technicians and radiologists may be available to perform and interpret the study.

While waiting for her ultrasound, the patient begins to complain of severe pain. Her BP drops to 70/40 and her HR increases to 130. She now has guarding and has rebound tenderness on her exam. What are your next steps in management?

EXHIBIT 32-1

ABDOMINAL PAIN: CAN’T-MISS DIAGNOSES

- perforated ulcer

- cholecystitis

- pancreatitis

- ischemic bowel

- diverticulitis

- appendicitis

- pyelonephritis

- ectopic pregnancy

- ovarian torsion

- testicular torsion

- tuboovarian abscess

- pelvic inflammatory disease

- myocardial infarction

- bowel obstruction

- volvulus

- gastrointestinal bleed

- abdominal aortic aneurysm

This exam is concerning for a ruptured ectopic pregnancy: a surgical emergency. The patient may be losing a significant amount of blood into her abdomen. A bedside FAST (focused abdominal sonographic study for trauma) ultrasound exam can confirm free fluid in the abdomen (Figure 32-1). A FAST exam is a rapid, bedside test that can be used to evaluate for the presence of free fluid in the abdomen or around the heart (blood, in the setting of trauma). The patient should be aggressively fluid resuscitated with blood products, if available, or fluids if not. If the treatment facility has the capability, the patient should go to the operating room with a gynecologist for surgical repair. If those resources are not available, she should be immediately transferred to the nearest facility with surgical capability, which may include transfer to a general surgeon if a gynecologist is unavailable.

Figure 32-1. Ultrasound showing ruptured ectopic pregnancy.

There are several red flags in this patient’s case. The presence of abnormal vital signs, and especially worsening vital signs throughout a patient’s visit, should warn the EP there might be a life-threatening problem. Rebound and guarding on physical exam are concerning for a ruptured viscus. In this case, the patient had a ruptured ectopic pregnancy. In a different clinical scenario, rebound tenderness may be a sign of appendicitis, cholecystitis, diverticulitis, perforated peptic ulcer, ruptured abdominal aortic aneurysm, or other serious conditions. These patients all need prompt surgical consultation.

Significant lab abnormalities, such as electrolyte problems, acidosis, and severe anemia may also prompt admission or transfer. Stable abdominal pain patients with normal vital signs and reassuring physical examinations, who are able to tolerate PO fluids, and with non-concerning labs and imaging studies (as indicated), may possibly be safely discharged to quarters or full duty. Discharged patients with abdominal pain should have a repeat abdominal exam in 24 to 48 hours if the pain continues, as well as specific instructions to return sooner for worsening or concerning symptoms. These return precautions may include worsening pain, persistent vomiting, high fevers, or other new concerns. If the patient is unable to follow up with their primary care physician, it is reasonable to have them return to the ED.

Chest Pain

You are working in the ED at a deployed Air Force base. Your next patient is a 55-year-old obese male contractor who presents complaining of chest pain. His vital signs are BP 150/80, HR 95, RR 16, T 97°, and Spo_2 98% on room air. What additional history will help you determine if this patient is at high risk for a life-threatening condition? What are the top “can’t-miss” chest pain diagnoses? What is the most important test you need to order for this patient?

Chest pain accounts for 3% of ED visits and can range from common active duty problems such as muscle strains, costochondritis, and viral syndromes to truly life-threatening etiologies.[12] Six life-threatening causes of chest pain a provider should consider in every chest pain patient are acute coronary syndrome, pulmonary embolus, aortic dissection, hemothorax, pneumothorax, esophageal rupture, and pneumonia (Exhibit 32-2). Before any chest pain patient can leave the ED, these diagnoses should be ruled out, either by history and physical exam or with diagnostic testing.

The patient should be asked to describe his chest pain: when did it start? What does it feel like? What makes it better or worse? Are there associated symptoms such as shortness of breath, nausea, diaphoresis, or cough? He should be questioned about his risk factors for acute coronary syndrome, such as smoking, family history, hypertension, hyperlipidemia, and diabetes. He should also be questioned about risk factors for a pulmonary embolus: smoking, prolonged immobility, leg swelling, family history, and known hypercoaguable disorder. In any chest pain patient, it is important to conduct a thorough review of systems and inquire about recent fevers, coughing, or other illness, as well as recent cardiac or esophageal procedures.

Physical exam should focus on cardiopulmonary and abdominal exams, as well as assessing the extremities for peripheral edema and distal pulses, and the neck for jugular venous distension. All chest pain patients should quickly have an electrocardiogram (ECG) performed and interpreted by an EP. The American College of Emergency Physicians and the American College of Cardiology recommend that an ECG be performed within 10 minutes of arrival for all patients with chest pain.[12] Most EDs have quality standards that require an ECG to be performed and interpreted by an EP within 10 to 15 minutes of a patient’s arrival.

Your patient reports that he “doesn’t go to the doctor” but has been told he has high blood pressure. He has a 40-pack-a-year smoking history, and his father died from a myocardial infarction (MI), or heart attack, at age 45. On physical exam, the patient appears sweaty and uncomfortable, but the exam is otherwise unremarkable. The nurse hands you the ECG (Figure 32-2). What are your next steps in management?

EXHIBIT 32-2

CHEST PAIN: CAN’T-MISS DIAGNOSES

- acute coronary syndrome

- unstable angina

- ST elevation myocardial infarction

- non-ST elevation myocardial infarction

- aortic dissection

- pulmonary embolism

- pneumothorax

- hemothorax

- pneumonia

- esophageal rupture

Figure 32-2. Twelve-lead electrocardiogram with ST segment elevation in leads II, III, and aVF for an inferior acute myocardial infarction. April 12, 2005.
Reproduced from: https://en.wikipedia.org/wiki/
File:ECG_001.jpg

The ECG shows an ST-elevation myocardial infarction (STEMI)—a true cardiac emergency. ST elevation on ECG indicates that damage (infarction) is occurring throughout all layers of the heart muscle. A thrombus (clot) has occluded blood supply to part of the heart, and heart muscle tissue is dying.[13] Once this is diagnosed, the EP must immediately initiate treatment, potentially before a full history or physical exam can be obtained. The patient should be placed on oxygen and should receive aspirin. He should receive nitroglycerin for ongoing pain. However, nitroglycerin can drop a patient’s blood pressure and should be used judiciously once IV access has been obtained (allowing fluid resuscitation if the patient becomes hypotensive).

In many stateside military and civilian facilities, STEMI patients are taken immediately to the cardiac catheterization lab to undergo an invasive procedure to open the blocked artery. In the deployed setting, this resource is usually not available. Instead, patients can be given thrombolytics, which are IV medications that help break up the clot. These medications all carry risks of bleeding complications, and the patient should be counseled about their risks and benefits. After receiving thrombolytics, the patient will likely require transport to a higher level of care for cardiology consultation and intensive care management. In this case, the STEMI seen on ECG makes the patient’s disposition easy for the EP. But what if his ECG had been normal or shown nonspecific changes?

There are many other life-threatening causes of chest pain that can present with a normal or nonspecific ECG. The patient should have additional blood work and imaging performed. A chest x-ray can be useful in showing a definitive diagnosis such as pneumothorax or pneumonia. If there is a high suspicion for an aortic dissection or pulmonary embolus, a CT of the chest with IV contrast should be obtained, because they are not readily diagnosed with a standard chest x-ray. Elevated cardiac enzymes may clinch the diagnosis of MI in a patient with a borderline ECG.

Many patients who present to the ED with chest pain are admitted to the hospital, especially those who are older and have risk factors for acute coronary syndrome. It is difficult to exclude many of the life-threatening causes of chest pain without a period of observation. Patients with potential cardiac risk factors and no etiology of their chest pain found in the ED require observation, repeat exams, repeat ECGs, and serial cardiac enzyme screens in addition to some form of stress test. According to the resources at a facility, this process may be done in the ED, a chest pain observation unit, or an inpatient ward, or via a coordinated outpatient approach. All patients who are discharged with a diagnosis of chest pain should have close follow-up with their primary care physician or appropriate specialist and should be given clear return precautions.

Headache

You are working in a stateside military ED and your next patient is a 45-year-old woman with a history of migraines, who presents with a chief complaint of a severe headache. The nurse pulls you aside and says, “This patient is here all the time. Just give her some pain meds for her headache and send her home.” What additional history do you need to obtain before treating the patient? What key questions can you ask to avoid missing any red flag headache diagnoses?

Three-quarters of Americans experience a headache each year, and headaches account for 2 million ED visits.[14] Most of these patients have a primary headache disorder such as migraines, cluster headaches, or tension-type headaches, and can be treated symptomatically and discharged. However, a subset have a “secondary” headache: a pathologic process such as a tumor or vascular event in which head pain is the presenting symptom. To help distinguish between a regular migraine headache and a headache with a potentially more serious cause (Exhibit 32-3), the patient should be asked additional questions. How did the pain start? What does it feel like? Does anything make the pain better or worse? Where is it located? What time of day is it worse? What medications are you taking? Are there associated symptoms such as fever, nausea, vomiting, photophobia, or neck stiffness?

EXHIBIT 32-3

HEADACHE: CAN’T-MISS DIAGNOSES

- intracranial hemorrhage

- meningitis

- intracranial mass

- cerebrovascular accident

- acute angle closure glaucoma

- hypertensive encephalopathy

If the patient endorses fever and neck stiffness, this is concerning for meningitis, a life-threatening infection of the fluid around the brain and spinal cord. Many medications such as nitroglycerin, calcium channel blockers, and estrogen can have a side effect of headache, and many recreational drugs can cause headaches as well. If the patient has recently decreased her intake of caffeine, she may have a withdrawal headache. Multiple members of a family with new headaches, especially in the winter months, should raise suspicion for carbon monoxide poisoning.[14] New headaches that worsen over a period of weeks, especially headaches that are worse in the morning, are concerning for elevated intracranial pressure from a mass lesion or neoplasm.

The patient states that pain started suddenly 30 minutes ago. She describes the headache as diffuse, severe, and nothing like her previous migraines. The patient rated her pain as 10/10 on a pain scale since the headache started. She feels dizzy and nauseated but has not vomited.

There are many red flags in this patient’s history. Pain that is abrupt and maximal at onset is concerning for a subarachnoid hemorrhage.[14] The patient will need IV access, a careful neurological exam, and immediate non-contrast head CT. Except for glaucoma patients, virtually all patients presenting with headache should receive analgesia and should be kept in a quiet, dark area.

All patients with headaches also require a thorough neurological exam. Tenderness over the sinuses or purulent drainage from the nose could indicate sinusitis. In elderly patients, the temporal arteries should be palpated to evaluate for temporal arteritis. Acute angle closure glaucoma can present with headache in addition to visual changes, conjunctival injection, and pupillary changes. If this diagnosis is suspected, patients should have their intraocular pressures checked. Any new deficit on neurological exam is an indication for further imaging. Patients with altered mental status or new onset seizures also require further imaging.

On exam, the patient appears in severe pain and mildly disoriented. The neurological exam is otherwise normal. The CT head scan is shown in Figure 32-3. What are your next interventions?

The patient’s CT scan shows a subarachnoid hemorrhage—a neurosurgical emergency. In the ED, the initial management involves resuscitation, reversal of any coagulopathies, and stabilization. The patient should be attached to a cardiac monitor and her BP should be carefully monitored. She will need frequent neurological exams, and if her neurological status deteriorates further, she will require intubation for airway protection. She will require neurosurgical consultation and will be admitted, likely to the intensive care unit (ICU), to be monitored for additional bleeding, vasospasm, and other complications. Nonsteroidal antiinflammatory drugs, aspirin, and other blood-thinners should be avoided when treating her pain.

In managing headaches, special care should be given to certain populations. The elderly are unlikely to develop new onset migraines, and are at much higher risk for chronic subdural hematomas that can present with only mild headaches. Physicians should have a low threshold to order a CT scan on elderly patients with new onset headaches.[14] In pregnant patients, a headache can be the first sign of preeclampsia. If untreated, this condition can progress to eclampsia, cerebral hemorrhage, or both. Most headache patients with stable vital signs, a normal neurological exam, and no red flags, and who improve with ED treatment, can be safely discharged without a specific diagnosis.

Figure 32-3. Computed tomography head scan showing subarachnoid hemorrhage.

Trauma

You are working in the ED at deployed multinational hospital. You receive a trauma alert. The incoming patient is a 22-year-old male enlisted soldier injured in an improvised explosive device (IED) blast. The medic at the scene reports that the patient has altered mental status, bruising over his right chest and abdomen, and a right below-the-knee amputation. His prehospital vitals are HR 130, BP 80/60, RR 30, and Spo_2 85% on room air. How will you systematically manage this patient when he arrives to the ED? What key interventions in the field could potentially save his life?

According to the Joint Theater Trauma Registry (JTTR), most combat-related injuries in Operation Enduring Freedom and Operation Iraqi Freedom occurred as a result of injury from explosions (78%), usually IEDs. Due to improvements in body armor, there was a low rate of thoracic injuries. The highest rate of injury was to the extremities (54%), followed by the abdomen, face, and head. JTTR statistics show that hemorrhage is the leading cause of potentially preventable combat-related death. Tactical Combat Casualty Care (TCCC) principles and practice have greatly reduced mortality from hemorrhage, along with damage control resuscitation and surgery, rapid patient evacuation, and sophisticated patient transport mechanisms.[15]

Initial stabilization of trauma patients in the deployed setting may depend on self-care or a combat lifesaver or combat medic. Most medics and physicians in the deployed setting have been trained in TCCC (discussed in Chapter 33, Tactical Medicine), and the EP will likely also have been trained in Advanced Trauma Life Support. Both of these courses provide a standard, algorithmic approach to managing trauma that focuses on immediate stabilization of the patient’s life-threatening injuries. The pneumonic “XABCDE” can be used to remember the sequence of care in a trauma patient: first treat exsanguinating hemorrhage, then move on to airway, breathing, and circulation, followed by disability and exposure. When a threat to survival is found, it must be rapidly addressed and stabilized before moving on to the next letter.

The patient arrives with a tourniquet in place at his right lower extremity amputation. He is immediately attached to a cardiac monitor and placed on supplemental oxygen. Bleeding is controlled and rapid assessment of his extremities shows no additional hemorrhage. His airway is intact and he is able to speak in short sentences, although he is tachypneic, with decreased breath sounds on his right side. Vitals are HR 145, BP 80/40, RR 35, and Spo_2 80% on supplemental oxygen.

This collection of vital signs and physical exam findings is concerning for a tension pneumothorax, a respiratory emergency and form of obstructive shock. Air has built up in the pleural cavity and is putting pressure on the lung, preventing inflation and leading to hypoxia and hypotension from decreased venous return and pressure on the heart. The patient should undergo immediate needle decompression with a 14-gauge needle followed by chest tube insertion.

After these procedures, the patient’s hypoxia improves and you continue the primary survey.

Circulation can be assessed quickly by palpating pulses. A palpable radial pulse indicates a systolic BP of at least 80, and a palpable femoral or carotid pulse indicates a BP of at least 60. Tachycardia and hypotension can be signs of shock, but it is important to remember that these may be late findings, especially in a healthy, active duty population. Certain trauma patients, such as the elderly, those in neurogenic shock, and those taking beta-blocker medications, may not be able to mount a tachycardic response. In any case, hemorrhagic shock should be treated aggressively with blood products, or fluids if blood is unavailable.

The patient should have a quick evaluation of his mental status (D for disability). This can be performed using the pneumonic “AVPU”: alert/awake, verbal, painful, or unresponsive (Exhibit 32-4). Is the patient fully awake? Does he only respond to voice? Does he only respond to painful stimuli, or is he completely unresponsive? Also, he should be exposed from head to toe to evaluate for any additional injuries.

At this point in evaluation, additional studies are often performed as adjuncts to the primary survey. A positive FAST exam in an unstable patient is an indication for operative intervention. Trauma x-rays (usually with portable chest x-ray and portable pelvis x-ray devices) are also performed at this point. A CT scan may be performed to further evaluate for specific injuries (Exhibit 32-5).

EXHIBIT 32-4

“AVPU” SCALE FOR CONSCIOUSNESS ASSESSMENT

- Alert. The patient is alert and awake.

- Verbal. The patient responds to verbal stimuli.

- Pain. The patient responds to painful stimuli.

- Unresponsive. The patient is unresponsive.

EXHIBIT 32-5

TRAUMA: CAN’T-MISS DIAGNOSES

- shock

- airway compromise

- tension pneumothorax

- massive hemothorax

- open pneumothorax

- flail chest

- cardiac tamponade

- brain herniation

- aortic disruption

- spinal injuries

- pelvic ring disruption

- hemoperitoneum

Once the XABCDEs have been performed and immediate life threats addressed, the patient should be asked additional history and should undergo a head-to-toe secondary survey. A pneumonic to guide the additional history is “AMPLE”: allergies, medications, past illnesses, last meal, and events involved in the trauma. The secondary survey consists of a systematic assessment of the patient, inspecting and palpating all body parts for injuries while also performing a more thorough neurological exam. As these steps are performed, a nurse or tech should send a panel of blood work to the lab. Depending on the nature and severity of the trauma, these may include a type and cross for blood, complete blood count, basic metabolic panel, lactate, coagulation panel, urinalysis, alcohol level, and drug screen. After these steps are completed, additional imaging can be ordered based on the results of the secondary survey and suspected injuries. This may include extremity x-rays, a retrograde urethrogram or cystogram, and CT scans of the head, spine, chest, abdomen, and pelvis.[16]

Your patient’s vitals stabilize after needle decompression, chest tube placement, and blood transfusion. Initial portable chest x-ray shows a pneumothorax and right-sided pulmonary contusions (Figure 32-4). The FAST exam is negative. The secondary survey shows bruising and tenderness over the right side of the head but no ongoing bleeding at the amputated right lower leg with the tourniquet secured. The patient is sent for additional imaging. A CT head scan (Figure 32-5) shows a right-sided subdural hematoma, and x-rays of the right leg are consistent with a traumatic below-the-knee amputation. What are your next steps in management?

Figure 32-4. Chest x-ray showing right-sided pneumothorax.

The patient’s subdural hematoma will require urgent neurosurgical evaluation and possible surgery if his neurological status deteriorates. This is a case in which the deployed environment provides unique challenges. The patient presented to the ED at a multinational hospital, where a neurosurgeon is likely available. If he had presented further forward, he would have required evacuation, possibly by a critical care air transport (CCATT) or tactical critical care evacuation (TCCET) team, to get him to neurosurgical care in an expeditious manner. He will need to be admitted to the hospital, likely to an ICU setting, for continued management of his chest tube, neurosurgical evaluation of his subdural hematoma, and orthopedics, trauma, and/or vascular evaluation of his amputation. Once these conditions have stabilized to the point where he is deemed safe for flight, he will require transport out of theater by a CCATT team.

Shock

You are working in a stateside military ED. Your next patient is a 22-year-old male who collapsed after his physical fitness test (PFT) and is carried in by his friends. His skin is warm and flushed and he appears confused. His is tachycardic, with HR 138 and BP 70/40. Your colleagues begin to attach the patient to monitoring devices and start two large-bore IV lines. You know minimal history at this point, but the patient’s vital sign abnormalities are concerning for shock.

Figure 32-5. Computed tomography head scan showing subdural hematoma.

Shock refers to a state of hypoperfusion in which oxygen delivery to the tissues is inadequate to meet the metabolic demands of the body. Broadly speaking, it is defined as a mismatch between tissue oxygen demand and supply that results in cellular death.[17] If shock is not rapidly treated, it leads to end-organ failure and death. There are four broad categories of shock: hypovolemic, cardiogenic, distributive, and obstructive (Table 32-1).[17]

Hypovolemic shock is the most common, especially in the deployed environment. It is defined as a loss of circulatory volume, most commonly from hemorrhage or dehydration. Treatment focuses on volume expansion with blood, crystalloid, or both as indicated.[18] Cardiogenic shock is caused by cardiac dysfunction, usually from an MI, and the heart pump is unable to meet the demands of the body’s tissues. Treatment involves judicious use of fluids, inotropes for pump support, and reperfusion therapy for MI. Obstructive shock involves some blockage of blood leading into or out of the heart, either from a physical blockage such as a massive pulmonary embolus, or a pressure-gradient blockage caused by a tension pneumothorax or cardiac tamponade. The causes of obstructive shock may all present as pulseless electrical activity (PEA) and should all be considered when working through the “H”s and “T”s during a code (see the Cardiac Arrest section below). Lastly, distributive shock results in vasodilatation caused by the release of inflammatory mediators and cytokines, which leads to a decrease in systemic vascular resistance and a compensatory increase in cardiac output. Sepsis is the most common cause, but anaphylaxis, neurological injuries, and certain toxins can also cause this presentation.[17]

TABLE 32-1

CATEGORIES AND CAUSES OF SHOCK

Category

Causes

Hypovolemic

Trauma

Gastrointestinal bleeding

Severe dehydration (gastroenteritis, burns)

Cardiogenic

Acute myocardial infarction

Rate problems: bradycardia or tachycardia

Toxins

Cardiomyopathy

Distributive

Sepsis

Anaphylaxis

Neurogenic

Toxins

Obstructive

Pericardial tamponade

Pulmonary embolism

Tension pneumothorax

Patients with shock require the EP’s immediate attention. Often the EP must begin treatment simultaneously with the history and exam, and before diagnosing the shock state’s etiology. The EP should rapidly assess the patient’s general appearance and vital signs. Patients in shock will often be hypotensive, tachycardic, and tachypneic. If the patient has respiratory distress or is unable to protect his airway secondary to confusion, he may require intubation. Supplemental oxygen should be considered for all patients, and most patients will benefit from two large-bore IVs and fluids.

Patients in septic shock in particular may require large volumes of crystalloid fluid. If the blood pressure does not improve after 1 to 2 L of crystalloid, or if the patient is unable to tolerate large volumes of fluid (particularly the elderly and patients with heart failure), vasoactive medications, such as norepinephrine or dopamine, may be required to increase blood pressure and improve tissue perfusion. All patients presumed to be in septic shock should have labs ordered to look for the source of infection (blood cultures, urinalysis, urine cultures, cerebrospinal fluid tests, etc) and be started on early, broad-spectrum antibiotic therapy. As the patient is stabilized, the EP can obtain a more detailed history and perform a full physical exam.

Your patient continues to be hypotensive, tachycardic, and tachypneic. He is able to speak in short sentences, but has swelling to his face and airway. You noticed diffuse urticaria all over his body, and wheezing on lung exam. His friends state that they saw him get stung by a bee after the PFT, so they brought him to the ED.

In this case, a more thorough history and exam points to a clear etiology for the patient’s symptoms: distributive shock secondary to anaphylaxis from a bee sting. The mainstay of treatment for anaphylaxis is aggressive fluid resuscitation and epinephrine to counteract vasodilation and bronchospasm. Epinephrine is typically given subcutaneously initially, but may also be given via an IV route.[18]

The patient receives a 2-L normal saline bolus, 0.3 mg of 1:1,000 subcutaneous epinephrine, 50 mg of IV diphenhydramine, and 125 mg of IV methylprednisolone and albuterol given via nebulization. He remains slightly tachycardic, but has gradual normalization of his blood pressure. His wheezing and airway edema improve after the epinephrine and nebulizer treatment. During a repeat exam, he is awake, alert, oriented appropriately, able to speak in full sentences, and in no respiratory distress. He is discharged from the ED after 6 hours of observation, with an EpiPen (Mylan Inc, Hatfield, Hertfordshire, United Kingdom), clear instructions to carry it with him at all times, and a follow-up referral to his primary care manager.

Patients with this type of shock may sometimes be discharged from the ED. Patients with anaphylaxis who are asymptomatic after one dose of epinephrine can be observed for 4 to 6 hours and, if they remain asymptomatic, safely discharged. Observation is necessary because some patients may require a repeat dose of epinephrine. Nearly all other patients who present in shock will require admission, often to the ICU, for continued fluid resuscitation and hemodynamic monitoring. In the deployed setting, patients in shock are stabilized and then transported out of theater by CCATT, whose staff are able to continue treatment with vasoactive medications, blood products, antibiotics, and fluids en route to the next level of care. Indicators that shock has resolved include normalization of vital signs, improved urine output, down-trending lactate, and normal volume status.[18]

It is important to remember that certain special populations will present differently. In pediatrics, the most common causes of shock are dehydration secondary to infectious gastroenteritis and hemorrhagic shock secondary to trauma.[17] Pediatric patients are able to compensate for a large amount of volume loss with minimal change in vital signs. Thus, they can appear well even in the early stages in shock. When these compensatory mechanisms fail, they will deteriorate rapidly, and the EP must be ready to intervene. In contrast, the elderly have limited reserves and are often unable to tolerate the hemodynamic changes of shock. The elderly are more susceptible to infectious diseases and are also more likely to present with cardiogenic shock. Underlying comorbidities such as cardiac or renal disease may make them unable to tolerate aggressive fluid resuscitation. The EP may need to treat these patients with small fluid boluses and monitor them closely for the development of complications such as pulmonary edema.

Poisoning

You are working in the ED in a forward deployed location. Your next patient is a 22-year-old female brought in by her roommates. They state, “We found her in her bed, acting confused. We’re worried that she took something. She’s been really sad lately.” What are key questions to ask the patient and her roommates? What are your initial orders to your nurse? What further tests will you order to work up her possible ingestion?

Poisonings, whether from an accidental or intentional ingestion, are a common ED complaint. The field of toxicology is a subspecialty of emergency medicine. It is estimated that at least 5 million poisonings occur in the United States each year, although the actual number may be even higher due to underreporting.[19] The poisoned ED patient can present in conditions ranging from completely awake, alert, and asymptomatic to completely obtunded with unstable vital signs. As with any ED patient, assessment begins as soon as the EP looks at the patient and continues with the ABCs.

Initial priorities are securing the patient’s airway and treating potentially reversible causes of her altered mental status. These treatments, often referred to as the “coma cocktail,” include 100% oxygen to treat hypoxia, a finger-stick glucose test to evaluate for hypoglycemia (followed by the administration of dextrose if glucose is low), and naloxone to reverse an opioid overdose. If chronic alcoholism is suspected, thiamine can be given before glucose. If the patient is obtunded, the airway should be secured with intubation. Many toxins can affect breathing. Opioids will decrease the respiratory rate, salicylates can increase the respiratory rate and cause pulmonary edema, and various inhalants may cause bronchospasm. As the ABCs are addressed and concerning conditions stabilized, the EP must also remember to place the patient on “suicide watch” with a sitter in the room who can provide 1:1 supervision.[20]

If the patient is able to talk, or if there are others who can provide the history, it is important to ask the following questions: What was ingested? How much was ingested? When did this occur? Why? (Was it an accidental or intentional overdose?) A head-to-toe physical exam should be performed on all patients, paying particular attention to vital signs, mental status, pupils, skin, and presence of track marks or other evidence of drug use. Some poisonings cause common, recognizable “toxidromes,” described in Exhibit 32-6.[20]

The patient is sleepy and reluctant to answer your questions, and protecting her airway. Physical exam is remarkable only for mild right upper quadrant tenderness. On further questioning, her friends report that they last saw her 4 hours ago. When they found her in her dorm room, there was an empty bottle of acetaminophen next to her bed. When confronted, the patient is unable to tell you exactly how many she took. She states that she “just wanted to sleep and not feel sad anymore.”

Although additional history has helped identify the patient’s likely ingestion, she should still undergo a broad workup to look for complications of her ingestion and to identify any possible co-ingestions. Most acutely poisoned patients are worked up with cardiac monitoring; an ECG; complete blood count; comprehensive metabolic panel, acetaminophen, salicylate, and ethanol levels; urinalysis; and urine or serum drug screen. Females of childbearing age should be tested for pregnancy. If the patient has metabolic acidosis, a serum osmolality may help further narrow the differential. Other than acetaminophen, salicylates, and ethanol, tests for specific levels of a toxin (eg, methanol) are usually sent to a lab, but results take several days. The EP must treat presumptively based on the history, exam, and other lab findings.

EXHIBIT 32-6

POISONING “TOXIDROMES”

Anticholinergic

- mad as a hatter (altered mental status)

- blind as a bat (mydriasis)

- hot as Hades

- red as a beet

- dry as a bone

Cholinergic

- salivation

- lacrimation

- urination

- defecation

- gastrointestinal upset

- excessive bradycardia

Sympathomimetic

- tachycardia

- hypertension

- mydriasis

- diaphoresis

- hyperthermia

- agitation

Opioid

- miosis

- apnea

- hypoxia

- flash pulmonary edema (rare)

In treating the poisoned patient, the EP must consider methods of preventing absorption or aiding elimination of the toxin. These include activated charcoal, whole bowel irrigation, and gastric lavage. Activated charcoal is given PO or via nasogastric tube to absorb toxins still in the gastrointestinal tract. It is most effective if given within 1 hour of toxin ingestion, but is occasionally given later for extended-release toxins or potentially lethal ingestions.[21] It does not bind metals, alcohols, or hydrocarbons and should be used cautiously in patients with altered mental status, who are at increased risk for aspiration.

Whole bowel irrigation is infrequently utilized and involves giving the patient polyethylene glycol solution (eg, GoLytely [Braintree Laboratories; Braintree, MA]) to flush out the bowel and prevent the absorption of a toxin. It is occasionally used for patients who have ingested extended-release preparations and patients with illicit drug packet ingestions (“body packers”). Gastric lavage is seldom performed due to a high risk of aspiration and questionable benefits. However, if a patient presents immediately after a lethal ingestion, it may be attempted. It involves a very large orogastric tube that is instilled with water to flush and remove pill fragments from the stomach.[19]

Your patient confesses that she took the acetaminophen about 4 hours ago, placing her outside the window for gastric lavage or activated charcoal. She denies co-ingestions. While in the ED, she begins to have nausea and several episodes of non-bloody, non-bilious emesis. Her labs are unremarkable, other than an acetaminophen level of 240. What are your next steps in management?

Acetaminophen is one of the most common and most dangerous ingestions seen in the ED. Because an acute ingestion will often have minimal symptoms, and because the potential for long-term liver damage is high, the EP should consider checking acetaminophen levels for every poisoned patient. In overdose, acetaminophen is metabolized to N-acetyl-p-benzoquinone imine (NAPQI), which causes liver damage. Levels can be plotted on Rumack-Matthew nomogram. A level of 150 or greater at 4 hours is considered toxic. Patients with a toxic ingestion should be started on the antidote, N-acetylcysteine. Starting this antidote promptly after ingestion can prevent liver damage and death.

The patient is started on N-acetylcysteine and admitted to the ICU for monitoring. Once she is medically cleared, she is given a psychiatric evaluation and transported back to the United States for continued psychiatric treatment.

Most poisoned patients are admitted to the hospital, often to the ICU, for close cardiopulmonary monitoring. If a poisoned patient is asymptomatic after several hours of observation in the ED, they may possibly be safe for discharge after psychiatric evaluation. Consultation with a poison control center, if available, is recommended. In the deployed setting, patients who present with an intentional ingestion as a suicide attempt will likely need to be removed from theater and transported back to the United States for psychiatric treatment.

Cardiac Arrest

You are working in a stateside military ED. You receive a 911 call stating that a 65-year-old male collapsed on the golf course and became unresponsive. The medical technicians that you sent to the scene report that the patient is pulseless and apneic. Basic life support (BLS) has been started. How will you manage this patient in the ED? What instructions should you give your technicians as they are en route to the hospital?

An estimated 250,000 Americans die each year from unexpected cardiac arrest. Many of these cases occur outside of a hospital, and most occur in men aged 50 to 75 who have underlying heart disease.[22] In a way, the cardiac arrest patient is the quintessential emergency medicine patient: obviously sick and in need of rapid assessment and interventions that, if performed correctly, may make the difference between life and death. Managing a cardiac arrest and its aftermath can be an intellectually stimulating yet emotionally draining experience for the EP. In an arrest, the EP will end up treating not only the patient, but also his or her family, who will require extensive explanation and support, whatever the outcome.

The initial goals in managing a cardiac arrest include the principles of BLS: to “support or restore effective oxygenation, ventilation, and circulation until return of spontaneous circulation or until ACLS [advanced cardiac life support] interventions can be initiated.”[23] BLS focuses on early defibrillation and effective chest compressions. The old pneumonic “ABC” has been altered to “CAB” for these patients to shift focus to early, effective chest compressions. First responders should check for a carotid pulse for no more than 10 seconds. If no pulse is present, responders should start cardiopulmonary resuscitation (CPR), pushing hard and fast, 100 to 120 compressions per minute, and allowing full chest recoil between compressions. The patient should receive two rescue breaths with a pocket mask or bag valve mask between compressions. The airway should be opened with a head tilt, chin lift technique, or jaw thrust technique in the setting of trauma. An automated external defibrillator should be attached to the patient as soon as possible, and the patient should be shocked as recommended by the defibrillator.[23]

As more advanced practitioners arrive on scene, and once the patient arrives in the ED, more advanced resuscitation techniques can be started. The ACLS process continues to emphasize early, effective CPR, but also includes advanced airway techniques, such as intubation, and IV medications such as epinephrine and amiodarone. End-tidal capnography can be a useful adjunct to evaluate the effectiveness of compressions and the correct placement of the endotracheal tube.

The patient arrives in the ED pulseless and apneic. CPR and bag valve mask ventilation are in process. He is attached to a cardiac monitor, which shows ventricular fibrillation (Figure 32-6).

Cardiac arrest from a primary cardiac disorder often presents with this rhythm or with pulseless ventricular tachycardia, which is treated in the same manner. In these patients, early defibrillation has been shown to increase survival. If defibrillation is performed within the first minute or two of an arrest, as many as 90% of patients return to their baseline neurological status.[23] The ACLS algorithm involves defibrillation followed by 2 minutes of CPR, defibrillation, IV epinephrine, and IV amiodarone. IV access should be obtained as quickly as possible, and if IV access is not immediately available, an interosseous line should be placed instead. Many ACLS medications can also be given via the endotracheal tube, but given the widespread availability of interosseous lines and their ease of insertion, the endotracheal tube method is being used less frequently. A finger-stick glucose screen should be rapidly obtained because hypoglycemia can be a rapidly reversible cause of altered mental status and cardiac arrest.

Figure 32-6. Rhythm strip showing ventricular fibrillation.
Reproduced from: https://commons.m.wikimedia.org/wiki/File:De-Rhythm_ventricular_fibrillation_(CardioNetworks_ECGpedia).png.

Figure 32-7. Rhythm strip showing pulseless electrical activity.
Reproduced from: https://en.m.wikipedia.org/wiki/Pulseless_electrical_activity.

The patient receives two shocks and two rounds of IV epinephrine and IV amiodarone. He remains pulseless and apneic. On the next rhythm check, the cardiac monitor shows PEA (Figure 32-7).

PEA is defined as cardiac electrical activity without associated mechanical pumping.[23] Successful resuscitation of a patient in PEA should be focused on rapidly identifying and treating the cause. The EP may think of the “H”s and “T”s (Exhibit 32-7) to remember all the potential causes of PEA. All patients in PEA should be treated with oxygen and ideally intubated to correct for hypoxia. As discussed previously, a finger-stick glucose screen can rapidly identify hypoglycemia. Blood that is rapidly run through an i-STAT machine (Abbott Laboratories, Chicago, IL) can be used to identify hypokalemia or hyperkalemia and acidosis. Patients in PEA should be kept warm. A bedside ultrasound can be performed to evaluate for cardiac tamponade and to evaluate the right side of the heart for changes consistent with a large pulmonary embolus. Based on the clinical scenario, the patient may require an emergent pericardiocentesis to treat a tamponade, needle decompression for tension pneumothorax, or IV thrombolytics for suspected pulmonary embolus or MI. The patient should continue to receive high-quality CPR and IV epinephrine every 3 to 5 minutes. If a reversible cause of PEA is not rapidly discovered and corrected, the patient’s prognosis is extremely poor. Only 1% to 4% of patients with PEA survive to hospital discharge[24] (see Exhibit 32-7).

EXHIBIT 32-7

CARDIAC ARREST “H”S AND “T”s

- hypovolemia

- hypoxia

- hydrogen ion (acidosis)

- hyper/hypokalemia

- hypoglycemia

- hypothermia

- toxins

- tamponade (cardiac)

- tension pneumothorax

- thrombosis (acute coronary syndrome and pulmonary embolism)

Figure 32-8. Rhythm strip showing asystole.
Reproduced from: https://commons.m.wikimedia.org/wiki/File:EKG_Asystole.jpg.

After several rounds of epinephrine, intubation, IV fluids, and a normal blood glucose level, the patient remains pulseless. His rhythm strip shows asystole (Figure 32-8).

Asystole has a very poor prognosis because even minutes without oxygen to the brain portends very poor functional outcomes. For patients in asystole, treatment should still be focused on restoring perfusion with high-quality CPR and identifying a reversible cause. After 20 minutes of combined BLS and ACLS, resuscitation is unlikely to be successful. Bedside ultrasound can be a useful adjunct in evaluating for cardiac activity. If the patient has been in asystole for 20 minutes and shows no cardiac activity on ultrasound, it is reasonable to stop resuscitative efforts. The EP must then ensure that the patient’s family is updated and their questions are answered. If possible, the patient’s primary care doctor should be contacted as well.

Only a small percentage of resuscitated cardiac arrest patients survive to hospital discharge, and of those that do survive, many suffer from anoxic brain injury. If the patient regains a pulse but does not regain consciousness, the EP should initiate targeted temperature management. Randomized control trials do not show any benefit of therapeutic hypothermia versus targeted temperature management. Maintaining a constant temperature between 32° and 36°C for at least 24 hours postarrest is the current recommendation, and this has been shown to improve both survival rates to hospital discharge and neurological outcomes.[24] The procedure is usually started in the ED and continued in the ICU once the patient is admitted. If acute coronary syndrome is suspected, the postarrest patient should be strongly considered for emergent cardiac catheterization.

Case-Based Approach Summary

The above cases are only a sample of the life-threatening chief complaints an EP may encounter. They are meant to emphasize the common processes in the approach to the emergency medicine patient, regardless of initial patient complaint. In these cases, the EP must quickly determine whether the patient is “sick or not sick.” Another key skill is the ability of the EP to simultaneously obtain history and diagnoses, while starting to treat the patient. Unlike the orderly, thorough approach to the patient history taught in medical schools, the EP must quickly obtain basic history while simultaneously relaying orders to nurses and technicians and rapidly thinking through a list of “can’t miss/worst case scenario” diagnoses. This is often done with incomplete records and potentially no help from the patient themselves if they are in extremis. These cases also emphasize the challenges in diagnosis and treatment based on the EP’s practice environment: forward deployed location, theater hospital, or stateside medical facility. Once initial patient stabilization is complete, the EP can focus on the next phase of patient care: disposition.

DISPOSITION

Potential dispositions from the ED include admission to the hospital for observation, additional workup, or directly to the operating suite; transfer to a different facility with a higher level of care; discharge home or to self-care; and of course, unfortunately, transfer to the morgue. The EP must consider numerous factors to determine the most appropriate place for disposition. For example, considering a terminal patient whose primary issue is managing pain and maintaining quality of life, sending them home may be the best course. Their terminal disease will not be cured by a hospital admission, and admission can in fact be detrimental (the hospital can expose patients to numerous nosocomial infections and be less comfortable). Discharge home is appropriate as long as pain medications can be administered at home.

The decision to admit or discharge a patient is one of the unique challenges of emergency medicine. The EP must make this decision in a timely manner, often with an incomplete history of present illness, minimal to no knowledge of the patient’s past medical history, and equivocal testing. Although this can seem daunting at first, the skilled EP can often make a disposition decision after their first interaction with a patient. Performing serial examinations and discussing the case with a consultant can help the EP decide.

When collaborating with consultants, it is essential that the EP remain an advocate for the patient. Consultants generally prefer brief presentations with specific requests or questions. In the case of the previous chest pain patient, a consulting cardiologist might expect to hear, “I have a 55-year-old man with multiple cardiac risk factors who presents with a STEMI on ECG. We have treated him with aspirin, nitroglycerin, and heparin, and would like him to go to the cath lab. Could you come evaluate him in the ED? Are there any other treatments you would like us to start?” Depending on the case and resources at the facility, a consultant may evaluate the patient in the ED and ultimately discharge him, admit the patient primarily, or manage the patient alongside another service (usually internal medicine). When possible, it is always better for a patient if the consultant examines them in person rather than providing advice over the phone. In many EDs, and especially in austere or forward deployed settings, this is often not possible. Specialist consultants may be in other parts of the country or region, or stateside. In these cases, sending pictures of ECGs and other images to the consultant may be the next best course of action. Some hospitals have telemedicine services, in which a consultant (often a neurologist for a stroke patient), can evaluate the patient via a video monitoring system.

When patients require admission, the EP must determine if they can be admitted to the current facility or if they require a transfer. In the stateside military setting, patients requiring admission may need transfer to a higher level of care; many stateside military hospitals do not provide neurosurgical capabilities. The patient presenting with a subarachnoid hemorrhage might require transfer to a civilian facility for further care. In the deployed setting, transfer becomes an even larger challenge. The deployed patient presenting with a ruptured ectopic pregnancy would certainly require transfer to a higher level of care for surgical treatment.

If transfer is required, the EP’s next question is how to most safely transport the patient: by air or by ground. This decision will rely on a multitude of factors including the stability of the patient, the resources of the facility, weather conditions, and the location of the accepting hospital. This decision will often be made in consultation with the accepting provider at the next level of care.

If the patient is admitted to the same facility, the EP may need to write admission orders for the inpatient unit. These should be done in consultation with the admitting physician and should make clear that the admitting physician should be contacted for any change in the patient’s status. Admitting the patient may require phone calls to multiple consultants to coordinate care.

Many patients can be safely discharged from the ED. However, the decision to discharge can produce anxiety for the EP and for the patient, especially if the patient is being discharged without a clear diagnosis. As discussed throughout the chapter, the purpose of an evaluation in an ED is to recognize and stabilize life-threatening conditions. Often, a skilled EP is able to determine that there is no life-threatening condition present and no reason for admission, but the cause of the patient’s chest pain, abdominal pain, or other symptom, is still unclear. In these circumstances, the EP must have a discussion with the patient about what has been done in the ED, what the next steps should be (primary care follow-up, outpatient follow-up with a specialist, further testing as an outpatient, trial of medication, etc), and any reasons to return to the ED.

Patients should be told what they should do to improve their condition, for example, ice, rest, elevation, and antiinflammatory medication for an ankle sprain. What the patient is NOT allowed to do should also be clearly written in the discharge instructions. For example, a patient presenting with a first-time seizure may be stable for discharge with outpatient neurology follow-up, but should be counseled not to drive or engage in other high-risk activities. In the military setting, particularly the deployed setting, patients with mild traumatic brain injury/concussion may be in a condition to be discharged, but should be counseled to avoid all strenuous physical activity until headache and other symptoms completely resolve and they have been cleared by their primary care doctor or neurologist.

Patients should be told when and where to follow up. For high-risk patients such as infants, pregnant women, and the elderly, and for high-risk complaints such as abdominal pain and chest pain, it is preferable if the EP can arrange a specific appointment for the patient to follow up, ideally in 24 to 48 hours, for a repeat evaluation. If this is not possible and the EP is truly concerned for the patient, the best option may be to have the patient return to the ED in 24 to 48 hours for a recheck. This procedure has often been used for undifferentiated abdominal pain in which appendicitis has not been ruled out.

SUMMARY

The approach to the emergency medicine patient, though different from other fields in medicine, should involve fundamentals of emergency care during evaluation and treatment of acute conditions. Perform rapid “doorway” assessments, determine whether the patient is sick or not sick, establish a safety net, check for red flags, and provide resource-appropriate diagnostics and treatment. Utilizing lessons in this chapter can help non-emergency MMPs provide better patient care.

REFERENCES

1.   Schneider SM, Hamilton GC, Moyer P, Stapczynski JS. Definition of emergency medicine. Acad Emerg Med. 1998;5:348–351.

2.   Mahadevan SV, Garmel GM. An Introduction to Clinical Emergency Medicine. Cambridge, UK: Cambridge University Press; 2005.

3.   American College of Emergency Physicians. The uninsured: Access to medical care. ACEP website. https://www.acep.org/News-Media-top-banner/The-Uninsured--Access-To-Medical-Care/. Published 2016. Accessed February 12, 2017.

4.   Sun BC, Burstin HR, Brennan TA. Predictors and outcomes of frequent emergency department users. Acad Emerg Med. 2003;10:320–328.

5.   Vinton DT, Capp R, Rooks SP, Abbott JT, Ginde AA. Frequent users of US emergency departments: Characteristics and opportunities for intervention. Emerg Med J. 2014;31(7):526–532. doi:10.1136/emermed-2013-202407.

6.   Ku BS, Fields JM, Santana A, Wasserman D, Borman L, Scott KC. The urban homeless: super-users of the emergency department. Popul Health Manag. 2014;17:366–371. doi:10.1089/pop.2013.0118.

7.   Clarke ME, Pierson W. Management of elder abuse in the emergency department. Emerg Med Clin North Am. 1999;17:631–644,vi.

8.   McCloskey LA, Lichter E, Ganz ML, et al. Intimate partner violence and patient screening across medical specialties. Acad Emerg Med. 2005;12:712–722.

9.   Jain AM. Emergency department evaluation of child abuse. Emerg Med Clin North Am. 1999;17:575–593,v.

10.   Work RO. Department of Defense Detainee Program. Washington, DC: DoD; August 19, 2014. DoD Directive 2310.01E. http://www.jag.navy.mil/distrib/instructions/DoDD2310.01E_Detainee_Program.pdf. Accessed February 12, 2017.

11.   Hastings RS, Powers RD. Abdominal pain in the ED: A 35 year retrospective. Am J Emerg Med. 2011;29(7):711–716.

12.   American Heart Association. Recommendations for criteria for STEMI systems of care. http://www.heart.org/HEARTORG/Professional/MissionLifelineHomePage/EMS/Recommendations-for-Criteria-for-STEMI-Systems-of-Care_UCM_312070_Article.jsp#.WKA2UmR95AY. Updated October 4, 2016. Accessed February 12, 2017.

13.   Antman E. ST-elevation myocardial infarction. In: Fuster V, ed. The AHA Guidelines and Scientific Statements Handbook. Oxford, UK: Wiley-Blackwell; 2009: 55.

14.   Lynch KM, Brett F. Headaches that kill: a retrospective study of incidence, etiology and clinical features in cases of sudden death. Cephalalgia. 2012;32:972–798.

15.   Beekley AC, Bohman H, Schindler D. Modern warfare. In: Savitsky E, Eastridge B, eds. Combat Casualty Care: Lessons Learned from OEF and OIF. Ft Detrick, MD: Borden Institute; 2012: chap 1. http://www.cs.amedd.army.mil/borden/book/ccc/UCLAchp1.pdf. Accessed March 17, 2017.

16.   Kman NE. Trauma. Clerkship Directors in Emergency Medicine (CDEM) curriculum. http://www.cdemcurriculum.org/index.php/ssm/show_ssm/approach_to/trauma. Updated 2008. Accessed March 17, 2017.

17.   Oker E. Shock. In: Hamilton H, ed. Emergency Medicine: An Approach to Clinical Problem Solving. 2nd ed. Philadelphia, PA: WB Saunders; 2003: 60–74.

18.   Avegno J. Shock. Clerkship Directors in Emergency Medicine (CDEM) curriculum. http://www.cdemcurriculum.org/index.php/ssm/show_ssm/approach_to/shock. Updated 2008. Accessed March 17, 2017.

19.   Wilson R, Wolf L. The poisoned patient. In: Hamilton H, ed. Emergency Medicine: An Approach to Clinical Problem Solving. 2nd ed. Philadelphia, PA: WB Saunders; 2003: 259–285.

20.   Thibodeau L. Poisoning. Clerkship Directors in Emergency Medicine (CDEM) curriculum. https://cdemcurriculum.com/poisonings/. Updated 2008. Accessed October 10, 2017.

21.   Charcoal, activated. Drugs.com. https://www.drugs.com/monograph/charcoal-activated.html. Accessed January 25, 2018.

22.   Lawson L. Cardiac arrest. Clerkship Directors in Emergency Medicine (CDEM) curriculum. https://cdemcurriculum.com/cardiac-arrest/. Updated 2008. Accessed October 10, 2017.

23.   Leschke R. Cardiopulmonary and cerebral resuscitation. In: Mahadevan S, Garmel G, eds. An Introduction to Clinical Emergency Medicine. New York, NY: Cambridge University Press; 2005: 47–62.

24.   Neumar RW, Shuster M, Callaway CW, et al. Part 1: executive summary: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 suppl 2):315–367.

Chapter 33

TACTICAL MEDICINE

LANNY F. LITTLEJOHN, MD,* AND BRENDON G. DREW, DO†

INTRODUCTION

BACKGROUND

Tactical Environment

History of Combat Death Statistics

Wounding Patterns

TACTICAL COMBAT CASUALTY CARE OVERVIEW

Origins

Definitive Proof of Effectiveness

Phases of Care

Contrast to Civilian Prehospital Care

HEMORRHAGE CONTROL

Tourniquets

Hemostatic Dressings

Junctional Hemorrhage

AIRWAY MANAGEMENT

CHEST TRAUMA

DAMAGE CONTROL RESUSCITATION

Fresh Whole Blood

Stored Constituents of Blood

Artificial Colloids

Crystalloids

Best Strategies for Fluid Resuscitation

Emerging Adjuncts to Damage Control Resuscitation

MEDICATIONS

Tranexamic Acid

Pain Control

Antibiotics

CASE REVIEW

CONCLUSION

*Commander, Medical Corps, US Navy; Command Surgeon, Naval Special Warfare Development Group, Dam Neck, Virginia Beach, Virginia

†Commander, Medical Corps, US Navy; Chairman of Emergency Medicine, Naval Medical Center San Diego, San Diego, California

INTRODUCTION

Medical practice in a limited-resource operational environment frequently differs from “standard” practice in a fully resourced hospital in the United States. Battlefield trauma care is based partly on standard US guidelines, such as the Advanced Trauma Life Support (ATLS) course, but also with an eye toward the unique considerations of a forward deployed environment. This chapter will highlight important operational medical skills and guidelines, such as those delineated in the Tactical Combat Casualty Care (TCCC) guidelines and the Prehospital Trauma Life Support (PHTLS) manual.[1] Thorough appreciation of these concepts is important not only for the practice of individual military medical officers (MMOs), but also for MMOs’ oversight and empowerment of further forward deployed providers (eg, corpsmen and medics) who provide care close to the point of injury.

BACKGROUND

Tactical Environment

Delivering medical care in the tactical environment is one of the most daunting tasks an MMO will be asked to prepare for and accomplish. This care takes place at the confluence of several challenging situations, including austere environments, limited resources (in both personnel and equipment), unusual and severe wounds, and the possible presence of a dangerous enemy. Exhibit 33-1 provides a more complete listing of conditions and concerns in this environment.

Considering these factors, MMOs must prepare to care for the severely injured while also considering human performance issues related to environmental extremes. In extreme and austere settings, the human body is required to operate outside its normal daily training pattern and adjust to the effects of high altitude, cold, heat, or other factors. Each of these conditions involve a host of problems and medical treatment options, including the very real concerns of infectious disease. Health problems caused by these threats, collectively referred to as disease and nonbattle injury (DNBI), have been the leading cripplers of fighting forces throughout history. These topics are further discussed in Chapter 20, Physical Fitness; Chapter 21, Performance Nutrition; Chapters 22 through 24, on environmental extremes; and Chapter 40, Preventive Medicine in the Deployed Environment.

Environmental elements affect not just the human body, but also the equipment required to care for it. The battlefields of Operation Enduring Freedom (OEF) have seen temperatures from below freezing, in January at Bagram Airfield in Parwan Province, to upwards of 137°F, in August in Helmand Province. In the Hindu Kush mountains, to the extreme northeast, operations reportedly took place as high as 15,000 to 17,000 feet, higher than any peak in the continental United States. In both Iraq and Afghanistan, fine dust penetrates nearly any container except a tightly sealed zip-lock bag. Thus, any equipment used in these conditions can be expected to eventually fail. Blood products may rapidly be rendered useless when generators fail or blood reefers (refrigerators) simply cannot maintain products at 0°C to 10°C indefinitely.

To prepare for success in the tactical setting, mindset is a fundamental consideration for MMOs. In addition to normal US practice standards of care, MMOs must also know how to handle the unique wounding patterns, resource limitations, and tactical considerations common in this setting. There are three main objectives in providing care to a casualty during a tactical or combat mission:

1. Provide the best possible care for the casualty.

2. Minimize additional casualties.

3. Maximize the probability of mission success for the unit.

Mindset is also enhanced by remembering the differences between principles and preferences, as described in the PHTLS manual.1(xxi) “Principles” are medical care goals that must be accomplished to best take care of the patient. “Preferences” are how these goals are accomplished in the context of the entire casualty care scenario. For example, in hemorrhage control, the principle is to stop the bleeding. The preference will depend on the unique casualty care scenario and the tactical setting. One might choose to immediately place a tourniquet while under effective hostile fire, even if there is only moderate bleeding, whereas in a safer environment, a provider might apply a pressure dressing as the initial action.

EXHIBIT 33-1

CHALLENGES OF THE TACTICAL ENVIRONMENT

- Hostile fire

- Darkness

- Altitude

- Weather extremes

- Prolonged evacuation

- Limited resources

- Provider training level

- Mission completion

- Tactical considerations

- Local disease prevalence

To deliver the very best care in challenging environments, MMOs must have a strong font of knowledge and a wider breadth of skills than their civilian counterparts. A provider should have multiple ways of accomplishing tasks such as securing an endotracheal tube. MMOs must also understand the tactics, techniques, and procedures unique to their unit; be thoroughly versed in the unit mission; and develop a collegial working relationship both with the command and with the medics or corpsmen working under their supervision. The joint operational environment US forces commonly work in requires an understanding of all other medical capabilities—those in other US units, interagency organizations, and coalition partners. Decisions must be made about which medical capability will be placed where during unit operations. Casualty scenarios almost always involve both medical and tactical problems. Thus, the MMO must communicate TCCC principles to unit leaders throughout their assignment to the unit so that appropriate management and evacuation plans can be developed in the context of the overall tactical situation.

Before discussing specific injuries in the combat environment, some further broad principles must be covered. Predeployment training for the different services continues to differ significantly, even for similar missions. It is incumbent on providers to pay close attention in training and to seek further training early once they are informed of a pending deployment. On their initial deployment, MMOs are rarely fully prepared to experience and manage combat trauma; thus, exposure to actual trauma, as well as contact with providers who recently returned from combat operations, is essential. Examples of in-depth trauma training for military providers can be found at the Navy Trauma Training Center at Los Angeles County/University of Southern California Medical Center, the Air Force Center for Sustainment of Trauma and Readiness Skills program at the University of Cincinnati Medical Center, and the Army Trauma Training Center at the University of Miami/Jackson Memorial Hospital Ryder Trauma Center. In addition to these programs, which leverage civilian-military partnerships, each service sponsors numerous local and unit training opportunities.

MMOs should study their unit’s various missions in depth prior to deployment, because not all tactical medicine will occur on combat missions. For example, Exhibit 33-2 lists the numerous possible missions of a Marine expeditionary unit deployment. Lastly, the MMO should thoroughly study the environment of care and resources available in the specific area of operations. Limited treatment and rapid evacuation to a higher level of care may quite possibly be the best option for a given patient and tactical scenario.

History of Combat Death Statistics

To understand the basic statistics involved in describing combat casualties, the terms “killed in action” (KIA), “died of wounds” (DOW), and “case fatality rate” (CFR) must be defined. Up to 90% of all casualties who do not survive die on the battlefield before arriving at a dedicated field hospital. These casualties are described as KIA. KIA has classically served as an indicator of weapon lethality and the utility of protective measures, both of which have increased steadily over time. If a casualty survives to be admitted to a field hospital, but then later dies from injury, they are described as DOW. DOW has been seen as an indicator of the effectiveness of combat casualty care. A combination of KIA and DOW is the CFR, which is an indicator of the overall lethality of the battlefield.

Organized prehospital trauma care had its birth on the 19th century battlefields of the Napoleonic wars. With each major conflict since, lessons learned were promulgated to the civilian sector; conversely, in times of peace, civilian medical advances were transitioned to the military medical community. These exchanges have not always been seamless, but the civilian community has often profited significantly from military medicine. The following examples of advances in military medicine led to major improvements in civilian medicine.

EXHIBIT 33-2

POSSIBLE MISSION PROFILES FOR A MARINE EXPEDITIONARY UNIT

- Amphibious assault

- Security, stability, transition, and reconstruction operations

- Support theater security cooperation activities

- Humanitarian assistance

- Noncombatant evacuation operations

- Tactical recovery of aircraft, equipment, personnel

- Airfield operations from expeditionary sea or shore-based sites

- Airfield or port seizure operations

- Joint and combined operations

- Maritime contingency operations

- Visit, board, search, and seizure operations

During the Civil War, Jonathan Letterman established an ambulance corps under the command of a medical officer, and the concept of a field hospital emerged, as well as the correlation of treatment time and survival rates. The prolonged trench warfare of World War I led to a significant rise in DNBI cases of trench foot, frostbite, and hypothermia. Blood products, first used on the battlefield at the close of World War I, were further developed during the interwar years. During World War II, blood products were further improved, as were methods of pain control in combat casualty care. A formalized triage system was utilized to prioritize casualty evacuation. Antibiotics were developed.[2] Brian J. Ford, a British scientist, noted, “If any good can be said to become of war, then the Second World War must go on record as assisting and accelerating one of the greatest blessings that the twentieth century has conferred on man—the huge advances of medical knowledge and surgical techniques. War, by producing so many and such appalling casualties, and by creating such widespread conditions in which disease can flourish, confronted the medical profession with an enormous challenge, and the doctors of the world rose to the challenge of the last war magnificently.”[3]

Moving surgical care further forward was the hallmark of the Korean War, with the development of mobile Army surgical hospital (MASH) units and helicopter casualty evacuation.[4] Helicopters were used extensively during the Vietnam conflict, but despite this rapid mode of casualty movement, the CFR remained essentially unchanged from World War II, due to a lack of significant changes in the training and equipment supplied to combatants and medics who provided initial care. Further, poorly designed and translated animal studies on blood volume replacement led to the recommendation to enhance lost circulating blood volume with crystalloid (replacing blood lost by a factor of three). In a 1970 cohort of 2,600 casualties, 7.9% of injuries resulted from isolated extremity wounds that would have been amenable to a simple tourniquet, and were likely worsened by crystalloid resuscitation.[5]

The CFR did not decrease significantly until OEF and Operation Iraqi Freedom (OIF)—from 16.5% in Vietnam to 8.8% today.[6] The KIA and DOW rates were similar in World War II and Vietnam: 88% and 12%, respectively. Considering OEF and OIF together, the KIA rate was 77% and the DOW was 23%. This indicates that casualties are surviving longer due to improved initial care and resuscitation (despite the increased lethality of weapons), and more severely injured casualties are making it to the combat support hospital before succumbing to their injuries.[7]

A major reason for this improvement was the change in tourniquet use. Early in OEF and OIF, there was still an inordinate amount of potentially preventable deaths. Holcomb et al[8] found that 25% of casualties in their series would have survived with the simple application of a tourniquet. Kelly et al[9] found a 7.8% rate of potentially preventable deaths resulting from failure to use a tourniquet when indicated. In the latest comprehensive study of deaths on the battlefield, by Eastridge et al,[10] there were 23.3 deaths per year from isolated extremity hemorrhage in the “pre-tourniquet” years, dropping dramatically to 3.5 deaths per year from this mechanism after tourniquets had been widely distributed on the battlefield and all combatants had been trained and encouraged in their use.

Wounding Patterns

For the past decade, the predominant type of injury on the battlefield has been penetrating wounds (75%). Survivability has been upwards of 90%; whereas in Vietnam it was 84%, and in World War II, 80%.[7] This increase is due to better trained tactical prehospital providers, better protective equipment, faster evacuation times, and improved far-forward care.

Better personal protective equipment such as modern body armor has changed the wounding patterns in the current conflicts in comparison to World War II, Korea, and Vietnam (Table 33-1). There are now fewer thoracic injuries and more head, neck, and extremity trauma. Most combat-related injuries are now from explosions, followed by gunshot wounds.[11] The extremities have the highest rate of injury, followed by the abdomen, face, and head.[12] The most common type of battlefield injury currently is the multiple fragment wound to multiple anatomic sites. Throughout all warfare over the past 2 centuries, the most common site of injury has been the extremity. Because the leading cause of preventable combat death is exsanguination from compressible hemorrhage, it is important to build a combat casualty care paradigm around hemorrhage control, moved as far forward as possible—even to the individual combatant and first responder.

TABLE 33-1

WOUNDING PATTERNS IN MAJOR US CONFLICTS

Conflict

Type of Warfare

Top Mechanisms (%)

Distribution, Top Sites (%)

Civil War

Napoleonic (set piece)

GSW, explosions

Data not found

WWI

Trench (defensive)

Explosions

Extremity (70)
Head/neck (17)
Other (4)

WWII

Mechanized land, amphibious assault

Mortar (39)
Bullet (33)
Grenade (12)

Extremity (75)
Thorax (8)
Other (9)

Korea

Amphibious, mechanized

Data not found

Extremity (67)
Head/neck (17)
Thorax (7)
Abdomen (7)

Vietnam

Jungle warfare, COIN

Bullet (30)
Mortar (19)
IED (17)

Extremity (74)
Head/neck (14)
Thorax (7)

OIF/OEF

COIN, asymmetric warfare

IED (64)
Bullet (26)
Mortar (3)

Extremity (55)
Head/neck (27)
Abdomen (6)

COIN: counterinsurgency

GSW: gunshot wound

IED: improvised explosive device

OIF/OEF: Operation Iraqi Freedom/Operation Enduring Freedom

WW: World War

TACTICAL COMBAT CASUALTY CARE OVERVIEW

Although the “golden hour” concept has been controversial when studying the injured as a population,13,14 what is unquestioned is that the lives of the injured overwhelmingly lie in the hands of those who place the first dressing. The right treatment, in the right tactical situation, and at the right time requires the focus of research, training, and education to be on the role and capabilities of the forward prehospital provider.

For decades, prehospital (and hospital) providers had been trained to care for combat casualties with principles based on civilian trauma care. However, combat trauma and civilian-based trauma differ in terms of wounds, resources, and environmental conditions. Toward the end of the 20th century, it was realized that the principles of ATLS, though sound within a civilian framework, were not just deleteriously affecting the outcome of the combat casualty, but were also dangerous for those delivering care at the point of injury. For example, treating a gunshot wound to the face in a tactical situation at night, a provider could blindly focus on the ATLS “A” for airway, leading to violation of tactical lighting principles and exposure to enemy fire. Airway maneuvers could wait until the patient had been moved to an area of cover, and maneuvers that do not require any bright “white” light could be performed, protecting both the patient and provider. As is stated throughout the TCCC curriculum: good medicine can be bad tactics, and bad tactics can get others killed and/or cause the mission to fail.

Origins

TCCC was an initiative that began at the Naval Special Warfare Command in 1993, resulting in the publication of the first introductory paper on the concept in 1996.[15] Although this article provided a solid foundation, the sheer volume of rapidly advancing research in the field of combat trauma has required the Committee on TCCC (CoTCCC) to meet regularly to review new research, direct findings from the battlefield, and recommendations from leaders in the field of combat trauma. The CoTCCC is composed of trauma surgeons, emergency physicians, operational unit physicians, combat medics, corpsmen, and pararescue specialists, spanning the entire realm of providers who might be called on to treat the injured.

The CoTCCC was initially independent, then became part of the Defense Health Board before being integrated into the Joint Trauma System. Recommendations and curriculum changes are published in the Journal of Special Operations Medicine and in the PHTLS manual. TCCC is the only set of battlefield trauma guidelines to receive a triple endorsement by the American College of Surgeons Committee on Trauma, the National Association of Emergency Medical Technicians, and the Department of Defense (DoD). The guidelines can be viewed open source at http://www.naemt.org/education/TCCC/guidelines_curriculum. Recently, the Committee on En Route Casualty Care and the Committee on Surgical Combat Critical Care were established by the Joint Trauma System at the Army Institute of Surgical Research in San Antonio, Texas, to broaden standardized treatment guidelines for combat trauma patients.

As recent lessons learned from war became integrated into civilian trauma care in the United States, a synergistic and reciprocal relationship developed between TCCC and Tactical Emergency Medicine Support (TEMS) protocols, which are practiced by law enforcement tactical teams, the FBI, and other state and federal agencies. Although the relationship between TCCC and TEMS is quite strong and direct, the relationship between the principles of TCCC and ATLS is less so.

Definitive Proof of Effectiveness

In the late 1990s, the 75th Ranger Regiment was directed by its commanding officer (General Stanley McChrystal) to aggressively adopt TCCC. McChrystal directed this elite combat unit to focus on four items in training: (1) marksmanship, (2) physical training, (3) small unit tactics, and (4) medical training (TCCC). Thus, TCCC was integrated into programs of instruction, training exercises, and planning at all levels. This integration, along with tactical leader assumption of responsibility for the casualty response system, continues to be an entirely different method from the training and casualty response approach taken by other ground combat units within the DoD—a paradigm that must change for battlefield trauma care to be improved. Results of a comprehensive analysis showed that on more than 8,000 missions over a 10-year period, the Rangers lost only 28 men, despite being one of the most heavily engaged units in combat operations. None of these deaths were from a preventable cause.[16] Recognizing its effectiveness, the Defense Health Board now recommends that TCCC training be provided in a tiered fashion to all personnel operating in the battle space.[17]

Phases of Care

TCCC is divided into three phases of care, with the priorities of care shifting depending on the phase. In care under fire (CUF), a provider is required to take actions in caring for a casualty when under “effective” hostile fire. While this definition is vague, in CUF fire is being directed toward the provider or casualty. The priority is to ensure that the uninjured provider stays reasonably safe so that medical care can be delivered when the situation allows (a dead or injured medical provider cannot provide effective care). The casualty should be retrieved only when suppressive fire can be effectively provided. The only two pieces of “medical” gear utilized at this time are a weapon (the best medicine on the battlefield is fire superiority) and a tourniquet (to stop life-threatening hemorrhage). Tourniquets are applied immediately by the casualty (self-aid) or by someone else once the casualty has been moved to cover (buddy aid or medical care).

Tactical field care (TFC) occurs once effective hostile fire is no longer present. There still may be a threat of hostile fire, but the risk is lower (if more enemy move into the area, the threat may increase and providers may find they are back in CUF). TFC is conducted in the forward environment, so gear remains limited to what the medic or far-forward medical officer carries on their person. This equipment will vary depending on the operation and available resources. If vehicles are in use, there may be extra equipment carried in a vehicle kit. If infiltration is by airborne operations or forced march, the equipment will be limited to a small medical pack.

The final phase of TCCC is tactical evacuation (TACEVAC). This phase may provide the first opportunity to begin resuscitation with blood products. There should be additional monitoring equipment available, as well as the presence of ventilators and other more advanced equipment. Older terms for evacuation are casualty evacuation (CASEVAC) and medical evacuation (MEDEVAC); CASEVAC usually indicates a “vehicle of opportunity” where dedicated medical care is not present, and MEDEVAC usually indicates the presence of a dedicated medical provider. In reality, these terms overlap considerably and have led to confusion, so TCCC refers to any evacuation as simply TACEVAC.

Contrast to Civilian Prehospital Care

The approach to trauma care in combat is different than the approach of ATLS in a civilian environment. The ATLS mnemonic “ABCDE” (Airway, Breathing, Circulation, Disability, Exposure) is not used in a tactical environment; instead, combat trauma is prioritized according to the “MARCH” paradigm: Massive hemorrhage, Airway, Respirations, Circulation, Hypothermia.

Control of bleeding takes precedence over all other efforts. Once a casualty loses blood, there may be a significant delay before volume can be replaced. Tourniquets should be used readily and early, with frequent reassessments for their need. Attention to the airway and cervical spine are delayed until the TFC phase, when the casualty and rescuer are both removed from hostile fire. Airway maneuvers require too much risk to the provider in terms of time and exposure in CUF. Because the majority of injuries are penetrating, the likelihood of an unstable cervical spine fracture is negligible during combat operations, unless there is significant blunt force trauma (as in a large explosive device blast or vehicular crash).

Casualties with loss of consciousness who are spontaneously breathing are given a nasopharyngeal airway and placed in the recovery position (on their side with slight flexion). To minimize the risk of hypothermia, clothing is removed only where necessary to treat injuries. Intravenous (IV) access is not performed for casualties with a strong radial pulse and normal mentation in the setting of mild to moderate wounds. Oral rehydration is adequate in these casualties.

Another concept included in TCCC is the futility of basic cardiopulmonary resuscitation (CPR) for any casualty without signs of life. The pathophysiology of circulatory arrest in a trauma scenario is completely different than in a medical scenario. Closed-chest CPR requires that the heart have adequate volume to pump. In trauma, an arrest is usually from causes that do not respond to closed chest compressions: hypovolemia due to hemorrhage results in inadequate volume; tension pneumothorax (TPTX) prevents venous return to the heart, leading to inadequate preload for CPR to be effective; and cardiac tamponade prevents the atria and ventricles from filling. Specific TCCC principles and techniques, shaped by the combat trauma setting, are discussed in detail below.

HEMORRHAGE CONTROL

Tourniquets

Tourniquets should be applied early and liberally if there is any question of exsanguinating hemorrhage. Despite the obvious effectiveness of tourniquets at saving lives due to exsanguination from extremity injuries, the tourniquet has fallen in and out of favor periodically over centuries.18–20 Concerns historically related to tourniquet application include loss of limb, ischemic pressure damage, rhabdomyolysis, nerve or vascular damage, and reperfusion syndrome. However, with updated technology and proper training, modern tourniquets applied properly do not result in these complications. Documented complications from currently approved tourniquets are primarily caused by improper application. Despite reported rates of “non-indicated” tourniquets ranging from 47%[21] to 74%,[22] research has shown that morbidity from liberal tourniquet use in the global war on terror has been minimal, and no permanent complications have been documented as a result of proper tourniquet application and management.23–25 While a complete discussion of the history of tourniquet use is beyond the scope of this chapter, no controversy currently exists as to the effectiveness of properly applied tourniquets at saving lives.

Numerous articles have been published on the evolution of the modern tourniquet.26–28 The push for an effective battlefield tourniquet was a direct result of continued cases of death from extremity exsanguination early in OIF/OEF. Several factors were taken into consideration, including ease of self-application; durability; logistics (cost, weight, and volume); and width. Wider tourniquets provide arterial occlusion at lower pressures and therefore lower the risk of direct pressure damage to tissue.

Of the CoTCCC-approved tourniquets, the most important factor in selecting which to carry is familiarity. More rapid application is associated with decreased blood loss. Proper training leads to familiarity and more rapid application (both in the decision to apply and in actual device employment). In a study of Canadian military personnel, the primary tourniquet fielded over several years was applied the fastest by trained medics.[29]

Proper application of a tourniquet includes stopping arterial flow distal to the tourniquet; venous tourniquets represent a significant concern. A tourniquet may be applied with enough force to initially stop visual bleeding, but it may not stop all arterial flow to the extremity. This eventually leads to paradoxical bleeding as venous return is impeded and tissues become engorged.[30] The risk of venous tourniquets is high in the CUF phase. With lifesaving maneuvers taking precedence over diagnostic maneuvers in some tactical situations, the patient’s uniform is not likely to be removed (so there is incomplete evaluation of the wound site) and boots may remain on their feet (so absence of distal pulse is not confirmed). Rates of venous tourniquet placement in the prehospital setting as high as 83% have been documented. Given the potential complications associated with a venous tourniquet, proper application is extremely important.

Properly applied tourniquets cause ischemia that starts at the area of application and extends distally. Factors such as duration of application, temperature, and location affect the extent of tissue injury. Despite the general consensus that tourniquets applied for less than 2 hours are safe,31,32 there is no consensus on the upper limit of “safe” tourniquet use. A recent extensive review published in the orthopedic surgery literature was unable to definitively answer this question.[33] Further complicating the discussion is a documented case of an upper extremity tourniquet left in place for 16 hours with successful return of function to the injured limb. Factors such as distal placement and cold ambient temperatures likely contributed to the good outcome in this case.[34]

With emphasis on early placement of tourniquets in the CUF phase of TCCC, any applied tourniquet must be repeatedly reevaluated for proper placement (absence of arterial pulse) and the need for continued use. The careful and deliberate process of evaluating tourniquets for removal is called conversion. The potential for significant blood loss and hemodynamic decompensation with the haphazard removal of tourniquets has been documented back to World War II.[35] Contraindications to attempted conversion include amputations, active shock, and an inability to continuously monitor the extremity. Tourniquets that have been in place for more than 6 hours should not be removed until the patient has reached a definitive care setting with laboratory and close monitoring capabilities. In 2015, the TCCC guidelines were updated to ensure that all tourniquets are reevaluated at each level of care and no more than 2 hours after initial placement. A step-by-step process for conversion was first published in 2005[27] and updated in 2015.[31]

Hemostatic Dressings

The last decade has witnessed a surge of products designed to manage severe bleeding in compressible areas not amenable to tourniquet application, or for use when a tourniquet might be deemed inappropriate. Collectively, these products are termed hemostatic dressings or hemostatic agents. However, despite extensive research, no single hemostatic dressing has emerged as superior. The ideal properties of current TCCC-recommended hemostatic dressings are listed in Table 33-2.[36]

In 2003, the first hemostatic agent selected by the CoTCCC was the HemCon (Medline, Northfield, IL) bandage; this was followed by QuikClot (Z-Medica, Wallingford, CT) granules.[37] After continued research into more efficacious products, in 2008 Combat Gauze (Z-Medica) was selected by the CoTCCC as the first-line hemostatic dressing. Today there are three products that meet the CoTCCC requirements for effective hemostatic dressings: HemCon ChitoGauze, Quick-Clot Combat Gauze, and Celox Gauze (MedTrade Products, Crewe, UK).

TABLE 33-2

PROPERTIES OF TCCC-RECOMMENDED HEMOSTATIC DRESSINGS

Criteria

Combat Gauze*

Celox Gauze†

HemCon Chitogauze‡

Stops arterial bleeding after 2–3 min of compression

Yes

Yes

Yes

Low side effects

Yes

Yes

Yes

Easy to use

Yes

Yes

Yes

Light weight

Yes

Yes

Yes

Tolerates environmental extremes

Yes

Yes

Yes

Long shelf life

3 years

4 years

3 years

FDA approved

Yes

Yes

Yes

Effective in coagulopathy

No

Yes

Yes

*Z-Medica, Wallingford, CT

†MedTrade Products, Crewe, UK

‡Medline, Northfield, IL

FDA: Food and Drug Administration

There are three main mechanisms of action for the hemostatic properties of these products. Dressings that concentrate clotting factors work through the rapid absorption of the water content of blood, leaving remaining coagulation proteins and platelets at the site of the wound. The archetype product with this mechanism of action was the original QuikClot granular formulation, adopted by the US Navy and the Marine Corps as their initial hemostatic agent of choice. QuikClot contained a zeolite mineral that absorbed water; however, its loose granules and an exothermic reaction caused safety concerns.[38]

Mucoadhesive agents (chitosans) react with blood and wounded tissue to form a glue-like substance that effectively seals or tamponades the wound. The hemostatic properties of chitosan appear to be by direct electrostatic interaction between negatively charged cell membranes of the erythrocytes and positively charged chitosan. These agents display strong adherence to tissues and physically seal bleeding wounds.[39] The first mucoadhesive product approved was the HemCon bandage, adopted by the US Army as its first-line hemostatic agent. However, because the mucoadhesive barrier is a physical phenomenon, there is a theoretical danger of re-bleeding if an initially hypotensive patient is resuscitated to a normal blood pressure.[40]

Procoagulants act by either activating the coagulation cascade or by supplying clotting factors at the site of injury. Combat Gauze is the only current FDA-approved product in this category. It is a gauze impregnated with kaolin, which activates the intrinsic pathway of coagulation.[41] Due to the efficacy concerns with HemCon and the safety concerns with the original granular QuikClot, the CoTCCC recommended Combat Gauze as the only hemostatic dressing that passed both efficacy and safety testing. Later, both Celox Gauze and ChitoGauze (two mucoadhesive products) were included, after well-designed studies showed their efficacy to be similar to Combat Gauze.42,43

Successful application of these agents requires that a wound be firmly packed so there is a direct interface between the hemostatic gauze and the injured tissue. After application, pressure is maintained by the tightly packed wound, supplemented with an adequate pressure dressing. For most hemostatic dressings, pressure is held manually after wound packing for a minimum of 2 minutes before pressure dressing application. In fact, in some wounds the method of packing appears to be more important than the hemostatic dressing utilized.[44] Additional methods to provide pressure similar to a pressure dressing are to use a stapler to approximate the wound edges over the dressing, apply a non-vented chest seal over the wound, or place a new device on the wound called the iTClamp (Innovative Trauma Care, Edmonton, Canada).

Junctional Hemorrhage

A recent review of battlefield casualties over a 10-year period found that 90.9% of deaths were due to hemorrhage. Sites of lethal hemorrhage were truncal (67.3%), junctional (19.2%), and peripheral extremity (13.5%).[10] Junctional regions are those areas of the body where the extremities join the torso, such as the groin or axilla, and are too proximal for extremity tourniquet application. High junctional wounds are often not amenable to hemostatic dressings and are therefore termed noncompressible. If one of the new junctional tourniquet devices had been applied to the casualties with junctional hemorrhage, it is postulated that up to three US casualties per month would have been saved over the last decade of combat operations.[45]

Three junctional devices are currently approved by the FDA: the SAM Junctional Tourniquet (SJT; SAM Medical Products, Portland, OR); the Combat Ready Clamp (CRoC; Combat Medical Systems, Fayetteville, NC); and the Junctional Emergency Treatment Tool (JETT; North American Rescue, Greer, SC). The unilateral CRoC device has been evaluated on humans as well as in swine, manikin, and cadaver models. Assembly time to final application was reported to range between 55 and 90 seconds, depending on the surface condition and casualty model used.[46] In the swine model, the device was 100% successful in controlling bleeding just superior to the inguinal ligament using four to nine turns of the windlass.[47] Both the JETT and SJT treat combined pelvic and lower extremity injuries by incorporating a pelvic binder with bilateral hemorrhage control devices at the femoral arteries just distal to the inguinal ligament. In a fresh human cadaver model designed to recreate arterial flow at normal physiologic blood pressures, blood flow was halted in the femoral arteries with four to eight complete turns of the windlass handle, achieving success in controlling hemorrhage in all cases. Bilateral control of hemorrhage was achieved in 10 to 17 seconds after application, whereas the CRoC took 68 seconds to achieve bilateral control.[48] Improvised control of hemorrhage at junctional sites can also be achieved by securing either a rigid water bottle or a rolled SAM splint over the inguinal area and securing tightly with a regular (extremity) tourniquet.

AIRWAY MANAGEMENT

Airway problems in the tactical setting may seem daunting, but treatment is usually not difficult with appropriate predeployment training and a planned approach. Airway management begins during the TFC phase of TCCC. Control of significant external hemorrhage remains the first priority.

Most casualties who need airway management are simply unconscious or have altered mental status; the most likely source of airway compromise is occlusion by the tongue. This can be addressed in several ways. Immediate placement of the casualty in the recovery position is the favored initial maneuver. After this has been done, a nasopharyngeal airway is recommended to allow for a patent airway past the tongue and soft tissues of the oropharynx. Casualties may go in and out of consciousness; therefore, oropharyngeal airways should be avoided because they may stimulate the gag reflex and vomiting.

Traumatic airway obstruction, commonly related to facial or neck trauma, may also occur. These injuries have accounted for nearly 2% of combat-related deaths in OIF and OEF.[49] Airway obstruction of this nature ranks as the third leading cause of preventable combat death. Depending on the training and skill of the operator, endotracheal intubation in the tactical setting may be difficult, so a surgical airway (cricothyroidotomy) is frequently the airway of choice. However, recent evidence suggests that the failure rate of cricothyroidotomy can be as high as 33% when conducted by prehospital providers.[50] Using the Cric-Key technique is currently the preferred method.[51]

While researchers look for improved methods of surgical airway management, MMOs should be prepared for other options such as supraglottic airways. These are more beneficial for the patient who may have airway compromise due to sedation or pain control. Because most airway compromise is from tongue occlusion or facial trauma, and most of these patients have an airway occlusion but are otherwise spontaneously breathing, it is usually not necessary to place the casualty on a ventilator or use a bag valve mask. However, if providers have the skills for advanced airway management, they should also be able to conduct positive pressure ventilation with these devices. Due to equipment failure and battery life problems, the presence of a bag valve mask is essential.

CHEST TRAUMA

According to the Joint Theater Trauma Registry, thoracic trauma has been the cause of lethal injury in 5% to 7% of all deaths in OEF and OIF.52,53 TPTX, which is lethal yet readily preventable, ranks as the second leading cause of preventable combat death. Thus, the evaluation of the chest, and the immediate treatment of life-threatening injuries that compromise breathing, ranks only behind controlling massive hemorrhage in preventing death in combat casualties. Potentially life-threatening wounds also include closed pneumothorax and open pneumothorax (a sucking chest wound that can significantly compromise breathing efforts). The most serious condition, TPTX, can result in rapid collapse of respiratory and cardiovascular function. This occurs as air progressively enters the intrapleural space over time from either the external environment (via a chest wound with a ball-valve effect) or from internal bronchopulmonary disruption. The progressive “tension” of air pressure decreases venous return to the heart. This decreases preload, places pressure on the heart chambers that further decreases filling, and collapses the ipsilateral lung, which impedes pulmonary oxygen exchange. Clinical hallmarks are symptoms of progressive dyspnea and altered mental status. Signs are hypotension, hypoxia, cyanosis, jugular venous distension, decreased breath sounds, and hyperresonance to percussion on the injured side of the chest.

Closed pneumothoraces are rare in the combat setting but can occur as a result of blunt trauma. This condition is rarely diagnosed in the prehospital setting and should not be expected to result in a TPTX unless the patient is placed under positive pressure ventilation. If penetrating chest trauma has occurred and there is any significant hemodynamic instability or respiratory distress, the presence of a TPTX should be assumed. Performing a needle thoracentesis has the potential to save a life in this situation, and even if TPTX physiology is not present, a pneumothorax is likely. The downside of needle thoracentesis is small compared to the potential life saved.

The standard first-line intervention for a suspected TPTX in the prehospital setting is the placement of a needle thoracostomy (NT) with a 14-gauge, 3.25-inch (8.25-cm) angiocatheter in the thorax to relieve pressure. However, concerns about this technique have arisen due to the technical aspects of needle placement. The classic teaching is to perform an NT at the second intercostal space in the midclavicular line, and that an audible and palpable rush of air should be heard and felt if any significant pressure is relieved. However, recent studies have challenged the effectiveness of this approach. Some of the disadvantages cited have been inadequate catheter length, kinking of the catheter, and occlusion by clots.54,55 Autopsy and computed tomography chest studies have demonstrated a 50% failure rate for standard length angiocatheters in the second intercostal space due to chest thickness. Other studies indicate that placement of the chest tube at the fourth intercostal space, anterior axillary line, has a higher success rate.[56] This location can be readily accessed without the removal of body armor, an advantage in certain combat settings.

When NT was isolated and standardized in a porcine model of TPTX, the failure rate of NT compared to tube thoracostomy (TT) was 58% (TT was successful in 100%).[57] It must be noted that an earlier paper by Holcomb et al showed a success rate for NT of 100%.[58] Careful analysis of the model showed that the definition of TPTX was a fall in cardiac output of 20% in the Holcomb paper, which was much milder than the definition in the former study, where cardiovascular collapse was precipitated (fall in systolic blood pressure [SBP] >50% or pulseless electrical activity). The conclusion could be made that NT is effective at relieving less severe compromise from tension physiology, but that finger thoracostomy or TT is likely required in the casualty who is rapidly decompensating.

The experience of the Israeli Defense Forces is instructive in this regard. Although their transport times are much shorter than the US experience in OEF and OIF, providers treated 111 casualties with NT over a 5-year period, and reported a failure rate of treatment for presumed TPTX with NT of 32%. All the failures required a TT in the field.[59] In the austere setting, it is likely that finger thoracostomy followed by an overlying vented chest seal is superior with respect to time, technical skill, and contamination than TT, but this has not been studied. The classical teaching of applying a three-sided dressing to allow for air to escape the chest has no evidence to support it, whereas vented chest seals have been very effective in animal models. TT may be favored when there is a Pleur-evac (Teleflex, Morrisville, NC) available and the casualty is spontaneously breathing, or if there is suspected significant hemothorax and a cell saver is available for autotransfusion. Neither of these situations is likely in the prehospital environment due to logistical restraints.

Open pneumothoraces are usually not lethal in and of themselves, but can lead to significant morbidity when they are large enough to compromise the natural physiology of breathing. When the chest wall defect is equal to or greater than two-thirds the size of the trachea, air will preferentially enter the chest through the wound during normal spontaneous respirations.[60] The use of a fully occlusive dressing, which has been recommended for decades, does not allow accumulating air to exit the chest. This has the potential of converting a less lethal wound (open pneumothorax) to a more lethal one (TPTX).[61] Thus, occlusive/non-vented chest seals require constant vigilance if used, which is not a desirable situation in a far-forward environment with possible multiple casualties and a rapidly evolving tactical situation. For this reason the current recommendation is to use vented chest seals to treat open pneumothoraces. Several studies indicate that most commercial vented chest seals are highly efficacious, unlikely to lose their seal (a dangerous complication) or become ineffective due to clotting blood.62,63

DAMAGE CONTROL RESUSCITATION

“Damage control” is a term of naval origin and refers to the capacity of a ship to absorb damage and maintain mission integrity. If a ship is damaged and begins to take on water, there are approaches used to minimize the damage so that the vessel remains afloat and suffers minimal “physiological disruption” to its critical systems and infrastructure. The term “damage control surgery” (DCS) was coined to refer to this same approach in a severely traumatized patient. DCS entails immediate surgery to control internal bleeding and minimize contamination from gastrointestinal trauma. In the present era, DCS has become the standard of care for battlefield trauma surgery. “Damage control resuscitation” (DCR), a logical offshoot of DCS, has become the standard of care for expeditionary medical facilities treating combat casualties.64,65 DCR focuses on minimizing the effects of the lethal triad (hypothermia, acidosis, and coagulopathy). It entails early transfusion of blood products to restore intravascular volume (minimizing crystalloid use), permissive hypotension, keeping the patient warm, and using adjuncts to support the coagulation system (tranexamic acid [TXA], fibrinogen, Factor VIIa). DCR should begin at the point of injury and continue to the time of initial lifesaving surgery and beyond.

Because 90% of battlefield deaths occur before the casualty reaches a medical facility, there is a keen interest in pushing damage control principles and techniques further forward.[66] Care of the severely traumatized combatant is difficult at the point of injury and differs significantly from civilian practice. Civilian concepts and procedures often have to be “unlearned,” and military medical practice may need adjustment to better fit the tactical situation.[67] Additionally, although the categories of shock are useful as a theoretical construct, in reality they are often unreliable in the individual casualty. In one study, for patients who had an estimated blood loss of over 40% (class IV shock), the median heart rate was 95 and the median systolic blood pressure was 120.[68] Vital sign derangements may signal that a patient is in shock, but normal signs do not ensure they are not in shock.

Ideally, casualties beginning to show the first signs of shock should receive fresh whole blood (FWB), or blood components that mimic the constituency of whole blood. Because this is not logistically feasible for mobile combat units dispersed away from organized medical facilities, a focus on hypotensive resuscitation and minimal fluid administration appears to be the only legitimate strategy. Circulatory access is obtained via the IV or intraosseous (IO) route, and fluid is administered to achieve enough perfusion to maintain a conscious patient with a palpable radial pulse. If fluid must be administered, it can be given via oral, IV, or IO routes.[69]

An important caveat to fluid resuscitation is that it must be determined whether the patient’s hemorrhage is definitively controlled versus uncontrolled (or even possibly uncontrolled). For casualties with definitively controlled external hemorrhage, the resuscitation endpoint should be an adequate SBP (≥110).[70] For any casualty with controlled external hemorrhage, but at risk of ongoing internal hemorrhage (eg, from a gunshot wound to the torso or high amputation from an improvised explosive device), the provider should still consider hypotensive resuscitation targets, which are adequate mentation, a palpable radial pulse, or an SBP of 90 to 110,[70] as the mainstay of prehospital resuscitation endpoints. While it may seem unnerving and counterintuitive based on protocols in civilian trauma, hypotensive resuscitation has reduced the risk of death in all trials in which it has been investigated.[71]

The 1994 landmark, paradigm-shifting paper by Bickell et al showed that crystalloid resuscitation for patients with penetrating torso trauma produced a lower survival rate than delayed resuscitation.[72] However, transport times in this study averaged 15 minutes, whereas, in the combat environment, evacuation times can be from 2 to 4 hours (Desert Storm) to 15 hours (Mogadishu), depending on the conflict, region, and existing military presence and medical evacuation structure.[73] Fortunately, ATLS now only recommends 1 L of crystalloid.[74] The Bickell study, along with mounting information that IV fluid resuscitation exacerbates the profound inflammatory state of hemorrhagic shock, prompted the Office of Naval Research to ask the Institutes of Medicine to review fluid resuscitation strategies.[75] Ultimately, the TCCC guidelines were rewritten to limit fluid resuscitation to patients in shock, with the use of blood products, lower volumes, and specific endpoints as a goal.[76]

Since the 2005 World Health Organization expert consensus panel on prehospital care for the trauma patient found little evidence that advanced prehospital interventions were superior to basic interventions,[77] it is imperative that every medical provider be an expert in hemorrhage control, know how to quickly move the patient to a surgical facility, and be cognizant of the nuances of DCR. When considering fluid resuscitation for the patient in shock, there are four objectives in the prehospital setting:

1. Enhance clot forming ability.

2. Minimize the negative effects of resuscitation (edema, hemodilution).

3. Restore intravascular volume and organ perfusion.

4. Optimize the delivery of oxygen.

Other than FWB, the ideal resuscitative fluid is yet to be found. The debate about crystalloids versus colloids in the treatment of shock has continued unabated since they were introduced. Blood components such as packed red blood cells (PRBCs), while necessary to transport oxygen, also increase morbidity and mortality.[78] Artificial hemoglobin carriers have significant side effects that continue to restrict their use in humans. No resuscitative fluid is totally benign, and all may potentiate the cellular injury associated with hemorrhagic shock if not used judiciously. These agents should be viewed as medications with specific indications and dosing parameters.

It should be noted that only combined resuscitation with red blood cells (RBCs) and plasma is associated with improved survival, even when evacuation times are short.[79] In a recent article on fluid resuscitation by the CoTCCC,[80] the preferred fluids for hemorrhagic shock in descending order of preference were:

1. FWB.

2. 1:1:1 plasma, RBCs, and platelets.

3. 1:1 plasma and RBCs.

4. Reconstituted dried plasma, liquid plasma, or thawed plasma alone or RBCs alone.

5. Hextend.

6. Lactated Ringer (LR) solution or Plasma-Lyte A (Baxter Healthcare, Deerfield, IL).

Fresh Whole Blood

Nothing replaces lost blood from hemorrhage like FWB from an immediate donor. Because it is fresh, one unit has the hemostatic power of 10 units of platelets.[81] The only prehospital guidelines that currently support the use of FWB are the TCCC guidelines (TACEVAC section). Whole blood transfusion was the standard for resuscitation from hemorrhagic shock in World War II, Korea, and Vietnam.[82] Since the Vietnam era, objections to FWB use have arisen, including the risks of ABO incompatibility, transfusion-related disease, graft versus host disease (GVHD), and reduced exercise tolerance in donors. However, current evidence appears to refute these concerns. In OIF III (2003–2011), 13% of all transfused patients received FWB[83] without significant sequelae. Approximately 10,000 FWB transfusions to US personnel occurred in OEF and OIF, and only two complications of survivable transfusion-related reactions were recorded, as well as one fatal case of GVHD.[84] In an article on blood donation in the Norwegian Special Forces, there was no decrease in either physical or skill (shooting) performance after donating one unit (450 mL) of blood for “buddy transfusion.”[85] Cold-stored whole blood is FDA approved for up to 21 days; however, FWB is not currently FDA approved and has been utilized only in emergency combat trauma scenarios. Currently the US Army’s 75th Ranger Regiment has an approved protocol[86] based on updated evidence[87] that allows providers to draw O-negative blood from donors prior to missions for use in case of severe trauma with significant hemorrhage. This program is now becoming more widely used within US Special Operations Command.

Stored Constituents of Blood

The past century has witnessed many changes to the practice of blood administration. One of the most profound has been the transition from using whole blood to using components of blood (RBCs, plasma, platelets), which came about without clinical validation of which patients needed which products.

Stored blood transfusion involves major complications, and is an independent predictor of mortality in civilian trauma, likely due to the toxic products of stored components that accumulate over time.[78] When FWB is not available, thawed plasma at a 1:1 ratio with PRBCs is the current resuscitation strategy for hypovolemic shock due to blood loss at combat support hospitals. Simultaneously, a whole blood donor drive is initiated.

Plasma alone is an effective volume expander, does not activate the pathways of cellular injury, and provides physiologic quantities and ratios of clotting factors. Freeze-dried plasma is used extensively by the Israeli Defense Forces,[88] but is approved for use by only a few US special forces far forward. Freeze-dried plasma can be reconstituted in minutes and given to expand plasma volume, provide clotting factors, and buffer the acidosis that occurs with shock. However, plasma has all the drawbacks of blood product transfusion, and frozen plasma involves the logistical burden of cold storage and transport. DoD-funded investigations continue on autologous freeze-dried plasma, and its use may spread from the special operations community to regular combat medical units. Currently freeze-dried plasma is not FDA approved, and there is no mechanism by which conventional medics and corpsmen can utilize it.

Artificial Colloids

Colloids are more effective than crystalloids at expanding plasma volume because of the oncotic properties of the large molecules they contain.[89] There are many colloids on the market, but the most widely used in TCCC is Hextend, which is a hydroxyethyl starch in a balanced salt solution similar to LR. Another product, Hespan (B. Braun Medical, Bethlehem, PA), is hydroxyethyl starch in a normalized saline solution. Hextend remains the TCCC forward resuscitative fluid of choice due to its volume-expanding capabilities (6 to 8 hours), decreased logistical burden, and less deleterious coagulation effects than Hespan.[90]

A recent Cochrane review concluded that when fluid resuscitation is required, there is no appreciable difference in outcomes after resuscitation with colloids versus crystalloids.[91] Because combat casualties are resuscitated in a much different environment than civilians, however, colloids offer the distinct advantage of less volume and weight. Resuscitation with Hextend results in one-third the volume requirement of LR[92]; additionally, it has a favorable acid-base profile and has been shown to decrease overall fluid requirements. For these reasons Hextend has replaced LR as the fluid of choice carried by medics in the field.[93]

Crystalloids

During the Vietnam War, crystalloid resuscitation became the standard of care, and volume replacement was recommended at three times the amount of blood loss.[94] This approach was later found to worsen outcomes and also contributed to the development of abdominal compartment syndrome and acute respiratory distress syndrome (known as Da Nang lung when it was first characterized).95,96 It was not until the Bickell study that this practice of aggressive crystalloid resuscitation began to change. This is not a new concept; in 1918 Cannon et al had written that “inaccessible or uncontrolled sources of blood loss should not be treated with IV fluids until the time of surgical control.”[97] Fluid resuscitation in uncontrolled hemorrhage is now known to dilute clotting factors and exacerbate coagulopathy, worsen acidosis (normal saline [NS] and LR have a pH of 5.0 and 6.5, respectively), and disrupt early thrombus.[98]

Crystalloid resuscitation may be considered if no other fluids are available and the casualty needs some sort of volume replacement to maintain blood pressure and mental status. Large volume IV fluid resuscitation is associated with coagulopathy on arrival in the emergency department[99] and contributes to the coagulopathy of trauma.[100] This coagulopathy almost doubles mortality in certain patients.[101] Crystalloids distribute rapidly to the interstitial space and are not as effective for expanding blood volume as colloids, adding only 275 mL to the intravascular space for every 1 L infused.[102] If blood products or Hextend are not available, LR is preferred to NS because it does not induce hyperchloremic acidosis as NS does.[103]

Special mention must be made of one particular crystalloid, hypertonic saline (HTS), for use in the casualty with multitrauma who also has traumatic brain injury (TBI). In TBI, secondary injury, usually related to some degree of hypotension or hypoxia, may be avoidable. Mortality doubles in a hypotensive patient with TBI when compared to normotensive TBI casualties.[104] HTS may be the optimal resuscitative fluid for these patients when hypotension must be treated and cerebral edema avoided.[17] HTS refers to any concentration of sodium chloride above physiologic (0.9%); common concentrations are 2%, 3%, 5%, 7%, and 23%. The osmotic actions of HTS have been well categorized. The discovery of extraosmotic actions such as immune modulation and augmentation of cerebral blood flow are intriguing and invite further study, but the evidence remains mixed. A metaanalysis of six trials and 604 subjects showed that HTS-dextran provided a discharge survival rate of 38%, versus 27% for the NS control, in the subgroup of patients who had sustained multitrauma with concomitant TBI.[105] A randomized, controlled trial in TBI cases comparing HTS (7.5%) to LR showed no difference in ultimate neurologic outcomes or mortality.[106] Data from the Research Outcomes Consortium likewise showed no benefit of HTS solutions in TBI.[107] Once started, HTS should be titrated to keep serum sodium concentrations at 145 to 155 mEq/L, and cessation should be gradual secondary to concerns of rebound cerebral edema and herniation.

Best Strategies for Fluid Resuscitation

Two broad approaches may be considered for resuscitation in combat casualties. In the delayed resuscitation approach, fluid is withheld until bleeding is definitively controlled. This was the approach in the Bickell paper; it is appropriate if transport times are very short, typically less than 30 minutes. In contrast, permissive hypotension is the TCCC-recommended approach. Here fluid is given only to improve SBP to approximately 90 mm Hg, which corresponds to preserved mentation and a palpable radial pulse. This standard TCCC approach should be utilized in almost all combat casualty care scenarios. A Hextend bolus of 500 mL is given if blood products are not available, and this may be repeated once if required by resuscitation endpoints.

Resuscitation endpoints generally used are mental status, heart rate, SBP, mean arterial pressure (MAP), skin texture and color, and urine output. Laboratory tests such as lactate or base deficit are beneficial only to guide resuscitation after hemorrhage has been controlled.[108] However, these tests are usually not available until a Role 2 facility is encountered and thus are not useful in the initial management of severely injured casualties. Once natural hemostasis has occurred in penetrating trauma animal models, re-bleeding has been found to occur at around 94 mm Hg.[109] In the only randomized controlled trial in humans of hypotensive endpoints versus normal resuscitation strategy, there was no difference in survival.[110] Thus it is reasonable to promote an endpoint strategy of normal mentation and an SBP of 80 to 90 mm Hg or MAP of 60 to 65 mm Hg, corresponding to a palpable radial pulse.

Hypothermia is common in combat casualties, and even mild hypothermia can affect the function of platelets and clotting factors.[111] Thus, the capability to deliver warmed fluids is critical in the far-forward setting. To preserve heat in casualties, the patient’s clothing and protective gear should be left on (when feasible) during transport. Forward providers should have hypothermia prevention management kits available and use them aggressively. Doors should be closed on vehicles and aircraft during transport.

Emerging Adjuncts to Damage Control Resuscitation

Advances in controlling extremity and junctional hemorrhage over the last decade have left truncal hemorrhage as the source of most potentially survivable injuries. In the landmark paper by Eastridge et al, truncal hemorrhage represented 67.3% of all potentially survivable injuries due to hemorrhage.[10] Two innovations may possibly contribute to reducing deaths due to truncal hemorrhage when there is a delay to surgical care. Resuscitative endovascular balloon occlusion of the aorta (REBOA) involves placement of an endovascular balloon into the aorta to control hemorrhage and increase afterload in patients with exsanguinating hemorrhage. Civilian trauma centers have successfully used REBOA, and it is beginning to transition into forward resuscitative care.[112] It is imperative that the balloon be placed either in zone I (supraceliac aorta) or zone III (infrarenal aorta). Zone I placement is essentially a balloon “cross-clamp” of the aorta, so balloon inflation time is limited to less than one hour due to mesenteric ischemia. Zone III placement may be helpful in cases of pelvic fractures, but placement here with a vascular wound proximal to the balloon would result in more rapid exsanguination.[113] In civilian trauma centers, placement is confirmed by fluoroscopy, which is not available in forward theater. The use of ultrasound is difficult due to its user-dependent nature. Therefore, a landmark approach is normally used. Because of mixed civilian results, lack of methods to reliably confirm balloon position, and uncertainty of the internal wounding pattern, REBOA is not currently recommended for use in the combat environment, but research on the technique will continue.

Self-expanding polyurethane foam to control severe intraabdominal hemorrhage is also gaining traction as a method to decrease potentially survivable deaths due to truncal bleeding. It is nearing FDA approval, is more easily administered by prehospital providers than REBOA, and may be used for up to 4 hours as a hemostatic bridge to definitive surgical care.[114]

MEDICATIONS

Tranexamic Acid

The acute coagulopathy of trauma is gaining recognition as a significant factor in treating patients with traumatic hemorrhage. Recent reports show that coagulation derangements are present on presentation to the emergency department in 38% of combat casualties[115] and 25% of civilian trauma victims[116] presenting to a level I trauma center. While the causes of coagulopathy are multifactorial (consumption of factors and platelets, dilution from prehospital resuscitation, hypothermia, acidosis, inflammation), the phenotype of this initial coagulopathy appears to be primarily fibrinolytic (increased fibrinolysis), particularly when standard prehospital resuscitation strategies are followed.[117] If this is true, then stabilizing initial thrombus with an antifibrinolytic such as TXA makes sense. Several recent studies have shown this to be an effective therapy to decrease mortality from hemorrhage in trauma patients.

The largest and most important study was the CRASH-2 trial.[118] This prospective randomized controlled trial included 20,211 trauma patients with significant hemorrhage or at risk of significant hemorrhage. The patients were randomized to receive either placebo or TXA (1 g of TXA over 10 minutes within 8 hours of injury, and then an additional 1 g as an infusion over 8 hours). Absolute risk reduction in the TXA group was significant in this trial, and the number needed to treat was around 68 overall.

Early treatment with TXA is important. The CRASH-2 trial analysis showed a significant survival advantage if given within 1 hour of injury (P < .0001). If given from 1 to 3 hours post injury, the significance fell (P = .03). Given after the 3-hour point, the risk of death due to bleeding increased (P = .004).[119]

The MATTERS trial, a retrospective study of 896 patients who required a blood transfusion, took place at Camp Bastion, a large combat support hospital in Helmand Province, Afghanistan.[120] In this trial, 293 casualties received TXA (the remainder did not). The TXA group had a lower unadjusted mortality (P = .03) despite being more severely injured (higher injury severity score; P < .001). Benefit was greatest in a subgroup of patients who received a massive transfusion (P = .004). TXA use was independently associated with survival (CI 3–17) and less coagulopathy (P = .003).

Dosing of TXA is per current TCCC guidelines: if it is anticipated that a patient will need a significant blood transfusion (eg, presents with hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding), then 1 g of TXA in 100 mL NS or LR should be administered as soon as possible, ideally within the first hour of injury. The second infusion of 1 g TXA should begin after other IV fluid treatment. The greatest survival benefit reported is when TXA is given within 1 hour of injury and continues for up to 3 hours after injury. If it is initiated beyond that timeframe, the risk of death due to bleeding could increase.

Pain Control

Recent military conflicts have prompted significant advances in controlling pain (see Chapter 36, Acute Pain Management in the Deployed Environment). These advances have benefited patients (and providers) from the point of injury through definitive care in the United States. Three areas in particular have driven this change. The first is the need to deliver pain medications without IV access. This has led to advances in transmucosal (oral and nasal) medication administration. The second is the resurgence of ketamine use in the US military. During a period when the US military relied on the morphine auto-injector, other military121,122 and civilian[123] providers around the world in austere, resource-limited situations were proving ketamine’s safety and efficacy. The third is the recognition that early control of pain on the battlefield decreases the incidence and severity of posttraumatic stress disorder (PTSD).[124]

Advanced knowledge of limited resuscitation strategies among providers has decreased the need for IV or IO access in the combat environment. Access is logistically challenging (carrying supplies) and technically difficult (unsterile conditions, evacuation, and vehicle movement) in the combat environment. Providers are comfortable and familiar with oral medications such as nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, and opiates/opioids from training and hospital practice. They are much less likely to be familiar with oral transmucosal fentanyl citrate (OTFC), expanded use and variable-dose ketamine, and the intranasal administration of medications including fentanyl, ketamine, midazolam, naloxone, and flumazenil. In 2014, the CoTCCC published expanded pain control guidelines under the title “Triple Option Anesthesia,” and the Wilderness Medical Society published “Practice Guidelines for the Treatment of Acute Pain in Remote Environments.” Both organizations included recommendations for the use of OTFC and ketamine.125,126

While a broad array of analgesic and sedative options exist, this discussion will focus on OTFC, ketamine, and intranasal medication administration. Common hospital practice for pain control relies primarily on acetaminophen, NSAIDs, and oral or IV opioids. Very few formal training programs include a discussion of alternative drugs and alternative routes of administration. One exception is ketamine, which has seen an expanded profile of use over the last decade in civilian care. Ketamine has been used extensively outside of the United States and by other militaries for decades. Low-dose ketamine is used in acute and chronic pain control, intraoperative and postoperative burn care, depression, emergence reactions to general anesthesia, and postoperative opioid hyperalgesia. Historical concerns related to increases in intracranial127–129 and intraocular pressure[130] have been dispelled by recent literature. Ketamine has been shown not to increase the incidence of PTSD in at-risk military personnel[131] and has even been used to treat PTSD.[132] Another benefit of ketamine is multiple routes of administration, including IV, IM, and intranasally. Given logistical challenges in the austere setting, intranasal delivery can be particularly useful. Other medications that can be delivered intranasally include fentanyl, midazolam, naloxone, and flumazenil.

Low-dose (subdissociative) ketamine is typically given at doses of 0.2 to 0.5 mg/kg by slow IV push or drip over several minutes. Dissociative dosing is 1 to 2 mg/kg IV or 4 to 5 mg/kg IM. Intranasal dosing is 0.5 mg/kg/dose. TCCC guidelines recommend titrating lower doses of ketamine until pain control is achieved or nystagmus is observed. In the authors’ experience, dissociation via the intranasal route is very difficult to achieve because the patient becomes less and less cooperative.

No discussion of ketamine would be complete without a discussion of its psychiatric and behavioral side effects. These behavioral disturbances are classically referred to as emergence reactions, but they actually occur in two distinct phases. The first is during the titration of low-dose ketamine, when the patient becomes incompletely dissociated and occasionally quite difficult to control. These side effects may also be observed as dissociative doses of ketamine are wearing off, which is the classic emergence reaction. In either instance, most cases resolve with reassurance, but some cases may require additional medications. The tactical situation dictates whether the provider needs to calm the patient with midazolam or completely dissociate the patient with additional ketamine. One example is during TACEVAC, when uncooperative or agitated patients present a danger to themselves, the providers, and the aircraft/aircrew. Midazolam can cause respiratory depression, which is challenging to observe and manage during flight, so increasing the dosage of ketamine may be the best option.

Several military studies have been published on the safety and efficacy of OTFC. The original dose of 1,600 µg was shown to be safe and effective without side effects, except in cases where IV opioids were coadministered.[133] A more extensive and recent review of lower dose OTFC (800 µg) demonstrated safety and efficacy as well.[134] Wedmore was the first to discuss the additional safety measure of taping the fentanyl “lollipop” to the patient’s finger.[135] This has commonly been described as the “SOF PCA” (Special Operation Forces patient-controlled analgesia). The weight of the patient’s upper extremity will pull the medication out of the mouth when and if the patient becomes somnolent. This prevents both overdosing and choking on the lollipop.

Antibiotics

Antibiotics also fall into a specific group of medications that are considered time sensitive in combat injuries.[136] Early tactical care recommendations for antibiotics were based on likely tactical situations where irrigation and surgical debridement were not immediately available.[137] Choices focused on antibiotics with the most favorable logistical (and tactical) properties, such as broad spectrum of action, ease of administration, long duration of action, and lower cost.[138]

Current TCCC guidelines recommend moxifloxacin, cefotetan, or ertepenem for use, as soon as tactically possible, at the point of injury. Moxifloxacin is given to casualties who can tolerate oral medication administration without vomiting or risk of aspiration. Ertepenem or cefotetan can be given IV or IM for patients unable to tolerate oral medications. Anecdotally, medics tend to prefer ertepenem for its once-daily dosing and lack of reactivity in patients allergic to penicillin or cephalosporin. Broad-spectrum antibiotics are discontinued as soon as possible, tailored to the patient’s wounding pattern and operative care. In addition to published TCCC guidelines and updates, the best available evidence and expert recommendations were compiled in 2008[139] and updated in 2011 by the Infectious Diseases Society of America and the Surgical Infection Society.140–142

In 2009, a review of antibiotic use in patients with combat wounds who were treated and returned to duty found decreased wound infection rates with systemic antibiotic prophylaxis.[143] More recently, in 2011, a larger retrospective review of point-of-care antibiotics was conducted. The authors found no benefit and no harm from antibiotics alone (such as multidrug-resistant infections).[144] This study does not provide enough information to dissuade providers from administering antibiotics early; rather, it demonstrates the complicated nature of the problem, which includes difficulty adhering to guidelines,[145] mechanism of injury,[146] evacuation time, and time to surgical care. The 2011 study also supports data showing that multidrug-resistant pathogens do not contaminate the initial wound.144,147,148 Rather, colonization and infection by multidrug-resistant pathogens are healthcare related.149,150 The 2011 panel weighed their recommendations for antibiotics as 1C (strong recommendation/low-quality evidence) for point-of-injury antibiotics, and 1B (strong recommendation/moderate-quality evidence) for the antibiotics to be given within 3 hours. The fact that no recommendation received a 1A (strong recommendation/high-quality evidence) reinforces the challenges associated with reviewing care in the most austere conditions.

CASE REVIEW

A remarkable example of coordinated use of recent techniques, tactics, and procedures in tactical medicine occurred on a cold night in mountainous terrain in February 2016. During a Special Operations-led assault force mission in the early morning hours, several members were injured, including one US combatant who was shot in the chest twice just above the ballistic plates in his armor with 7.62-mm caliber rounds. The patient was immediately moved to a protected area and evaluated. In addition to the gunshot wounds (two entrance wounds in the high chest and one large exit wound in the back) he had shrapnel wounds from a grenade on his arms and face. IV access was obtained early, and TXA and freeze-dried plasma were administered. The patient was then transported by litter (during which his IV was lost) to a helicopter landing zone and turned over to an aeromedical team. The patient was evacuated via a 15-minute flight to a prepositioned DCS team.

During the flight, evaluation showed the patient in obvious shock with a weak radial pulse at 130 beats per minute and an oxygen saturation in the 80s. Due to the ambient temperature, the oxygen saturation was deemed unreliable and mental status was used as evidence of end-organ perfusion (pain medication was withheld after the patient stated he could forgo it). A sternal IO needle was placed when no adequate IV access could be found, and the patient received an additional unit of RBCs. Also, a small amount of hemostatic dressing was used on the still actively bleeding exit wound, and a vented chest seal was placed over the dressing. An ultrasound quickly ruled out cardiac tamponade or intrabdominal bleeding, but showed large hemothoraces bilaterally. Additional needle thoracostomies were performed bilaterally due to respiratory distress. The patient was more comfortable sitting up, so he was allowed to remain in that position during the flight.

On arrival to the surgical team, the patient continued to worsen. Tube thoracostomies were performed bilaterally, with a few hundred milliliters drained from the left and two liters drained from the right. The patient was intubated, and a large bore central line was placed. He subsequently lost vital signs, and a left lateral thoracotomy was performed. Open cardiac massage was performed for several minutes while intravascular volume was restored. The casualty regained spontaneous circulation after several minutes, and resuscitation continued while he was transported to a Role 3 facility. His Purple Heart ceremony was conducted the next day, and his recovery was uneventful.[151]

This case is presented because it represents the successful translation of evidence-based trauma care to the far-forward environment. The casualty’s DCR was begun at the point of injury with an antifibrinolytic and plasma. IO access was used when IV access was difficult. No crystalloid, other than that used to carry reconstituted medications, was used at all. His 1:1 RBC-to-plasma resuscitation was continued nonstop until he reached Role 3 care (at a combat support hospital). The surgical team was very far forward, while still in a secure location. If the surgical team had not been located where it was, the next nearest location would have been over 2 hours away by helicopter. If standard ATLS protocols had been followed by the aeromedical team, the patient would have been intubated or a surgical airway placed (because he was hypoxic with bleeding around the mouth), he would have been given crystalloid, and he would have received medications that might alter his mental status. If any of these maneuvers had been used, the patient might not have survived. The medical team was extremely well trained and drilled together intensely and often, which is a testament to the value placed on military medicine. Military medical providers protect those who protect the nation.

CONCLUSION

Optimized medical care in the tactical setting is a challenging and rapidly evolving field. If approached with the right mindset, the correct predeployment training, and a proper understanding of the both the principles of Tactical Combat Casualty Care and the overall context of the current resources in the area of operations, good outcomes will be ensured for those who go forth to secure the interests of the nation.

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106.   Cooper DJ, Myles PS, McDermott FT, et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA. 2004;291(11):1350–1357.

107.   Bulger EM, May S, Brasel KJ, et al. Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: a randomized controlled trial. JAMA. 2010;304(13):1455–1464.

108.   Tisherman SA, Barie P, Bokhari F, et al. Clinical practice guideline: endpoints of resuscitation. J Trauma. 2004;57(4):898–912.

109.   Sondeen JL, Coppes VG, Holcomb JB. Blood pressure at which rebleeding occurs after resuscitation in swine with aortic injury. J Trauma. 2003;54(5 Suppl):S110–S117.

110.   Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma. 2002;52(6):1141–1146.

111.   Hess JR, Brohi K, Dutton RP, et al. The coagulopathy of trauma: a review of mechanisms. J Trauma. 2008;65(4):748–754.

112.   Brenner ML, Moore LJ, DuBose JJ, et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg. 2013;75(3):506–511.

113.   Morrison JJ, Galgon RE, Jansen JO, Cannon JW, Rasmussen TE, Eliason JL. A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock. J Trauma Acute Care Surg. 2016;80(2):324–334.

114.   Rago AP, Larentzakis A, Marini J, et al. Efficacy of a prehospital self-expanding polyurethane foam for noncompressible hemorrhage under extreme operational conditions J Trauma Acute Care Surg. 2015;78(2):324–329.

115.   Niles SE, McLaughlin DF, Perkins JG, et al. Increased mortality associated with the early coagulopathy of trauma in combat casualties. J Trauma. 2008;64:1459–1465.

116.   Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003;54:1127–1130.

117.   Bolliger D, Szlam F, Levy JH, Molinaro RJ, Tanaka KA. Haemodilution-induced profibrinolytic state is mitigated by fresh-frozen plasma: implications for early haemostatic intervention in massive haemorrhage. Br J Anaesth. 2010;104:318–325.

118.   Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 201;376:23–32.

119.   Roberts I, Shakur H, Afolabi A, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet. 2011;377:1096–1101.

120.   Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012;147:113–119.

121.   Austin TR. Ketamine: a revolutionary anesthetic for the battle casualty. J R Army Medical Corps. 1972;118:15–23.

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124.   Holbrook TL, Galarneau MR, Dye JL, Quinn K, Dougherty AL. Morphine use after combat injury in Iraq and posttraumatic stress disorder. N Engl J Med. 2010;362:110–117.

125.   Butler FK, Kotwal RS, Buckenmaier CC 3rd, et al. A triple-option analgesia plan for tactical combat casualty care: TCCC Guidelines change 13-04. J Spec Oper Med. 2014;14(1):13–25.

126.   Russell KW, Scaife CL, Weber DC, et al. Wilderness Medical Society practice guidelines for the treatment of acute pain in remote environments. Wilderness Environ Med. 2014;25:41–49.

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128.   Hughes S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is ketamine a viable induction agent for the trauma patient with potential brain injury. Emerg Med J. 2011;28(12):1076–1077.

129.   Wang X, Ding X, Tong Y, et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth. 2014;28(6):821–827.

130.   Drayna PC, Estrada C, Wang W, Saville BR, Arnold DH. Ketamine sedation is not associated with clinically meaningful elevation of intraocular pressure. Am J Emerg Med. 2012;30:1215–1218.

131.   McGee LL, Maani CV, Garza TH, Slater TM, Petz LN, Fowler M. The intraoperative administration of ketamine to burned US service members does not increase the incidence of post-traumatic stress disorder. Mil Med. 2014;179(8):41–46.

132.   Feder A, Parides MK, Murrough JW, et al. Efficacy of intravenous ketamine for treatment of chronic posttraumatic stress disorder: a randomized clinical trial. JAMA Psychiatry. 2014;71(6):681–688.

133.   Kotwal RS, O’Connor KC, Johnson TR, Mosely DS, Meyer DE, Holcomb JB. A novel pain management strategy for combat casualty care. Ann Emerg Med. 2004;44(2):121–127.

134.   Wedmore IS, Kotwal RS, McManus JG, et al. Safety and efficacy of oral transmucosal fentanyl citrate for prehospital pain control on the battlefield. J Trauma Acute Care Surg. 2012;73:S490–S495.

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139.   Murray CK, Hospenthal DR. Prevention and management of combat-related infections clinical practice guidelines consensus conference: overview. J Trauma. 2008;64(Supplement):S207–S208.

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142.   Murray CK, Obremskey WT, Hsu JR, et al. Prevention of infections associated with combat-related extremity injuries. J Trauma. 2011;71(2 Suppl 2):S235–257.

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148.   Wallum TE, Yun HC, Rini EA, et al. Pathogens present in acute mangled extremities from Afghanistan and subsequent pathogen recovery. Mil Med. 2015;180(1):97–103.

149.   Weintrob AC, Murray CK, Lloyd B, et al. Active surveillance for asymptomatic colonization with multidrug resistant gram negative bacilli among injured service members—a three year evaluation. MSMR. 2013;20(8):17–22.

150.   Scott P, Deye G, Srinivasan A, et al. An outbreak of multidrug-resistant Acinetobacter baumannii-calcoaceticus complex infection in the US military health care system associated with military operations in Iraq. Clin Infect Dis. 2007;44(12):1577–1584.

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Chapter 34

MASS CASUALTY PREPAREDNESS AND RESPONSE

GERARD DEMERS, DO, DHSC, MPH,* AND JOHN WIGHTMAN, MD†

INTRODUCTION

SCOPE OF THE PROBLEM

IMPACT ON HEALTHCARE SYSTEMS

GARRISON PREPAREDNESS AND RESPONSE

Emergency Management Cycle

Incident Command System

DEPLOYED ROLES FOR JOINT HEALTH SERVICES

Defense Support to Civil Authorities

Foreign Humanitarian Assistance

Combat Operation Injury Patterns

UNIVERSAL MASS CASUALTY PRINCIPLES

Scene Management

Rapid Needs Assessment

Triage

Casualty Collection Points

Transportation Management

SUMMARY

*Captain, Medical Corps, US Navy; Navy Medicine East EMS/Disaster, Medical Director, Prehospital and Disaster Medicine Specialty Leader, Department of Emergency Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland; Associate Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Colonel, US Air Force, Medical Corps; formerly, Wing Surgeon, 24th Special Operations Wing, Air Force Special Operations Command, Hurlburt Field, Florida; Professor and Chair, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

Vulnerant omnes, ultima necat.

“Every hour wounds, the last one kills.”

INTRODUCTION

When a catastrophic event results in patient volume, injury severity, or both greater than a medical system is designed to manage at any given time, it is identified as a mass casualty situation, or MASCAL in military terminology. The only generally accepted commonality among these incidents is that they generate more patients and care requirements within a span of time than a response system can manage with available resources at the normally accepted standard of care. According to the World Health Organization (WHO), “Mass casualties following disasters and major incidents are often characterized by a quantity, severity, and diversity of injuries and other patients that can rapidly overwhelm the ability of local medical resources to deliver comprehensive and definitive medical care.”[1]

Terms sometimes used interchangeably with MASCAL are tragedy, disaster, catastrophe, and calamity, and although none of these have exact definitions either, there are distinctions. A tragedy is any event that causes great suffering, but that could involve one person or a hundred, and is certainly viewed through the lens of each person being physically or emotionally impacted. Other terms often relate to relatively large-scale events causing significant or widespread damage. However, none of them have to involve casualties. If an entire region’s communications system becomes disabled or destroyed, it might be considered a calamity, but no casualties would be directly generated by such an event, regardless of whether its cause is a natural solar flare or a terrorist attack. Collapse of a major bridge might be considered a disaster for the people who depend upon it for personal transportation, commerce, and delivery of goods and services to specific areas, but if no people were on it at the time, it might not result in a mass casualty incident (MCI).

Additionally, what might cause an MCI in a rural community may be routine in a major urban area with a robust emergency medical services (EMS) system and several trauma centers. Multiple-casualty incidents can be effectively and efficiently managed when the processes and resources are in place to do so according to the standard of care accepted by the prevailing culture. The purpose of this chapter is to propose a systematic approach to mass casualty response for the military medical officer (MMO) and suggest considerations for effective medical response operations.

SCOPE OF THE PROBLEM

The scope and nature of MCIs are determined by myriad variables: cause (human-made or natural); magnitude (small or large); scope (confined or widespread); population density (urban or rural); duration (short or long); second-order effects (environmental hazards, transportation limitations, communications capabilities, medical infrastructure, etc); and many more. Total number of casualties (few or many), rate of patient encounters (fast or slow), mechanisms of injuries (trauma or no trauma), distribution of severity (minor to critical), and location or setting (local or remote) also greatly affect the ability of any given healthcare system to manage an MCI.

Causes of MCIs are a convenient way to categorize these occurrences, for example, natural versus man-made (the latter can be further divided into accidental and intentional). Natural disasters include relatively sudden phenomena such as avalanches, earthquakes, and tornadoes; rapidly developing situations such as cyclones and hurricanes, floods and tsunamis, wildfires, winter storms, and volcanic explosions; or progressively worsening circumstances such as extreme heat, drought, and medical epidemics. Accidental manmade events may be precipitated by engineering failures; explosions at industrial and residential sites; or damage to tanks containing hazardous material (HAZMAT) being transported by truck, rail, or ship. Other manmade incidents may be intentionally caused by active shooters or other perpetrators of interpersonal violence, by crashing aircraft into buildings or detonation of explosives, by purposefully causing an industrial or transportation HAZMAT release, or by intentional widespread dissemination of chemical, biological, or radiological (CBR) materials through a dispersion device or a “dirty bomb.” Every one of these actions may result in a wide spectrum of effects, depending on multiple other factors.

Explosive events illustrate event magnitude well because they can be retrospectively quantified based on observations of their effects. The truck-bomb detonated in front of the Murrah Federal Building in downtown Oklahoma City on April 19, 1995, had a blast energy equivalent to 2.2 metric tons of trinitrotoluene (TNT). There were 164 immediate deaths and 680 people injured,[2] many of whom walked to a nearby hospital, significantly impacting the care delivered in the hospital’s emergency department to more seriously injured casualties transported later by EMS.[3] By contrast, the natural explosion of Mount Saint Helens in Washington State on May 18, 1980, generated a blast energy estimated at 24 million metric tons of TNT-equivalents.[4] Nonetheless, this event killed 57 people,[4] so magnitude by itself does not necessarily tell the complete story. The volcano was located in a rural area and the population at risk had significant warning time.

Scope and population density are related concepts. Although large geographical areas or multiple locations may be affected by one or more catastrophic events, the number of casualties will in part be determined by how many people are present. Relatively few people were killed or injured during the Tunguska event of June 30, 1908, when a meteorite estimated to be about the size of a football field exploded in the atmosphere above a sparsely populated region of Siberia with a blast energy equivalent to a 1950s-era thermonuclear device.[5] On the other hand, an actual nuclear device detonated over urban Hiroshima, Japan, on August 6, 1945, immediately killed about 66,000 people and injured an additional 69,000. Each figure was more than a quarter of the population of the city.[6] However, even population density must be considered within the context of the entire event. Drought over a large geographical region might lead to casualty numbers one or more orders of magnitude greater than an out-of-control fire in a city.

Scope also impacts the burden on a given healthcare system. As tragic as the events of September 11, 2001, were, the separated crash locations of New York and Virginia meant that more resources were available at each site than there would have been if all the hijacked aircraft had crashed in one location. Furthermore, these related but separate incidents—at least the two that generated nonfatal casualties to treat—occurred in sizable metropolitan areas where robust trauma systems were in place to manage the large total numbers of injured victims.

Event duration is important with respect to resource depletion. Many healthcare systems may be able to manage the first few, first dozen, or even first hundred casualties—depending on rate of presentation (see discussion below)—but may not be able to sustain a previously acceptable level of care if resources are used at a rate faster than they can be replenished. Even on an individual scale, running out of blood products, for example, limits what can be done for just one casualty who requires more than is available at any moment. On a larger scale, ongoing natural events (eg, multiple consecutive storms, persistent flooding, uncontrollable fires, epidemics) and other situations such as war can produce casualties faster than they can be adequately managed locally or redistributed out of an affected system, use supplies faster than they can be replaced, and exhaust personnel faster than they can be relieved.

Permissive operating environments are those in which host nation military and law-enforcement agencies have control of the population and the intent and capability to assist operations the responding military intends to conduct. Nonpermissive environments are those where host nation forces are either incapable of maintaining control of the population or are hostile to the responding military’s intent. MCIs may occur in either. Those resulting from direct-action combat engagements will be discussed later in this chapter. Complex humanitarian emergencies (CHEs) are a special category that can affect millions of people through many mechanisms, such as violence, disease, starvation, and adverse environmental conditions, over many years and sometimes decades.[7] CHEs may be characterized by any combination of the following[8]:

- widespread damage to societies and economies;

- extensive violence or loss of life;

- massive displacements of people;

- need for large-scale, multifaceted humanitarian assistance;

- hindrance or prevention of humanitarian assistance by political and military constraints; and

- security risks for responders.

The US and other militaries are often called upon to respond to these disasters[9] (which clearly meet Lumley and Ryan’s definition of a catastrophe “where the social fabric of society is disrupted and the medical infrastructure fails”[10]). Sometimes a US military intervention within a nonpermissive environment is required; Operation Restore Hope to Somalia in the early 1990s is a prime example.[11]

IMPACT ON HEALTHCARE SYSTEMS

Disruption or incapacitation of the medical infrastructure is just one of the many second-order effects of disasters. This certainly occurred in Hiroshima and Nagasaki, with widespread destruction of each city by detonation of nuclear weapons. On a smaller scale, this also occurred in Joplin, Missouri, when a category EF5 tornado ripped through the city and severely damaged the only two medical facilities for miles.[12]

The impact of the total number of casualties depends on the availability of space, personnel, equipment, supplies, process efficiencies, and surge capacity of the medical system. Surge capacity is the ability of any system to rapidly accommodate a large increase in throughput. Medical surge capacity involves a continuum with three distinct stages[13]:

1. Conventional capacity. Traditional and normal patient-care facilities and staff meet their normal goals in providing care (status quo).

2. Contingency capacity. Minor adaptations are made that may have minimal impacts on standards of care, but adaptations are not enough to result in significant changes to standards of care.

3. Crisis capacity. A fundamental, systematic change to a system in which standards of care are significantly altered.

The rate of casualty contacts is an important determinant of responsiveness—both in the field as responders encounter victims, and in treatment facilities as casualties arrive on their own or are brought in by bystanders or EMS—as part of the demand side of the supply-and-demand balance. The more compressed the number of casualties per unit of time, the more difficult it will be for any system to manage without needing to alter the standard of care to do the most good for the most people. This concept also relates to event duration, insofar as more casualties might be adequately managed if they arrive over an extended period of time.

One key ability of a system to respond to an MCI is to limit—to the extent possible—the number of patients and the rate of patient encounters for any given resource, so that each component of the response is still able to conduct relatively normal operations with conventional capacity, or satisfactorily adjust to the abnormal circumstances employing its contingency capacity. Every day across the United Sates, some emergency departments efficiently manage 500 patients per 24 hours, while others struggle to effectually care for 50.

Effective casualty management at any location often depends on dividing the workload into manageable pieces. Appropriate staging of casualties and employment of various transportation resources can make casualty movement more efficient. Distributing patients to many different facilities based on moment-to-moment receiving capacities, as well as matching injury type and severity to medical and surgical capabilities, can make the entire system more efficient and effective, especially if no one site is forced to transition from contingency mode to crisis mode.

The cause of the event often dictates what types of casualties are generated. Many cause injuries in one form or another, but even within the general category of trauma, several factors should be considered. For instance, an active shooter will mostly inflict penetrating trauma on the victims. Casualties with gunshot wounds to the neck or torso, but without obviously fatal head wounds, will usually benefit from transport to a trauma center, even if it is 20 minutes further away than a less-capable hospital. Because penetrating extremity wounds can often be stabilized in the prehospital setting, transportation to a facility even farther away might be appropriate for these casualties.

Casualties from an active-shooter event (ASE) have similar injury patterns to those seen in combat environments. Rates of casualty generation often depend on the skill and motives of the gunman, density of the targeted population, and type of weapon used.[14] In one epidemiological study, the most commonly used weapon was a pistol (60%), followed by rifles (27%), and shotguns (10%).[15] ASEs in the United States occurred 160 times between August 2016 and February 2018, with casualty numbers ranging from 0 to 53.[15] The median mortality rate during ASEs is 2, and the median number injured is 4. Business settings were reported as the most frequently attacked (37%), followed by schools (34%), and outdoor settings (17%).[14]

During explosive events, mechanisms of injury include thermal injury from the fireball; direct effects of the blast overpressure (ie, primary blast injury); blunt trauma from bodily displacement; and penetrating wounds from ballistic objects. Building collapse can also cause crush trauma to many casualties at once. Explosions and fires in civilian settings may be caused by intentional means (eg, arson or improvised explosive devices [IEDs]) or unintentionally (eg, vehicular crashes, industrial accidents, or faulty electrical wiring). They may also be caused by natural sources (eg, lightning strikes that initiate wildfires). Explosions in confined spaces or involving structural collapse are associated with greater morbidity and mortality.[16] Building collapse leads to inhalation injuries, crush injuries, and higher fracture rates in survivors.16,17

Many circumstances determine casualty numbers in conventional explosions, including confined space versus outdoors, size of the explosive charge, proximity of victims to the explosion, and presence of intervening barriers or body armor.[18] The most prevalent post-blast injuries among survivors are multimodal trauma, often with occult internal injuries due to the effects of blast overpressure. Explosive injuries tend to simultaneously affect multiple body regions and organ systems. Blast-related injury patterns include burns, retained foreign bodies, barotrauma, amputations, and traumatic brain injury, among others.[19]

MCIs that occur at mass gatherings have been associated with high rates of morbidity and mortality.[20] Mass gatherings pose several logistical problems for responders, including high crowd density, crowd control, restricted points of entry and movement, difficult access to victims, low security-to-medical personnel ratios, poor fire safety measures, and limited on-site medical care.[21] From 1982 to 2012, 290 mass gathering MCIs were reported, with multiple etiologies and resultant injury mechanisms. The majority (55.9%) of these MCIs involved the movement of people under crowded conditions, leading to stampede. Special hazards such as airplane mishaps, vehicular crashes, and pyrotechnic displays occurred in 19.6%. These categories of injuries were followed in frequency by structural failures (13.1%), intentional manmade events (9%), and toxic exposures (2.4%).[22]

Myriad other accidental and natural events cause trauma as well, but not all MCIs involve trauma. Healthcare systems must be prepared for disease epidemics and the potential consequences of HAZMAT or CBR exposures. Equipment resources could be severely stretched if hundreds of victims in one area required mechanical ventilation after an intentional release of an organophosphate chemical or botulinum toxin. The same might be true following accidental release of a corrosive gas.

Epidemics and pandemics often develop slowly relative to other natural and manmade MCIs. Over the course of time, however, they can consume enormous amounts of resources, and finding solutions in the forms of antimicrobial prophylaxis and treatments for emerging pathogens, particularly when developing new vaccines, can be a lengthy process. CHEs are often initiated by drought or other reasons for population displacements, but MCIs on smaller scales may occur in multiple locations with epidemics in temporary camps or interpersonal violence in fights for scarce survival resources.[23]

Events affecting large geographical areas might cause a variety of effects. Winter storms generate cold injuries and hypothermia, and also often lead to increased numbers of motor vehicle crashes, falls, power-tool injuries, carbon monoxide exposures, dehydration (if access to water is prevented for days), and exacerbations of chronic illnesses due to degraded access to necessary healthcare services and prescription refills.[24]

How the severity of illnesses or injuries is distributed throughout the casualty population affects the resource burden at any one location within the responding system. Some event types typically generate more severe injuries than others. For example, the majority of initial survivors from explosions in open areas are often discharged from emergency departments,[19] whereas explosions inside commuter buses or trains usually generate a higher proportion of critical or severely injured casualties.25–27 Building collapses often increase the number of immediate fatalities,[2] but extrications over an extended period of time will decrease the rate of patient encounters.

The location of the event is an important consideration in both planning and response, which are critically dependent on the capacity and capabilities of the medical infrastructure and the prevailing standard of care acceptable to the population impacted. The level of care deemed appropriate within one culture may not be the same as within another culture. Americans generally expect a high level of care available to all, and persons in countries with socialized healthcare may expect some rationing of resources during the course of even normal operations. Those from impoverished nations may not expect much, and may prefer alternative approaches to healthcare not typically available from the US military operating in their country.

MCIs may occur in any setting: motor vehicle crashes, aircraft or shipboard mishaps, combat operations, or in military support of civilian communities (domestic or international settings). Geographical distribution of casualties may range from concentrated clusters of survivors in an ASE14,15 to widespread areas in an earthquake.28,29 Medical response to MCIs may occur during deployments in urban or geographically isolated settings. Military medical assets may be pre-staged in anticipation of combat-related casualties in conflicts around the world or called upon to augment or fill an MCI response capability in non-combat scenarios as events dictate. Military assets must also be ready to participate in a community response while at home station.

GARRISON PREPAREDNESS AND RESPONSE

Permanent military bases, particularly in the United States, are integral to the communities surrounding them. Military personnel and their families often live off base and civilians commonly work on base. Many military bases are small cities in themselves, and their approach to emergency management should mirror that of other governmental organizations. According to the Federal Emergency Management Agency (FEMA), “Emergency management is the managerial function charged with creating the framework within which communities reduce vulnerability to hazards and cope with disasters [and] protects communities by coordinating and integrating all activities necessary to build, sustain, and improve the capability to mitigate against, prepare for, respond to, and recover from threatened or actual natural disasters, acts of terrorism, or other man-made disasters.”[30] Emergency management is a multidisciplinary function operating within the National Response Framework (essentially the country’s disaster plan, in which authorities, responsibilities, and functions of agencies at all levels are delineated).[31] FEMA has outlined the following eight principles of emergency management:

1. Comprehensive: emergency managers consider and take into account all hazards, all phases, all stakeholders, and all impacts relevant to disasters.

2. Progressive: emergency managers anticipate future disasters and take preventive and preparatory measures to build disaster-resistant and disaster-resilient communities.

3. Risk-driven: emergency managers use sound risk management principles (hazard identification, risk analysis, and impact analysis) in assigning priorities and resources.

4. Integrated: emergency managers ensure unity of effort among all levels of government and all elements of a community.

5. Collaborative: emergency managers create and sustain broad and sincere relationships among individuals and organizations to encourage trust, advocate a team atmosphere, build consensus, and facilitate communication.

6. Coordinated: emergency managers synchronize the activities of all relevant stakeholders to achieve a common purpose.

7. Flexible: emergency managers use creative and innovative approaches in solving disaster challenges.

8. Professional: emergency managers value a science and knowledge-based approach based on education, training, experience, ethical practice, public stewardship, and continuous improvement.[30]

Emergency Management Cycle

Establishing comprehensive general and MCI response programs involves hazard vulnerability assessments, which identify pre-event risks and mitigating factors for reasonably foreseeable disasters, and estimate the associated seriousness of the potential impact of such events on the population and infrastructure. Operational planning for MCIs is optimally predetermined and deliberate, with an “all-hazards approach” across all phases of the emergency management cycle: mitigation, preparedness, response, and recovery (Figure 34-1). This includes developing contingency plans for provisioning, staffing, and training MCI response teams, as well as establishing interagency relationships before urgent or emergent needs arise. Scenario-based training should be added where setting-specific disasters might occur (eg, coastal areas should prepare more for hurricanes and tsunamis, some inland regions flood more than others, certain areas are more prone to earthquakes, and many people live close to industrial sites).[32] While these preparations ideally should occur prior to deployment in a crisis, expedient “just-in-time” training may be required for unprepared responding personnel.

Notification of the need for an MCI response can come with “some warning” or as a “no warning” request for assistance. “Some warning” may occur when an event and its effects can be anticipated, such as in the case of hurricane landfall predictions with likely flooding and possible epidemics. “No warning” may occur in earthquakes or terrorist attacks.[33] In some circumstances, preparation and predeployment of medical assets may be staged in or near a region anticipating a natural event, if there is sufficient deployment time before and protection of those assets as the event unfolds. Organizers of prearranged mass gatherings should always prepare and exercise primary, alternate, contingency, and emergency response plans.[34]

The mitigation phase focuses on eliminating or lessening the impact of disaster-related events and subsequent complications that may result. Factors influencing disaster mitigation include capability of local and regional assets along with medical system resilience to the types of events that could be encountered. Mitigation effectiveness depends on the availability of information on potential hazards, impact risks, and existing or obtainable countermeasures.

The mitigation phase includes long-term policies, programs, and activities designed to anticipate and reduce the adverse effects of unavoidable natural disasters, predictable accidents, and even some intentional events. One example of a casualty mitigation effort is a community evacuation policy for hurricane-prone locations. Another method for mitigating disaster impact on response capacity is establishing memoranda of agreement or understanding between nongovernmental organizations and governmental agencies to provide mutual aid or supporting functions in the event of disasters.[35]

The medical objective for the preparedness phase is to have local governments, civil agencies, and individuals create plans to enhance emergency management operations. These plans are used to develop a constant level of readiness and MCI-response capability via multidisciplinary and interagency collaboration. Medical preparedness measures include training in the incident command system (ICS), updating mutual-aid agreements, operational planning with equipment checks and supply inventories, refamiliarization with communications systems, practicing emergency personnel-recall procedures, and conducting exercises to practice casualty care and patient tracking. Having appropriate response mechanisms, procedures, training, and logistical support in place before an event enhances the ability for medical personnel to respond as effectively as possible to any emergency situation. These measures can be described as operational readiness to deal with disasters; this readiness can be enhanced by rehearsals, developing long-range and short-range strategies, and building early warning methods to protect the population at risk and activate response teams.

Figure 34-1. Emergency management cycle.
ICS: incident command system; MCI: mass casualty incident; PHTLS: Prehospital Trauma Life Support; TCCC: Tactical Combat Casualty Care

Preparedness also involves ensuring that strategic caches of equipment, medical supplies, and other essential items are maintained for regional catastrophe response. Pre-staged equipment near high-risk areas decreases the lift requirements for medical assets responding from outside the affected area. In addition, pre-identified alternative insertion locations and backup care and staging areas provide options in case primary medical treatment sites are rendered unusable.

If the necessary preparations have not been made, the responding medical team is unlikely to effectively meet the immediate needs of the affected population. Personnel who do not conduct prehospital response as part of their normal duties should seek training such as the Prehospital Trauma Life Support course.[36] Communities likely to be affected could also be trained in programs such as basic first aid and Stop the Bleed.[37] Specialized training may also be required for interagency operations, such as medical support of law enforcement in ASEs, as well as other agency contingent roles or functions.

The aim of MCI response is to provide immediate support to reduce morbidity and mortality in the affected population. This is accomplished by providing emergency services including search and rescue, extrication, extraction, stabilization, and evacuation of casualties until more permanent and sustainable solutions can be realized. The response phase focuses on immediate civilian-community or military-garrison actions, which, almost by definition, must occur using functional resources from the affected region. Local resources may be subsequently augmented by governmental, nongovernmental, or ad hoc volunteer teams pre-staged or deploying from a distance. All agencies must be able to respond effectively with experienced leaders and trained personnel, deploy quickly with adequate means of conveyance and logistical support, and possess appropriate interagency communication systems, optimally having rehearsed procedures for emergency settings.

In addition to potential casualties directly generated by an event, patients with exacerbations of chronic medical conditions may present seeking care in large numbers. Community infrastructure may be significantly impacted by a disaster through loss of healthcare access, public health services, or basic utilities, and patients with chronic medical conditions may decompensate due to loss of medications or require services such as outpatient dialysis or oxygen therapy.[38] Gaps in a locally impacted health system may be filled by dedicated teams, including relief of local medical staff, augmentation of local medical facilities for surge capacity, dissemination of provisions, mass prophylaxis or immunization programs, establishment of preventive health measures, and medical support of responders deployed away from their home bases. During these activities, important considerations include how working conditions, such as sanitation, cold or heat stress, dehydration, and psychological stress, may affect responder health. Addressing these issues will decrease the likelihood of adverse effects on team members and consequent loss of manpower.

The recovery phase focuses on rebuilding and restoring the affected community. Recovery begins right after the emergency, and recovery activities may occur concurrently with response efforts. The recovery phase’s duration depends on community resilience, remaining infrastructure, and extent of additional resources brought into the region. Medical response teams may transition operations to temporarily support the affected community until return of local medical system functionalities. After action reports (AARs) are compiled during the recovery phase to help improve processes and team performance for subsequent operations. These activities then loop back to the mitigation phase.

Incident Command System

An ICS is a standardized incident management concept of command and control that allows an integrated organizational structure across agency and jurisdictional boundaries. The basis for the ICS was developed in the 1970s following a series of devastating California wildfires. AARs from these events assessed that outcomes were suboptimal due to unnecessary duplication of constrained resources, lack of standardized communication between responding agencies, ineffective tactics, and inadequate coordination of efforts.[39]

MCI response missions are coordinated through common ICS principles, which provide a unified command structure and a response framework that is not specific to the disaster type, location, or scope. This “all-hazards approach” is best employed in operations where multiple governmental and nongovernmental agencies interact concurrently in the same setting.[39] Tactical field collaborations occur more efficiently within an ICS. Personnel from different organizations are integrated in defined functional roles regardless of an individual’s rank within an individual agency. Positional authority may be granted to personnel with the appropriate skill requirements to meet mission objectives. An ICS provides the flexibility to rapidly activate and establish an organizational structure around needed MCI response functions.

The ICS organizational structure is developed in a modular fashion based on the nature and size of an incident, from a localized to a regional, multijurisdictional response. The specific structure established for any MCI is based on management needs and personnel available to fill functional sections or positions, such as command, operations, planning, logistics, and administration or finance (Figure 34-2). The organization’s configuration is assembled under the authority of the incident commander, who should be the most qualified and appropriate person as the situation dictates. The operations section directs all tactical response to achieve incident objectives. The planning section is responsible for collecting, evaluating, documenting, and synthesizing information to produce actionable plans. The logistics section is responsible for obtaining, maintaining, and accounting for essential personnel, equipment, and supplies. It is also responsible for support services such as facilities, transportation, communications, food, and medical services for incident responders. The finance or administration section is responsible for funding operations, cost analysis, contract negotiation, and timekeeping.

Medical operations are generally assigned to the operations or logistics section under the ICS framework. The primary mission of medical responders is to deliver efficient care to the largest number of victims possible. If focus strays from mission-critical functions, tactical response efforts may be diffused or duplicated at the scene. Having personnel use an ICS event checklist or job-action sheet (Exhibit 34-1) ensures a frame of reference to guide response efforts within a unified command structure.

Figure 34-2. Incident command system functional structure.

DEPLOYED ROLES FOR JOINT HEALTH SERVICES

When healthcare infrastructure and personnel must be brought with deploying forces and set up in countries where insufficient or inadequate resources exist locally, military doctrine dictates a tiered system to manage casualties at any point of injury (POI) through a global system of en-route care and interval stops at mobile or fixed locations, each fulfilling various roles in the continuous management of casualties. Deployed military medical capability is designated in four roles (formerly called “echelons”) of care capabilities[40] (Chapter 14, Introduction to Health Service Support, has a detailed description of the medical roles of care in these settings). En-route care includes care rendered as casualties are moved from POI to definitive care.

Role 1 medical response generally consists of embedded individual or team medical assets within military units who stabilize casualties at the POI and move them to designated casualty collection points (CCPs). Medical supplies are limited at Role 1 and there is no capacity for holding patients, so casualties must be evacuated for further care via ground, air, or water assets as soon as possible. Particularly in Afghanistan, evacuation by air was more commonly employed due to distances and terrain involved and the risks from IEDs on ground evacuation routes.

To augment Role 1 near the POI, Role 2 capability is commonly delivered by medical assets that are mobile enough to be moved periodically to match operational requirements. These platforms are modular and typically include emergency medical resuscitation and surgical intervention assets. Role 2 Light Maneuver teams or units provide advanced medical capabilities where they can be rapidly accessible or deployable with short notification. Limitations of Role 2 staging locations include potential mismatching of resources in asymmetric warfare settings and denied environments, where injuries occur in unexpected locations outside the “reach” of air assets, creating redundancy when assets are placed in close proximity to each other, resulting in overflying of some locations, and creating security risks if enemy forces attack these positions.

EXHIBIT 34-1

JOB ACTION SHEET EXAMPLE

EMERGENCY PLAN
Operations Section
Job Action Sheet
Medical Services Subsection
Triage Unit Leader

TRIAGE UNIT LEADER

Positioned Assigned To: ___________________________________

You Report To: __________________________________(Treatment Areas Supervisor)

Operations Command Center: ______________________ Telephone: _________________

Mission: Sort casualties according to priority of injuries, and assure their disposition to the proper treatment area.

Immediate

□ Receive appointment from Treatment Areas Supervisor.

□ Read this entire Job Action Sheet and review organizational chart on back.

□ Put on position identification name badge.

□ Receive briefing from Treatment Areas Supervisor with other Treatment Area unit leaders.

□ Establish patient Triage Area; consult with Transportation Unit Leader to designate the ambulance off-loading area.

□ Ensure sufficient transport equipment and personnel for Triage Area.

□ Assess problem, triage-treatment needs relative to specific incident.

□ Assist the Patient Areas Supervisor with triage of casualties, if requested by Treatment Areas Supervisor.

□ Develop action plan, request needed resources from Treatment Areas Supervisor.

□ Assign triage teams.

Intermediate

□ Identify location of Immediate, Delayed, Minor Treatment, Discharge and Morgue areas; coordinate with Treatment Areas Supervisor.

□ Contact Safety & Security Officer about security and traffic flow needs in the Triage Area. Inform Treatment Areas Supervisor of action.

Extended

□ Report emergency care equipment needs to Materials Supply Unit Leader. Inform Treatment Areas Supervisor of action.

□ Ensure that the disaster chart and admission forms are utilized. Request documentation/clerical personnel from Labor Pool if necessary.

□ Keep Treatment Areas Supervisor apprised of status, number of injured in the Triage Area or expected to arrive there.

□ Observe and assist any staff who exhibit signs of stress and fatigue. Report concerns to Treatment Areas Supervisor. Provide for staff rest periods and relief.

□ Review and approve the area documenter’s recordings of actions/decisions in the Triage Area. Send copy to the Treatment Areas Supervisor.

□ Direct non-utilized personnel to Labor Pool.

□ Other concerns:

Role 3 medical treatment facilities (MTFs) are relatively fixed in position, and are similar to stateside hospitals with more resources and capability to manage the demands of MCIs than even Role 2 Enhanced facilities. Resources at Role 3 typically include teams of providers, often enough to work shifts; specialized providers and support personnel; and greater availability of blood products, advanced diagnostic imaging, and laboratory assets. Additional capabilities may include neurosurgery, vascular surgery, or other surgical specialties.

Role 4 MTFs provide definitive care with resources such as medical and surgical subspecialties, rehabilitation, and prosthetics. These facilities are generally outside of theater boundaries and provide support to the population at risk on an area basis subject to the limitations of evacuation assets to reach the facility. Role 4 care is typically found in large overseas MTFs (eg, Landstuhl Regional Medical Center) and US-based hospitals and medical centers. Distribution of extraordinary casualty numbers to appropriate facilities throughout the United States—whether the need arises from a domestic disaster or combat casualties returning from overseas—may be managed through the National Disaster Medical System, which is the administrative system under the US Department of Health and Human Services (DHHS) for coordination of resources across jurisdictions throughout the United States.[41]

Despite the tiered structure of deployed capabilities, casualties do not necessarily flow through the four roles in a sequential manner. For example, some casualties may be evacuated directly from the POI to a Role 3 facility, or from a Role 2 forward surgical capability directly to a Role 4 hospital to begin more definitive care.

None of the roles provide every service a casualty might require, and none possess unlimited surge capacity. Therefore, medical personnel should be aware of local medical resources and engage with host nation hospitals in the area whenever available and politically feasible. Regardless of whether deployment occurs overseas or in the United States, conducting site surveys, establishing interpersonal relationships, and preparing written working agreements with medical facilities for specialty care and surge overflow incorporates these resources into medical contingency plans, and thereby establishes a regional capability regardless of country.

Defense Support to Civil Authorities

Stark contrasts may be seen in the response capability of different communities. Industrial nations with robust EMS and healthcare systems may be able to absorb and effectively treat significant numbers of casualties; however, rural or low-income locales may not have adequate health system infrastructure to deal with critical conditions or any significant volume of casualties.

The United States has a tiered domestic disaster response, with local efforts committed first until resources are exceeded. Requests for state aid are then made to support local efforts. When local and state efforts are overwhelmed, the federal government may be asked for national-level assistance. Once a declaration of federal disaster is made, the president of the United States may task the DHHS, the Department of Defense (DoD), or both to provide domestic assistance to local and state assets. When the DoD provides this support, it is known as defense support to civil authorities.42,43 The DoD may also provide specialized support capabilities such as CBR, nuclear, or high-yield explosive disaster response. Examples of DoD domestic disaster response include assistance to Colorado in 2013 for flooding, to the mid-Atlantic and northeastern United States in 2012 for Super-storm Sandy, to Kansas in 2007 after a tornado struck Greensburg, and to the Gulf Coast in 2005 for Hurricane Katrina.

Unique or robust support commonly provided by the military includes transportation, logistics, communications, and rapidly deployable medical care. Transportation and logistical support is often the key capability needed in an area affected by a disaster, either because local or regional assets were disabled or destroyed, or because sufficient resources were not present even before the event.[9] Due to a constant state of readiness, military transportation assets and logistical support can be provided relatively quickly once approvals flow down from the National Command Authority (ie, the president of the United States and the secretary of defense), but approval and mobilization commonly takes 3 to 4 days.

Disasters may drastically impact communication infrastructure in an affected community by damaging wireless or radio towers, causing sustained power outages, and overwhelming networks burdened with too many users. Devastation of the communications infrastructure leaves responding agencies and local populations unable to dispatch medical resources, coordinate resource allocation, or relay critical updates.[44] Embedding self-contained communications capability with deployed units addresses these gaps. Intact communications allow for timely incident system status assessments to be used for initial and subsequent reports from the scene. These updates provide situational awareness to decision-makers. Status updates may also provide alerts to impacted citizens to guide them to temporary medical facilities, shelters, or evacuation destinations.[45] Military communications technology is some of the best in the world, and has the advantage of being designed for use in austere and harsh environments, so it is often helpful to regions with poor infrastructure or degraded capability.

US medical, surgical, and public health assistance can be deployed using a variety of teams from the DHHS or the DoD, but consideration must be given to what will be needed when. For instance, following an earthquake, a region may have a pressing need for acute trauma care when the request for US assistance is made, but that requirement will decrease over time as casualties are either saved or die. By the time trauma teams arrive 4 or more days after the event, they may no longer be needed.

Foreign Humanitarian Assistance

DoD assets may be used in support of foreign disaster relief operations when the following three criteria have been met: the military provides a unique service, international civilian capacity is overwhelmed, and the host nation requests assistance. DoD components provide disaster assistance under presidential directive when the secretary of state requests assistance to support another federal agency, or in emergency situations in order to prevent loss of life.46,47 Recent examples of DoD international disaster assistance include deployments to Southeast Asia in 2013 for Operation Damayan after Typhoon Haiyan (Yolanda) impacted the region, to Japan in 2011 for Operation Tomodachi after a magnitude 9.0 earthquake and subsequent tsunami, and to Haiti in 2010 for Operation Unified Response following a magnitude 7.0 earthquake.

Noncombat illnesses and injuries depend on the nature of the event. Injuries may include penetrating, blast, blunt, thermal, crush, or immersion injuries —or combinations of these. Physical injury represents the major cause of mortality and morbidity for larger MCIs, though secondary morbidity results from public health impacts.40,48–51

Natural disasters can have an especially devastating effect on the population. An annual average of 21 earthquakes over the last 30 years have resulted in a request for international assistance or a declaration of a state of emergency. Many factors in addition to earthquake magnitude influence the MCI casualty distribution. These include the time of the day the event occurred, distance of the population from the epicenter, secondary events triggered by the earthquake, urbanization grade, building standards and regulations, and access to medical care.[28] Death tolls from major earthquakes range from fewer than five to nearly a quarter million.[51]

The majority of conditions in casualties presenting in the first 3 days of an earthquake are due to trauma such as lacerations and musculoskeletal injuries. Crush injuries and subsequent complications pose significant additional challenges for medical management in austere conditions. In addition to acute renal failure, multiple organ systems can be affected. Complications from crush injuries include compartment syndromes, electrolyte abnormalities, arrhythmias, hypovolemic shock, sepsis, acute respiratory distress syndrome, disseminated intravascular coagulation, and cardiac failure.[52] After this acute injury period, the majority of care shifts to a nontrauma profile with a sustained increase in demand for medical services lasting at least 10 days following the earthquake.[52]

From 1980 to 2000, an average of 11,800 deaths per year were attributed to cyclones (hurricanes or typhoons). The average number of cyclone effects on individual nations was 46 per year, with many of these storm systems affecting multiple nations. Conversely, several nations experience multiple storms each year. For example, in 2004, the United States was struck by five hurricanes, four of which made landfall in the state of Florida. A less recent but massive cyclone in 1991 killed about 150,000 people in Bangladesh alone.[53] Secondary weather effects from cyclones include flooding (storm surges), landslides, and tornados. Minor injuries including lacerations, blunt trauma, and puncture wounds are common with cyclone-related incidents, and 80% of these injuries are restricted to lower extremities.[38]

CHEs may be created by US military combat operations, when collateral damage dramatically impacts large civilian populations. On the other hand, most civilian morbidity and mortality during CHEs is due to potentially preventable infectious diseases, malnutrition, and interpersonal violence.54,55 Impacted civilians may present for care during or immediately after combat operations.

Combat Operation Injury Patterns

Modern combat operations have transitioned from massive armies facing off with defined front lines to asymmetric warfare amid low-density, nonlinear, remote, disbursed operations (eg, Afghanistan) and complex urban conflicts (eg, Mogadishu).[56] Smaller conflict sizes have resulted in fewer overall US and coalition casualties, but substantial losses have occurred among the units actually engaged.[56]

Damage sustained depends on the mechanism of injury in each case. Recent rates for wound locations are head (8%), eyes (6%), ears (3%), face (10%), neck (3%), thorax (6%), abdomen (11%), and extremities (54%).[57] Injuries resulting from exsanguinating hemorrhage are often immediately lethal, and thus may benefit from rapid and effective intervention, but up to 50% of these casualties may die without immediate treatment. Approximately 20% of deaths from hemorrhage occur from injuries in body areas where the bleeding might have been controlled by simple direct pressure.56–58 Attention and direction of line commanders in mitigating this risk to forces has been demonstrated to be effective when implemented consistently throughout a combat unit.[59]

Peacekeeping operations have an estimated mean wounded-in-action rate of 3.16 per 1,000 troops per year. The estimated wounded-in-action rate for individual operations ranged from 0.49 to 12.50. In 188 casualty-generating incidents examined, an average of 3.8 troops were wounded and 0.86 killed.[59] The widespread use of enhanced vehicular shielding and individual body armor has subsequently led to increased survival from combat-related injuries. Nonetheless, protection of the head and torso has increased the proportion of extremity injuries, which have recently been described as comprising approximately 50% of all combat wounds.60,61

Combat-related injury patterns have changed over the last century, with an increased trend of injuries due to explosives compared to those caused by small-arms fire.62–65 In World War I, for example, 65% of all recorded combat casualties resulted from gunshots.[61] This decreased to 35% during the Vietnam conflict,[62] and recent estimates of casualties from direct-fire weapons in the Iraq and Afghanistan theaters are 16% to 23%.57,60 On the other hand, IEDs have been used with great effectiveness, and have increased in sophistication in both combat and noncombat settings. Recent estimates for combat-related MCIs caused by IEDs are approximately 18% of all treated casualties.[61] Traumatic amputations and penetrating extremity trauma following explosions may cause massive hemorrhaging, but on-scene application of single or multiple tourniquets by the casualty or a buddy has increased survival rates.[58] See Chapter 35, Chemical, Biological, Radiological, Nuclear, and Explosive Threats, for further details on conventional combat-related injury patterns.

Overwhelming numbers of casualty estimates (> 500,000) are projected in nuclear conflicts. Even single improvised nuclear devices in one location would cause a very high-magnitude MASCAL situation and likely disrupt the responding medical infrastructure at the same time.[66] Modeling of a range of scenarios has been completed, with various nuclear detonation yields (0.1–10 kilotons), heights of burst (ground and air), and weather conditions in several major US cities.[67] Nuclear or radiological devices cause injury through blast, thermal, light, and ionizing radiation effects. Potential for significant radiation exposure may exist with little or no evidence of physical trauma.[66] Radiological effects are determined by exposure time, distance from source, and any shielding that may have been present.[67]

UNIVERSAL MASS CASUALTY PRINCIPLES

The effects of trauma-causing MCIs occur in a trimodal distribution. The initial phase occurs with onset of the event or immediately afterward and is characterized by high mortality rates due to injuries. In the minutes to hours after onset, the second phase entails early trauma management. During the first 24-hour period, most fatalities occur and the majority of casualties are recovered. Medical care may be limited to on-scene stabilization at or near the POI for casualty management. In these circumstances, a greater emphasis is placed on the rapid evacuation of casualties to designated temporary staging areas or definitive treatment facilities. In the third phase, days to weeks after the disaster, efforts are directed at treating injury complications (eg, sepsis, multiple organ failure, and psychological problems). Having to move casualties long distances out of an affected area, either because the local system is overwhelmed or other facilities are more capable, can have an effect on these patterns.[68]

Regardless of the nature of the event, casualties presenting during MCIs surpass ordinary medical system capacity and require coordinated efforts to sort and prioritize available resources to meet the needs of as many casualties as possible. Based on the magnitude of the MCI, “minimum acceptable care” principles may apply. Austere conditions are said to exist when medical personnel, supplies, or equipment are limited, or when adverse conditions impact the ability to provide “normal care” to casualties.[68] Successful critical-care stabilization has been demonstrated in military and civilian operations with careful management of limited or constrained resources through planning, rehearsals, and continuous reevaluation; using equipment and supplies appropriate for each situation; leveraging evacuation assets in terms of type, timing, and transportation destinations; and employing the right people with the right skills at the right time across the complete continuity of care.[69]

MCI response first occurs at the local level and relies on unaffected medical assets at or near the scene. The remaining functional infrastructure becomes the initial part of the regional medical system of care for the MCI. Local medical resources may be severely impacted by the disaster through loss of hospital or emergency services staff, equipment, or hospital-based facilities. Once conventional capacity is exceeded, a number of factors influence the level of response to MCIs. These include well-developed plans, remaining functional infrastructure, operational resource allocation, effective triage, accessible staging areas, organizational communication, and clear chain of command. Coordination of medical response among personnel and facilities depends on the physical location of affected areas and distance to staging areas or medical facilities. External teams can deploy in an attempt to fill functional and logistical gaps in care delivery.

A tactical approach for MCI management includes a well-considered plan (Exhibit 34-2) and preestablished practices to provide interim medical services to an impacted healthcare system through resource deployment, field care principles, and designated medical facility reception. This approach includes specially trained responders and links field operations with medical facilities through an overall ICS structure. Assumptions for optimal MCI management include an effective triage process, field stabilization, and viable evacuation routes with ample transportation assets. However, this approach is based on the availability of sizable amounts of resources accessible or obtainable in a timeframe that will affect outcomes. Constrained resources will likely result in degraded system performance. In such situations, MCI tactics should be adapted to best meet specific situational needs. Duplicating or obstructing services through poorly coordinated efforts is a risk when deployed teams lack situational awareness on the ground.

Situational awareness involves consideration of mission objectives and rules of engagement. Other considerations include security issues from possible enemy activity or other threats to responders (eg, secondary IEDs, fire or flood, unstable structure) and number of personnel available plus knowledge of their individual and collective skill sets. Terrain, weather, time of day, time available to accomplish the mission while maximizing casualty outcomes, and the effects on the local civilian population (and the effects from civilians on the ability to deliver care) are also important factors. Estimates of the resources that will likely be required; known need for specialty resources (eg, decontamination teams); and the possibility of cascading events or new incidents in separate locations are just a few of the many considerations for responders.

Scene Management

A rapid situational analysis defines the circumstances of the MCI, and is paramount to guiding responders. This “rapid needs assessment” is critical to avoiding a “ready–fire–aim” approach. It establishes a baseline for decision-making and resource allocation (Exhibit 34-3). Responder team safety is a primary concern to preserve mission capability. MCI scenes will likely be chaotic, with normal operations disrupted. Effective responses require a systematic approach to deal with rapidly changing situations. Situations may become unstable at any time, posing new threats to responders. Dangers depend on the cause of the disaster and range from manmade security threats to environmental threats. Security threats may involve advancing hostile forces, an active shooter, or secondary explosive devices. Moreover, civil unrest often accompanies societal instability, leading to looting and violence as secondary security concerns.[70] Acute environmental threats include unstable building structures, hazardous materials or smoke exposure, potentially injurious debris, gas leaks, flooding, downed electrical lines, and stray animals, among others. Cascading events may lead to explosions, fires, and building collapses.

EXHIBIT 34-2

MASS CASUALTY INCIDENT PLANNING CHECKLIST

- Does MCI plan cover the tasks and responsibilities of all the organizations and personnel likely to be involved in the response?

- Is staff familiar with implementation of the MCI plan?

- Do involved organizations and personnel have an ongoing, mandatory MCI training program?

- Has the MCI plan been validated for expected type and volume of casualties? How?

- Are MCI responder tasks assigned in terms of positions rather than individuals?

___________________

MCI: mass casualty incident

EXHIBIT 34-3

MASS CASUALTY INCIDENT RAPID SITUATIONAL ASSESSMENT

- Determine the magnitude of the disaster or MCI response mission.

- Establish priorities and objectives for action.

- Evaluate the capacity of the local response (including resources and logistics).

- Determine external resource needs and prioritize actions.

- Plan execution of mission objectives (duration, scope, exit strategy etc).

- Know your role.

___________________

MCI: mass casualty incident

Mitigating risks—to the extent possible consistent with mission completion requirements—allows personnel to focus on locating casualties and extracting them from the POI to a CCP for triage. Many casualties may be located in multiple locations with restricted access and possibly obstructed from view, thus requiring ad hoc or professional search teams. Securing the location and scene support should occur as soon as feasible to prevent secondary casualties among bystanders or responders. Deciding between stabilization at the POI or rapid victim movement must be balanced with the risk assessment of ongoing and potential hazards.

Support for civil MCI response may be needed from volunteers, utility agencies, fire departments, law enforcement, local military units, or activation of specialty services (eg, urban search and rescue teams). Each of these agencies and services augments response personnel, secures scene hazards, and brings skills to help access casualties safely and expeditiously. Availability of these services and trained volunteers varies among domestic and international settings. In domestic disasters, the DHHS coordinates three programs that maintain registries of healthcare volunteers: the Emergency System for Advance Registration of Volunteer Health Professionals,[71] the Medical Reserve Corps,[72] and the NDMS.[73] National Voluntary Organizations Active in Disaster[74] and the WHO[75] are resources for international settings.

Volunteer efforts by individuals or organizations pose unique challenges. A rush of volunteers following a disaster without overall coordination can overwhelm a response system and make the situation worse.[76] Managing any volunteer response force is difficult, due to a variety of backgrounds and lack of experience among the volunteers. Additionally, well-meaning but untrained volunteers can increase the risks of personal injury, general and medical liability, and mission failure. Poorly prepared volunteers may present without proper medical screening or appropriate immunizations; with inadequate clothing or equipment; and lacking accommodations or shelter, food, and prophylactic medications.[77] These volunteers potentially become dangers to themselves or existing casualties and can drain limited resources from response efforts. Verifying credentials requires significant logistical support in the midst of chaotic situations. Prescreening volunteers provides a viable alternative.[76]

Rapid Needs Assessment

There is no exclusive set of criteria for initially measuring event magnitude and severity because every MCI presents a unique set of circumstances. Determining what has happened, what the impacts are, and what dangers exist is completed during the preliminary scene survey (see Exhibit 34-3). This survey should include casualty estimates with cursory injury pattern distribution, assessment of transportation assets including viability of access from base to scene to treatment destinations, and assessment of the functionality of receiving centers.[74]

Casualty estimates serve to guide MCI medical responses, and have been modeled in a number of different scenarios and calculated in real-world experiences. Cause, magnitude, and population density allow for casualty projections at an affected location.28,65,78–81 Casualty estimates for combat-related and noncombat-related MCI events have changed over time and vary with each incident.

Triage

MCI injuries span the full spectrum of trauma, with human effects ranging from expected emotional reactions to severe psychological trauma, and minor abrasions to “total body disruption.” The approach to acute resuscitation of combat-related versus noncombat-related injuries differs due to the unique aspects of combat: high energy and lethality of wounding instruments, multiple concurrent mechanisms of wounding, predominance of penetrating injury, persistence of threat in tactical settings, austere resource-constrained environment, and often delayed access to definitive care.[51] However, injury patterns considerably overlap in terrorist attacks and combat-related injuries, and classifying injury patterns assists in preparation for casualty care. A sample of potential injuries that may be encountered in MCI scenarios is listed previously in the scope and impact sections (although individual injury characteristics have been extensively evaluated in the literature and detailed descriptions are beyond the scope of this chapter).

Effective MCI management is based on the principles of triage to prioritize treatment or transport and allocate resources. Triage systems allow a measure of order in an otherwise tumultuous situation in which most factors may be out of the control of responders. Internal and external considerations influence this sorting process. The restraints of capability, time, and distance to stabilization or definitive care require responders to continuously adjust processes based on prevailing conditions. Triage may be performed at the POI, at one or more CCPs, or at fixed facilities depending on where casualties are found or present.

Less seriously injured persons may or may not seek immediate medical evaluation and may leave the scene. They may seek their own care at nearby medical facilities or find their own means of conveyance to other destinations. These casualties “self-sort” and may present as pedestrians, via personal vehicles, or on vehicles of opportunity such as buses or trucks. This may result in many less severe casualties flooding local medical facilities before more severely injured, nonambulatory casualties can be transported from the scene. Casualties who are still present at the scene when trained personnel arrive may be “globally sorted” by instructing all mobile victims to move to a designated area. This allows observation of these casualties at one location while triage teams sort remaining casualties who cannot move under their own power.

Triage algorithms or protocols are used to assess the physiologic status of each casualty. In the United States, casualties are traditionally sorted into five color-coded categories: immediate (red), delayed (yellow), minimal (green), expectant (blue), and deceased (black). The last two categories are by no means standardized, and black is sometimes used to identify expectant casualties. The term “expectant” is often used for casualties responders “expect to die,” thus relegating them to comfort care alone when resources are limited. A hemodynamically unstable patient with penetrating trauma to the head and a Glasgow coma score of 3 may be expectant and potentially mortally wounded. However, some expectant patients may be otherwise classified as immediate if resources are available. The authors believe the term should be reserved for casualties who responders “expect to reevaluate” for the possibility of more aggressive care once required resources become available. If resources do not become available, and casualties cannot be saved, they should remain expectant until they are pronounced dead.

Injuries categorized as immediate (red) require acute interventions to avoid mortality or further morbidity. Injury patterns in this category include uncontrolled internal or external hemorrhage, tension pneumothorax, and acute airway compromise, as well as threats to eyesight and limb salvage. Procedures for treating an immediate casualty may include tourniquets, compression, or hemostatic dressings; needle thoracentesis or sealing open pneumothoraces; and simple airway interventions such as placing a nasopharyngeal airway or rolling casualties into the recovery position.

Delayed (yellow) casualties present with injuries in need of intervention, but they are stable or can be stabilized until definitive care is available. Examples include head and torso injuries for which nothing can be done in the field, open fractures, and spinal injuries. Medical management for delayed casualties may include fluid resuscitation, fracture stabilization, analgesic medications, and antibiotic administration when indicated.

Minimal (green) casualties present with injuries that are not deemed to threaten life, limb, or eyesight. These include minor abrasions, lacerations with controlled bleeding, simple dislocations and fractures, and minor burns. These casualties can be managed effectively with minimal medical care, or they may self-treat, thereby bypassing the healthcare system entirely or presenting to a primary care location on another day.

A number of protocols can be employed to assist the triage process in the prehospital setting and in civilian and military hospitals.82–92 However, evidence favoring any particular system is limited; the majority of published articles communicate expert opinion only or the results of simulations and exercises. Extrapolating outcomes through retrospective analysis of trauma registries has also been used to assess various triage algorithms, but these findings may be limited because most casualties were not injured in MCIs, and even fewer were managed in situations when the standard of care had to be adjusted for limited resources.[78]

Widely used MCI triage algorithms include “SALT” (sort, assess, lifesaving interventions, and treatment and transport)[91]; “START” (simple triage and rapid treatment) for adults[84]; and “Jump-START” for pediatric patients, which recognizes distinctions between adult and pediatric physiology at triage decision points (Table 34-1).[85] General principles of out-of-hospital triage and treatment, regardless of system used, are as follows:

- interventions should be limited to immediate life-saving maneuvers, because resuscitation will consume limited resources and should be reserved for salvageable cases;

- patients in shock do not tolerate movement well, so resuscitation should be accomplished in an ongoing manner before and throughout transportation;

- casualties’ conditions may change at any time, so they should be reassessed regularly and priorities reassigned as indicated; and

- urgent interventions must never be delayed by documentation.

TABLE 34-1

COMPARISON OF TRIAGE ALGORITHMS

RPM: respirations, pulse, and mental status

AVPU: awake, verbal, pain, unresponsive

Data sources: (1) Benson M, Koenig KL, Schultz CH. Disaster triage: START, then SAVE—a new method of dynamic triage for victims of catastrophic earthquake. Prehosp Disast Med. 1996;11:117–124. (2) Romig L. Pediatric triage: system to JumpSTART your triage of young patients at MCIs. J Emerg Med Serv. 2002;27:52–58,60–53. (3) SALT mass casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association. Disaster Med Public Health Prep. 2008;2:245–246.

Time is critical in an MCI. Focusing too much on treatment during the triage phase limits the number of casualties who can be assessed and provided with necessary interventions in the field.

Other potential pitfalls can impede the triage process at the POI or CCP. Failure to consider HAZMAT or CBR contamination, IEDs placed near or on casualties, retained ordnance, or rescues requiring specialized expertise and equipment pose risks to medical teams. Lacking a coordinated and rehearsed team approach limits effective engagement with casualties. Inadequate medical size-up by the initial team will have repercussions for appropriate deployment and allocation of resources and staffing. Indecisive leadership causes obvious problems for subordinates carrying out the mission. Military rules of engagement may also affect triage operations if they restrict what care is authorized for noncritical casualties who may not be US or coalition personnel.

Once casualties are triaged at the scene, they should be brought to a CCP, where they may be re-triaged into treatment areas. Many civilian and military hospital-based emergency departments employ facility-based triage protocols that define expected time intervals for patient evaluation, such as the Emergency Severity Index.[86] However, this type of algorithm assumes a fully staffed and functional emergency department without resource constraints, thus allowing maximal resuscitation efforts of critical “full code” patients even if they have a poor prognosis. Expenditure of significant resources in personnel, time, and supplies may not allow for those resources to be used on other casualties under MASCAL conditions.

No matter what system is used at any location, not all the information necessary to make a completely accurate assessment will be available for all victims at all times. “Over-triage” occurs when casualties are assessed to be more serious than they are. This results in allocation of scarce resources that could be used for other patients. “Under-triage” occurs when casualties are deemed to be less serious than they are, which can lead to potentially unnecessary morbidity and mortality.[83] There are no universally accepted best-practice cut-offs for over- or under-triage, which are analogous to excessive sensitivity or inadequate specificity. Over-triage is more common when children are affected in MCIs, or when inexperienced personnel or bystanders make triage decisions.87,89 Most cultures would accept some excess over-triage that stresses the system in order to minimize the rate of under-triage that misses casualties who need emergent or urgent treatment.

In resource-constrained situations, critical care efforts are reserved for immediately salvageable casualties so that multiple victims can be effectively managed. MCI triage protocols provide a structure to focus triage decisions in an objective manner rather than subjectively assigning treatment based on personal opinion or biases. This improves inter-user reliability and reduces over- or under-triaging that might divert appropriate resources from more critical injuries.[88] However, different triage systems were developed from different problem sets, so they may not be universally applicable. For instance, the START methodology was developed for response to injuries sustained during earthquakes.[84] It gained very wide acceptance, but it may not be as effective for other situations (eg, ASEs) or nontrauma scenarios.[90] SALT[83] has been recommended as a US national standard,91,92 but has not yet been shown to improve outcomes in actual MCIs.

Casualty Collection Points

Functions at CCPs include triage, field treatment, and evacuation staging. Maintaining casualty flow depends on rapid assessment, initial stabilization, and appropriate disposition. The location of a staging area should be near enough to the MCI to be effective without posing undue risk to medical staff. These areas should have well-designated ingress and egress points, a decontamination area, and access to nearby transport areas for air, ground, or water evacuation. Patient flow should be linear to designated category areas listed above to mitigate against choke points (Figure 34-3). Casualty movement through the triage site should not backtrack through the treatment areas.

The triage officer oversees the triage team at the entry control point. Initial movement of casualties is directed toward the established treatment areas for stabilization or observation based on triage categories. Every member of the triage team should be familiar with the triage protocols in use and train through functional drills to facilitate effective casualty movement.[32] Distribution of casualties may require changing personnel numbers to meet the rate of casualty arrival as staffing and space allow.

Figure 34-3. Generic casualty-flow schematic of mass casualty incident response operations.

Treatment areas should be aligned with the triage categories of immediate (red), delayed (yellow), and minimal (green)—where resuscitation, stabilizing procedures, and first aid may be given, respectively—if all of them are necessary and can be established prior to casualty arrival. Depending on circumstances and available resources, expectant (blue) casualties should be located near the critical-care (red) area for rapid access if future resources permit field interventions.

Working areas should be spacious enough to manage anticipated number of casualties, be sheltered from the environment, have adequate illumination, and be climate controlled if feasible. Each area can be expanded and contracted as required to meet demand and efficient distribution of resources.

Additional considerations include the following questions:

- How should the area be secured?

- Does the location allow for easy access by litter teams bringing in casualties?

- How large should treatment areas be, and is there room for expansion if needed?

- Do treatment areas have optimal access to medical supplies?

- Does each area have unrestricted access to the transportation staging area?

- Where is the location for decedent casualties?

Medical regulators provide administrative oversight for patient tracking, provide overall casualty status updates (number and condition), and coordinate record-keeping during MCI operations. Information is relayed from respective medical recorders who identify, tag, and register patients in their treatment areas to the regulators who control evacuation. Casualties may be identified with any method that is reproducible and familiar to responders. Patients may be tracked by high-tech or low-tech methods, ranging from electronic medical records specifically designed for disasters,[93] to a paper and plastic system similar to that used by air-traffic controllers,[94] to a system of placing numbers on the casualties’ foreheads with indelible markers. Chosen methods should be consistently used throughout the MCI event.

Treatment teams should be comprised of medical personnel with appropriate levels of training to meet the medical requirements of the triage category assigned. The immediate area treatment teams should be familiar with interventional and resuscitative procedures in resource-constrained conditions. Other treatment areas can be staffed with providers and medics who do not have the same level of emergency skills, but who are able to care for delayed and minimal casualties and identify deterioration in their conditions.

Maintaining a dynamic triage process, where casualties are reassessed throughout the treatment areas, allows for recategorizing and changing treatment and evacuation priorities based on clinical status. Several special considerations affect triage flow. Situations with imminent threats may require “reverse triage,” in which casualties with minor problems in the green and yellow categories receive precedence in order to rapidly evacuate greater numbers from the scene for maximum overall survival, or first treating and returning to duty casualties who might play critical roles in stabilizing hazardous conditions, such as firefighting or combat security.

From a safety standpoint, security and decontamination procedures should be in place at the CCP to prevent injury of personnel and thereby compromise the MCI response mission. Security checkpoints should be used for screening unidentified personnel escorting casualties, clearing potential weapons and removing unused ammunition, and searching for unexploded ordnance and IEDs before casualties enter the CCP.

Decontamination stations are employed for suspected HAZMAT or CBR contamination. Decontamination teams should be well versed in procedural methods, have the appropriate level of personal protective equipment, and be familiar with hot, warm, and cold zones. Hot zones are designated areas around the immediate area of CBR contamination or incident scene. Entry into this zone should be through a controlled access point for accountability purposes and avoidance of contamination spread. Decontamination takes place in the warm zone, which is an area established around the hot zone as a buffer between the hot and cold zones. The cold zone is a contamination-free zone established around the warm zone where emergency operations can be directed and supported.

Finally, several functions may be stationed near the CCP to avoid disrupting triage and treatment operations. These include mortuary services, a bereavement area, public affairs access point for media control, and family notification and reunification areas.

Incident magnitude may range from a few critical patients in ASEs to several hundred patients in hurricanes or earthquakes. Needed resources for large numbers of casualties presenting simultaneously may necessitate several dedicated triage teams and multiple CCPs. Transportation delays may occur due to inadequate vehicle numbers or types, inclement weather, damaged and blocked roadways or inaccessible sites, or ongoing disaster-induced obstructions (eg, fire, water, ice and snow). In these cases, CCPs may become impromptu field medical stations where casualties will be managed for potentially extended periods of time.

Transportation Management

More severe casualties may be immediately transported from the scene instead of being brought to CCPs, depending on available resources and tactical conditions. Destinations may become “saturated” quickly, and transport routes may become inaccessible, requiring some receiving facilities to be bypassed for alternative sites. Situational awareness of the entire system allows provision of care and appropriate disposition for the greatest number of casualties presenting to be triaged. As patients are moved through the system of care, triage and re-triage occur based on changes in the status of the patient and the system.

Just as triage is performed for treatment, it should also be applied to casualty transportation. The US military uses urgent, priority, routine, and convenience evacuation categories to indicate how soon a casualty requires the next step in care. On a tactical level (essentially ground and rotary-wing evacuation), “urgent” signifies the need for care within the next hour (previously 2 hours by doctrine, until the secretary of defense mandated 1 hour in 2009[95]). “Priority” indicates evacuation is needed within 4 hours, and “routine” indicates 24 hours. “Convenience” refers to casualties who can be transported on the next vehicle with space available. On a strategic level (involving fixed-wing assets operated by the US Air Force), “urgent” communicates a request for evacuation as soon as possible, “priority” indicates within 24 hours, and “routine” means on the next aircraft with space available, but generally within 72 hours.

Other aspects of transportation triage must also be considered. One consideration is that evacuation categories do not necessarily have to align with treatment categories. Although most casualties who remain in the immediate treatment category after field interventions will likely be placed in the urgent evacuation category, those designated for delayed treatment based on what can be done for them in the prehospital setting might be assigned any of the urgent, priority, or routine evacuation categories based on how soon they need additional care. Another consideration involves prioritizing patients within a transportation category. For instance, if ten patients are awaiting urgent evacuation and only one helicopter with open berths arrives, the transportation officer must choose which two or three of the ten will be loaded on the aircraft. Patient condition, capabilities of the medical crew, capabilities and capacity of the intended destination, transportation time, and potential detrimental effects of movement must all be taken into account.

Casualty destinations are suggested based on proximity, but the closest facility may not always be the most appropriate.95–98 The closest facility might not be the one that can be reached in the shortest time, and it might not be capable of receiving more casualties without degrading the level of care delivered to all patients. In general, transportation time should be minimized both for casualty care and to place vehicular assets back in service quickly. However, at any moment in the course of the response, some casualties should be taken to medical facilities farther from the incident to avoid resource saturation or to access specialty services that may be further away. If any casualties have to be transported to closer but less capable facilities for initial stabilization, redistribution to regional trauma or referral centers may occur later.

As casualties are moved away from the scene of an MCI or transported from one medical capability to another, it is important not to turn a MASCAL at one location into a MASCAL at another location by overwhelming any given receiving facility. At the same time, it is the responsibility of the sending MMO to ensure the transportation mode and the platform used is the most appropriate for the casualty and the tactical situation. The MMO must ensure that the evacuation vehicle is sufficiently staffed and equipped to manage any specialty equipment (eg, a ventilator) and to perform intervention for any reasonably foreseeable deterioration. Additionally, personnel at the receiving facility must be fully informed of the casualty’s problems, what management has already been undertaken and what the results were, and what issues still need to be addressed. All documentation of care rendered prior to arrival and during treatment at the sending facility must accompany the patient or be securely transmitted to the receiving facility. (Continuation of care during transportation between treatment roles is discussed in detail in Chapter 39, Casualty Transport and Evacuation.)

SUMMARY

Effective management of MCIs requires planning, coordination, and communication. Goals of the responding assets are to bring medical and other essential resources to casualties when affected infrastructure cannot support a desirable standard of care for all those in need. MASCAL situations continue to arise in both garrison and deployed settings, caused by natural phenomena and armed conflict, whether mitigation and response resources are available or not. Individuals, teams, units, communities, states, and nations must be prepared to respond quickly and effectively if excess morbidity and mortality—physical or psychological—is to be prevented, moderated, or avoided. Military medical personnel must be vigilant and continuously prepared for the wide variety of operations in which they may be tasked, from local incidents (motor vehicle crashes, ASEs, etc) to defense support to civil authorities, foreign humanitarian assistance, and combat operations. Medical and surgical skills must be developed and practiced. Specific capabilities must be built into healthcare systems from backpacks to tents to constructed MTFs, and then integrated into surrounding communities or host nations when feasible. Potential requirements to increase capacity for surges in casualty rates must be considered in every setting.

MCIs are by definition situations in which not every casualty can be treated in the way they would be if unlimited resources were available, but these incidents can be managed in a reasonable and acceptable manner for the exigencies of each individual situation. MMOs must be ready to advise leadership on capabilities and preparations, respond with interventional skills and knowledge of how they fit into the overall healthcare system, and embrace change to improve processes far into the future.

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77.   Merchant RM, Janet E. Leigh JE, Lurie N. Health care volunteers and disaster response—first, be prepared. N Engl J Med. 2010;362:872–873.

78.   Institute of Medicine. Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary. Washington, DC: National Academies Press; 2011.

79.   Doocy S, Jacquet G, Cherewick M, Kirsch TD. The injury burden of the 2010 Haiti earthquake: a stratified cluster survey. Injury. 2013;44:842–847.

80.   World Health Organization. Mass Casualty Management Systems. Strategies and Guidelines for Building Health Sector Capacity. Geneva, Switzerland: WHO; 2007. http://www.who.int/hac/techguidance/tools/mcm_guidelines_en.pdf. Accessed February 10, 2018.

81.   Cao H, Huang S. Principles of scarce medical resource allocation in natural disaster relief: a simulation approach. Med Decis Making. 2012;32:470–476.

82.   Cross KP, Cicero MX. Head-to-head comparison of disaster triage methods in pediatric, adult and geriatric patients. Ann Emerg Med. 2013;61:668–676.

83.   Lerner EB, Schwartz RB, Coule PL, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;2(suppl 1):S25–S34.

84.   Benson M, Koenig KL, Schultz CH. Disaster triage: START, then SAVE—a new method of dynamic triage for victims of catastrophic earthquake. Prehosp Disast Med. 1996;11:117-124.

85.   Romig L. Pediatric triage: system to JumpSTART your triage of young patients at MCIs. J Emerg Med Serv. 2002;27:52–58,60–53.

86.   Gilboy N, Tanabe T, Travers D, Rosenau AM. Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition. Rockville, MD: Agency for Healthcare Research and Quality; 2011. AHRQ Publication No. 12-0014.

87.   Kennedy K, Aghababian RV, Gans L, Lewis CP. Triage: techniques and applications in decision making. Ann Emerg Med. 1996;28:136–144.

88.   Engum SA, Mitchell MK, Scherer LR, et al. Prehospital triage in the injured pediatric patient. J Pediatr Surg. 2000;35:82–87.

89.   Jenkins JL, McCarthy ML, Sauer LM, et al. Mass-casualty triage: time for an evidence-based approach. Prehosp Disaster Med. 2008;23:3–8.

90.   Kahn CA, Schultz CH, Miller KT, et al. Does START triage work? An outcomes assessment after a disaster. Ann Emerg Med. 2009;54:424–430,430.e421.

91.   SALT mass casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association. Disaster Med Public Health Prep. 2008;2:245–246.

92.   American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons, et al. Model uniform core criteria for mass casualty triage. Disaster Med Pub Health Prep. 2011;5:125–128.

93.   DeMers G, Khan C, Buono C, et al. Secure scalable disaster electronic medical record and tracking system. Prehosp Disaster Med. 2013;28:498–501.

94.   Graham RF, Hoskins JD, Cortijo MP, Barbee GA, Folio LR, Lutz CC. A casualty tracking system modeled after air traffic control methodology employed in a Combat Support Hospital in Iraq. Mil Med. 2011;176:244–245.

95.   Hudak JJ. The Origins of the “Golden Hour” of Medical Care and its Applicability to Combat Medicine. Leavenworth, KS: US Army Command and General Staff College; 2015.

96.   Einav S, Feigenberg Z, Weissman C, et al. Evacuation priorities in mass casualty terror-related events: implications for contingency planning. Ann Surg. 2007;239:304–310.

97.   Raiter Y, Farfel A, Lehavi O, et al. Mass casualty incident management, triage, injury distribution of casualties and rate of arrival of casualties at the hospitals: lessons from a suicide bomber attack in downtown Tel Aviv. Emerg Med J. 2008;25:225–229.

98.   Bloch YH, Schwartz D, Pinkert M, et al. Distribution of casualties in a mass-casualty incident with three local hospitals in the periphery of a densely populated area: lessons learned from the medical management of a terrorist attack. Prehosp Disaster Med. 2007;22:186–192.

Chapter 35

CHEMICAL, BIOLOGICAL, RADIOLOGICAL, NUCLEAR, AND EXPLOSIVE THREATS

EDWARD LUCCI, MD,* AND MELISSA GIVENS, MD, MPH†

INTRODUCTION

CHEMICAL WARFARE AGENTS

General Principles of Chemical Casualty Care

Personal Protective Equipment

Vesicants

Nerve Agents

Lung-Damaging Toxic Industrial Chemicals

Cyanide

Incapacitating Agents

Riot-Control Agents

Overview of Decontamination

Patient Decontamination Site

BIOLOGIC WARFARE AGENTS

Bacterial Agents

Viral Agents

Biological Toxins

RADIOLOGICAL AND NUCLEAR EXPOSURES

Radiation Effects

External Exposure

Triage and Treatment of Radiation-Injured Patients

Internal Exposure

EXPLOSIVE (BLAST) INJURIES

Mechanisms of Blast Injury

Evaluation and Management of Primary Blast Injury

CONCLUSION

*Colonel (Retired), Medical Corps, US Army; Chief, Department of Emergency Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland

†Colonel, Medical Corps, US Army; Associate Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

The chemical, biological, radiological, nuclear, and explosive (CBRNE) threat to the US military has changed dramatically in recent years due to advancing technological platforms associated with computers, drones, robotics, genetics, and synthetic biology. These changes have created an environment in which individuals, groups, or states can pose an almost invisible threat anywhere around the world. Innovative technologies that empower great good can also be used to inflict great harm. It is reasonable to anticipate that groups that used airplanes like missiles might use toxic industrial chemicals (TICs) like conventional chemical weapons, an emerging infection like a biological weapon, or radioactive isotopes to spread harm or terror, if they could gain access to them. While encountering conventional casualties on the battlefield remains a more likely scenario for today’s military medical officer (MMO) due to the increased accessibility of conventional weapons, the MMO must also remain vigilant for unusual scenarios that might represent the first clue that a CBRNE incident has occurred in a military or civilian population. Because environmental sampling for agent detection and rapid point-of-care testing for agent identification will not be routinely available to most MMOs in the austere environment or most hospital settings, the initial suspicion of a CBRNE attack will rest on clinical recognition of signs and symptoms of poisoning, infection, or injury.

Distinguishing a biological, chemical, or radiological weapons attack from that of an emerging infection or toxic industrial accident will be difficult and outside the normal experience of most MMOs. Regardless, today’s MMO must remain alert to the possibility and be prepared to recognize military or civilian CBRNE casualties of warfare or terrorism. This chapter will focus on key principles of CBRNE incident recognition and casualty management, emphasizing relevance to the MMO.

CHEMICAL WARFARE AGENTS

During the morning rush hour at 8 AM on March 20, 1995, in the heart of Tokyo, five small bags of dilute sarin nerve agent were simultaneously dropped in subway cars and punctured with umbrellas as the cars were converging under a hub of government buildings. It appeared as if someone dropped plastic bags with water on the subway car floors. That morning, the terrorist attack by the Aum Shinrikyo cult sent thousands of terrified Japanese, with varying degrees of nerve agent vapor poisoning, to the local healthcare system within minutes, and brought the city of Tokyo to a standstill. Ultimately, 12 people died, at least 5,500 victims presented for care, and almost one-quarter of the nearest hospital’s staff became secondary victims. St Luke’s Hospital received 640 victims that day because of news reports that it had the antidote.[1]

Less than a year earlier, in Matsumoto, Japan, the same cult had launched a sarin attack into the open air using an electric heater fan to direct nerve agent vapor toward a targeted apartment. Eight people died and 660 were injured in the first terrorist attack using sarin nerve agent on the general public.

Chemical warfare agents are toxic substances developed for military use to produce death, serious injury, or incapacitation. They may exist as solids, liquids, or gases, but most are stored as liquids and dispersed as a liquid or aerosol. TICs are industrially manufactured chemicals that could be used to produce mass casualties; some were used as chemical agents on the battlefield in World War I. Incapacitating agents and riot-control agents are chemical agents designed only to produce temporary effects without serious sequelae.

The modern use of chemical warfare agents dates to World War I, when the first chemical agent employed on the battlefield was chlorine gas and the most effective was sulfur mustard. Chemical weapons were not used in World War II. The United States and the former Soviet Union (USSR) both signed the Chemical Weapons Convention and agreed to destroy chemical weapons stockpiles beginning in 1990.[2] More than 31 countries and some terrorist groups possess chemical weapons, and many more are seeking to obtain them.[3] Since the 1980s there have been multiple instances of chemical weapons use on the battlefield, against civilian populations, and in terrorist attacks. The Iraqi military used both nerve agent and mustard against Iran during the 1980–1988 Iran-Iraq war, and widespread use of toxic chemical weapons has been reported in the 2011–present Syrian civil war.4,5 Because the threat remains high, MMOs have a critical responsibility to competently identify and manage chemical casualties in any setting.

The major categories of lethal traditional chemical warfare agents include: vesicants, nerve agents, lung-damaging (pulmonary) agents, TICs, and cyanide. Nonlethal agent categories include incapacitating agents and riot-control agents. It is important for the MMO to recognize several general features of chemical agents:

1. Each chemical warfare agent category requires similar treatment.

2. An act of chemical warfare or terrorism is likely to involve substances that cannot immediately be identified; real-time testing will be difficult; and the window for effective therapy will likely be narrow.

3. A chemical attack will be more easily recognizable when a group of exposed persons have rapid onset of comparable symptoms.[6]

General Principles of Chemical Casualty Care

General principles of chemical casualty care for the MMO to consider include identifying chemical threat agents and all exposed patients, protecting medical staff, ensuring proper triage, recognizing the need for decontamination (if liquid contamination is present), managing medical treatment and antidote availability, and ensuring proper patient disposition (evacuation or return to duty). For patients, treatment begins with removal from chemical exposure and decontamination. Persons who suspect they have been exposed should remove and bag their clothing and shower thoroughly with soap and water as soon as possible. Removing contaminated clothing can eliminate 85% to 90% of trapped chemical substances.[6] The MMO must appreciate that the majority of affected patients will be minimally exposed and reach medical facilities through their own efforts, so medical treatment facilities must make advanced preparation to handle ambulatory decontamination and provide psychological support to casualties.

Clinical signs of severe chemical exposure include altered mental status, airway obstruction, respiratory distress, cardiovascular instability, and seizures. Initial supportive treatment for casualties should be focused on airway management, maintaining ventilation and circulatory support, and administering antidote, if available, while simultaneously assessing for burns, trauma, and other injuries. Atropine, pralidoxime, cyanide antidote kits, hydroxocobalamin, diazepam, and Reactive Skin Decontamination Lotion (RSDL) are the most important drugs to stockpile for the treatment of chemical casualties.[7]

Personal Protective Equipment

The MMO managing contaminated patients with liquid exposure must ensure medical staff wear proper chemical protective clothing until the patient is decontaminated. The M40 Chemical-Biological Field Mask represents the latest generation of protective mask issued by the US military. When properly worn, the M40 mask will protect from all known chemical, biological, and riot-control agents.[8] The addition of the chemical/biological hood affords additional protection to the head, neck, and shoulders. Filtration is provided by one C2A1 filter canister mounted on either cheek. The new M50 Joint Service General Protective Mask (JSGPM), designed to replace the M40, is the first joint service model. The JSGPM provides improved vision and protection against nuclear, biological, and chemical threats, including designated TICs, with the M61 filter.[9] The chemical protective glove set consists of an outer butyl rubber glove for chemical protection and an inner cotton glove for perspiration absorption. The green or black vinyl over-boots are worn over combat boots and provide protection from chemical and biological agents and radioactive particles (alpha and beta) for a limited time. The Joint Service Lightweight Integrated Suit Technology (JSLIST) Chemical & Biological Protective Garment, a two-piece suit lined with carbon beads, provides 24 hours of protection against known biological and chemical agents and toxins in solid, liquid, or vapor form, and alpha and beta radioactive particles.[9] It should be worn in military environments under threat of nuclear, biological, or chemical attack.

Vesicants

Vesicants (“blister agents”) are agents that cause chemical burns. To the MMO, sulfur mustard or mustard (NATO designation H or HD) is the most important vesicant and is still considered a major military threat agent. It has been the most frequent chemical weapon used militarily since 1917, and was responsible for most of the chemical casualties in World War I.[10] Mustard is stored and deployed as a persistent liquid agent and constitutes both a liquid and vapor threat to exposed skin and mucous membranes.[11] Accidental exposure from old military ordinance has occurred.12,13

Mustard may be detected by multiple military detection devices including chemical agent monitors and detection papers.[11] Routine clinical lab testing for mustard in blood does not exist, but a metabolite, thiodiglycol, may be detected in blister fluid or urine, and advanced analyses of blood samples have verified human exposure to mustard.10,13

Properly wearing the full chemical protective mask and ensemble affords full protection against vesicants like mustard. The activated charcoal in the mask filters and over-garment absorbs mustard. The butyl rubber in the chemical protective gloves and boots is impermeable to mustard.[14]

Mustard liquid is absorbed through skin within minutes and rapidly distributed throughout the body.[10] While the exact mechanism of action of mustard is unknown, its effects are delayed, appearing hours after exposure. Mustard vapor is extremely irritating to the eyes, skin, and airways. Burning or pain may begin anywhere from 2 to 48 hours after exposure. Initial skin injury resembles sunburn, which may progress to blister formation. Blister fluid does not contain mustard and is not a contamination risk.[10] The earliest effects from mustard involving the airway will be burning of the nares, sinus pain, sore throat, and hoarseness. Injury to the upper airways may lead to cough and laryngitis. Damage descends to the lower airways in a dose-dependent fashion.[11] The terminal airways and alveoli are usually not affected, and pulmonary edema is rarely present.[15]

The MMO must appreciate that no specific antidote for mustard exists; therefore, early decontamination is critical. To be effective in the management of mustard casualties, decontamination must be carried out immediately in the field to prevent injury and further exposure. Unfortunately, patients usually present when pain and lesions develop, hours after exposure. Management may be simple or complex, and the extent and severity of injury is dose-dependent. Although lethality from mustard exposure is low, MMOs must be aware that most casualties will require some form of extended medical care.[10] Dermal injuries may be managed with standard chemical burn care.[11] Early treatment should be focused on keeping the casualty comfortable, maintaining oxygenation, and preventing infection. Severe eye injuries and vision loss are rare from mustard exposure, and most casualties who lose their vision due to mustard exposure can be safely reassured they will fully recover their eyesight.[10] Significant respiratory effects within 4 hours of exposure signify a severe poisoning and poor prognosis.[11]

Nerve Agents

The MMO must recognize that the nerve agents GA (tabun), GB (sarin), GD (soman), GF, and VX are the most toxic chemical warfare agents and are considered major military threats. They are hazards in both liquid and vapor states and can cause death within minutes after exposure. The only known battlefield use of nerve agent occurred during the Iran-Iraq War; however, there have been multiple episodes of use against civilian populations, most notably the 1995 Tokyo subway terrorist attack with the nerve agent sarin. Many countries have the technology to manufacture nerve agents, and weapons stockpiles remain major concerns.

Nerve agents are potent organophosphate acetylcholinesterase (AChE) inhibitors, causing cholinergic overstimulation and a clinical syndrome called “cholinergic crisis”(Table 35-1). Most exposures occur via inhalation or through the skin. The attachment of nerve agent to the AChE enzyme is permanent unless removed by medical therapy.[16] The MMO should consider nerve agent poisoning in instances of terrorism when multiple persons suddenly collapse with apnea, seizures, or coma. The initial effects of nerve agent, which may begin within seconds, depend on the dose and route of exposure; the severity of clinical effects are dose-dependent. Exposure to a small amount of nerve agent vapor causes effects on the eyes, nose, and airways. Miosis, often accompanied by eye pain, blurred vision, and nausea, is a characteristic finding in nerve agent vapor exposure to the eyes.[16] Rhinorrhea is characteristic of nasal airway vapor exposure, as is chest tightness, bronchoconstriction, and increased secretions. Exposure to a large amount of nerve agent vapor will cause rapidly cascading symptoms in minutes, culminating in loss of consciousness, convulsions, apnea, and muscle flaccidity (Table 35-2).[16]

TABLE 35-1

EFFECTS OF NERVE AGENTS IN HUMANS (CHOLINERGIC TOXIDROME)

Body Part or System

Effect (“DUMBBELLS”)

Skin and sweat glands

Diaphoresis

Urinary tract

Urination

Eye

Miosis (unilateral or bilateral), pain in or around the eye; complaints of dim or blurred vision

Nose

Rhinorrhea

Pulmonary tract

Bronchorrhea and Bronchospasm cough; complaints of tight chest, shortness of breath; wheezing on exam

Gastrointestinal tract

Emesis and Loose stools; increase in secretions and motility; nausea, vomiting, diarrhea; complaints of abdominal cramps, pain

Mouth

Lacrimation and Salivation

Muscular

Fasciculations (“rippling”), local or generalized; twitching of muscle groups; flaccid paralysis; complaints of twitching, weakness

Cardiovascular

Decrease or increase in heart rate; usually increase in blood pressure

Central nervous system

Acute effects of severe exposure: loss of consciousness, convulsion (or seizures after muscular paralysis), depression of respiratory center to produce apnea

Standard military chemical agent monitors and chemical agent paper will detect nerve agent.[14] The protective mask and chemical protective ensemble affords full protection. Butyl rubber gloves and boots are impermeable to nerve agents. Pyridostigmine bromide is a safe command-authorized military pretreatment against soman exposure. It is not an antidote and must be taken before exposure.[16]

Medical management includes decontamination for liquid exposure, ventilation, antidotal treatment, and supportive care. Removal of clothing is adequate to prevent exposure to trapped vapor. The need for ventilation will be obvious.[17] Three drugs are used to treat nerve agent exposure: atropine, pralidoxime chloride, and diazepam. The Antidote Treatment Nerve Agent Auto-injector (ATNAA) contains atropine and pralidoxime chloride.[17] Pralidoxime chloride should never be withheld out of concern it may be too late after exposure.[16] Convulsant Antidote, Nerve Agent (CANA) contains diazepam. Benzodiazepines are the only effective anticonvulsants for nerve agent poisoning and should be administered to all patients with severe intoxication.[16] Casualties with severe symptoms should be triaged as immediate and receive three ATNAAs and one CANA.[17] Casualties exposed to liquid nerve agent may worsen. Casualties who are walking and talking and no longer being exposed may be triaged as minimal.[17] Laboratory testing to confirm nerve agent exposure is based on measuring the level of AChE inhibition, rather than testing for parent nerve agent.[18]

TABLE 35-2

EFFECTS OF EXPOSURE TO NERVE AGENT VAPOR

Exposure Level

Effects*

Small (local effects)

Miosis, rhinorrhea, slight bronchoconstriction, secretions (slight dyspnea)

Moderate (local effects)

Miosis, rhinorrhea, slight bronchoconstriction, secretions (moderate to marked dyspnea)

Large

Miosis, rhinorrhea, slight bronchoconstriction, secretions (moderate to marked dyspnea), loss of consciousness, convulsions (seizures), generalized fasciculations, flaccid paralysis, apnea, micturition/defecation possible with seizures

*Onset of effects occurs within seconds to several minutes after exposure.

Lung-Damaging Toxic Industrial Chemicals

On the night of December 2, 1984, during floor cleaning at the Union Carbide pesticide plant in Bhopal, India, water contacted a tank of methyl isocyanate, resulting in an exothermic reaction and explosion. Within an hour, 40 tons of the chemical had vaporized and leaked out into the night air. Heavier than air, the vapor cloud settled along the ground and drifted into the surrounding densely populated slums. Over the next day, the dead and dying arrived by truckloads at local hospitals, and within 48 hours, 8,000 people had died and about 200,000 people were injured in the largest TIC disaster to date.[19]

Today’s MMO should recognize that the greatest chemical threat has shifted from structured military offensive capabilities to accidental or intentional release of TICs, such as in the Bhopal disaster.2,20 Chlorine and phosgene, two of the first chemical weapons used on the battlefield, are commonly used industrial chemicals today. Hundreds of TICs are used in industrial sites, publicly stored, and transported. To the military, lung-damaging TICs released on the battlefield as an aerosol, vapor, or gas are primarily an inhalational threat. When dispersed, they are usually heavier than air and hang close to the ground. TICs that commonly pose a military threat include: phosgene (CG), chlorine (Cl), oxides of nitrogen (NOx), hexachloroethane (HC) smoke, ammonia, and perfluoroisobutylene (PFIB).[20]

The military protective mask and filter will protect against some TICs, but not all. Specific filters or self-contained breathing apparatuses are mandated for certain TICs, such as ammonia. In addition, the protective mask is not effective in environments where TICs displace oxygen, creating a low oxygen environment.[14]

The severity of a TIC exposure is based on multiple factors, including the substance involved and its concentration, the duration of exposure, whether the exposure occurred within a confined space, whether there was loss of consciousness, and whether underlying lung disease is present. Some TICs act preferentially on the central airway compartment (upper airway), some act preferentially on the peripheral airway compartment (lower airway), and some act on both compartments (Figure 35-1). In large doses, TICs affect both central and peripheral airway compartments.

The clinical effects from centrally acting agents such as ammonia are immediate and include irritated upper airways manifested by nasopharynx, oropharynx, and larynx inflammation, resulting in sinus pain, painful swallowing, hoarseness, sensation of choking, stridor, and laryngospasm.[21] The onset of the clinical effects of peripherally acting agents such as phosgene is delayed, usually for hours. Toxicity may include irritation to the lower airways manifested by coughing and shortness of breath, followed by the development of pulmonary edema with production of clear foamy sputum.[21] A shortened latency period portends a more severe exposure and worse prognosis.

Medical management includes terminating exposure, which may include decontamination of any liquid on skin and removal of clothing to prevent further exposure from trapped vapors. There are no commonly available laboratory tests for the specific identification of lung-damaging agents.[21] Rest after exposure is critical. Physical activity in a symptomatic patient may precipitate acute clinical deterioration.[20] Treatment is supportive; supplemental oxygen is indicated along with bronchodilators for bronchospasm.

Figure 35-1. Airway compartments: central and peripheral.
Graphic courtesy of: US Army Medical Research Institute of Chemical Defense.

These patients can dramatically deteriorate after an initial latency period. Symptomatic patients require a period of observation with particular attention to airway management and treatment of pulmonary edema. Patients with hoarseness, stridor, upper-airway burns, or altered mental status may require endotracheal intubation. Patients with known exposure will require a period of observation of anywhere from 12 to 48 hours, depending on their presenting symptoms. Patients who remain asymptomatic 8 hours after exposure are unlikely to develop acute lung injury.[21] Patients presenting with shortness of breath can only be returned to duty at 48 hours, if physical exam and objective data are normal.[21]

Cyanide

There is no military use for cyanide.[22] The primary threat from cyanide for the MMO is its use as a toxic vapor deployed in an enclosed space. Forms of cyanide, such as hydrogen cyanide (AC) and cyanogen chloride (CK), are rapidly acting and highly lethal inhalational agents in high concentration. Cyanides are ubiquitous substances with widespread industrial use. Standard military field detection equipment can detect cyanide, and the chemical protective mask is fully protective against cyanide vapor.[14]

The most important route of cyanide exposure is via inhalation, after which it will be readily absorbed and rapidly distributed throughout the body. Cyanide interferes with oxygen transport and cellular respiration, thereby causing tissue hypoxia, anaerobic metabolism, and severe metabolic acidosis.

Cyanide should be suspected when a laboratory or industrial worker, or a group of individuals, suddenly collapse. The organs most susceptible to cyanide are the central nervous system and the heart. The MMO will find few and nonspecific physical findings, such as anxiety, agitation, vertigo, and feelings of weakness, followed by sudden loss of consciousness, convulsions, and apnea.[23] Classically described findings are severe respiratory distress in an acyanotic individual with “cherry-red” skin.[22] The hallmarks of severe cyanide toxicity are persistent hypotension and acidemia (lactic acidosis) despite adequate arterial oxygenation. Confirmatory lab tests for cyanide are not rapidly available, and while they exist, the turnaround time for test results is generally not rapid enough to support diagnostic use.[22] An MMO can expect to see anion gap metabolic acidosis from severe lactic acidosis in significant cyanide poisoning.[23]

Dermal decontamination is unnecessary in vapor exposures. Treatment begins with administering 100% oxygen and general supportive care. Severely symptomatic patients should be considered for specific antidotal therapy, either in a two-step process involving infusions of sodium nitrite and sodium thiosulfate, or with a single infusion of hydroxocobalamin (vitamin B12a), if available, to chelate cyanide.[22] While hyperbaric oxygen may be beneficial, it is not readily available, particularly in a mass exposure setting. For the MMO in the deployed setting, most inhalational exposure casualties who survive long enough to reach medical care will need little treatment.

Incapacitating Agents

Incapacitating agents cause impairments that are temporary and nonlethal. There are two known chemicals of concern: BZ, a synthetic glycolate anticholinergic compound aerosolized as a solid particle, and Agent 15, a compound speculated to be identical or similar to BZ.[24] These agents act as competitive inhibitors of acetylcholine with resulting effects that are generally the opposite of nerve agent poisoning. The United States has developed and stockpiled BZ, and it is reported that Iraq has stockpiled large amounts of Agent 15.[25]

BZ is dispersed as an odorless, non-irritating aerosolized solid.[25] It is primarily a respiratory threat, but it is also a risk via ingestion or absorption through the skin.[24] The characteristic of BZ that makes it incapacitating rather than toxic is its high safety ratio.[24] The high-efficiency particulate air (HEPA) filter of the chemical protective mask prevents exposure to BZ.[14] There is no current detection capability fielded.[24]

BZ intoxication causes classic anticholinergic symptoms that can be divided into peripheral effects, such as mydriasis, blurred vision, dry mouth, and dry skin, and central nervous system effects, such as altered level of consciousness, delusions, hallucinations, slurred speech, disorientation in time and place, and behavioral lability (from quietness to restlessness to combativeness).[25] BZ also produces shared illusions and hallucinations in groups.[24] The onset of symptoms depends on the dose and route of exposure. Symptoms may last 3 to 4 days.[24]

Medical management should focus on decontamination of skin and clothing, confiscation of weapons or similar items from the patient to prevent injuries from erratic behavior, and observation. The MMO should prioritize physical restraint, managing heat stress, control of symptoms with benzodiazepines, and the proper use of physostigmine antidotal therapy.[24] Early return to duty is not realistic for the majority of affected patients due to the usual time course of intoxication, which could last several days.

Riot-Control Agents

Riot-control agents are the chemical agents an MMO is most likely to encounter. Also called lacrimators or tear gas, riot-control agents produce temporary discomfort and eye closure, which renders individuals unable to fight.[26] Current military use includes law enforcement for riot control and gas chamber training exercises to evaluate proper use of the protective mask. The primary riot-control agents used in the United States are CN (mace), CS (tear gas), and OC (pepper spray). These agents are crystallized solids dispersed as fine particles via spray, grenade, or foam.[27]

The mechanism of toxicity of riot-control agents is not well characterized, and the main effects consist of temporary pain and burning of exposed mucous membranes and skin. The eye is the organ most sensitive to these agents.[27] Conjunctival burning leads to tearing and blepharospasm producing temporary blindness. Inhalation in the airways causes burning, sneezing, and coughing. The MMO might anticipate more serious pulmonary reactions in individuals with chronic pulmonary diseases.

Usually decontamination will not be needed if exposure was outdoors; however, the skin can be decontaminated with soap and water, and eyes should be decontaminated by flushing with copious amounts of water.[26] Medical providers do not require protection once an exposed patient has been decontaminated. Effects of exposure are usually self-limited and require no specific therapy but can be lethal under high concentration in a confined space. Also, because the effects are self-limiting, most individuals should be able to return to duty.[26]

Overview of Decontamination

Decontamination, the removal of hazardous chemical, biological, or radiological agents from a person or object, is a critical nonmedical task that is personnel, time, and equipment intensive. Performance while wearing protective equipment is degraded.[28] For suspected contaminated patients, decontamination should occur as quickly as possible after exposure. The goals are to immediately remove the agents from those exposed by non-toxic means, and to maintain an uncontaminated military medical treatment facility (MTF). Decontamination is not critical for people exposed only to vapor,[29] but for patients exposed to liquids, aerosols, or dry solids, thorough decontamination is required, especially when patients will enter a medical facility where staff are not in protective clothing. Three methods of skin decontamination are preferred by the US military:

1. RSDL is a packaged sponge containing liquid potassium solution that deactivates mustard (HD) and nerve agent. It may be used only on intact skin, not on wounds or eyes (only water, normal saline, or eye solutions are recommended for decontaminating the eyes). RSDL is carried by military members for immediate field self-decontamination, but its use does not eliminate the need for thorough decontamination later.[29]

2. Soap and water in copious amounts is effective for washing away most agents. It does not destroy biological agents or neutralize radioactive particles. The predominant effects are physical removal and dilution of agents.[29]

3. Hypochlorite solution, 0.5% (nine parts water to one part normal 5% bleach), can be wiped on the skin and rinsed with fresh water. The solution will cause a slow chemical decontamination reaction.[29]

The decontamination process requires controlled removal of the personal protective equipment (PPE) and skin decontamination before treatment in the MTF. Contaminated bandages are removed and wounds are flushed with sterile water. Bandages are replaced if bleeding recurs. Splints are thoroughly rinsed with 0.5% hypochlorite solution.[29] Wounds contaminated with vesicants or nerve agents may present a hazard to providers.[29] The risk from off-gassing from a contaminated wound is not significant, and removal of the foreign material effectively eliminates the hazard, so a chemical protective mask is not required for surgical personnel.[29] Patients are certified clean from chemical agents after decontamination using M8 paper, the Joint Chemical Agent Detector (JCAD), or the Improved Chemical Agent Monitor (ICAM).[29]

Patient Decontamination Site

Ideally, decontamination of casualties should be done in the field before evacuation to a medical facility (unfortunately, most victims bypass prehospital care and arrive unannounced at the closest MTF). Decontaminated casualties arriving from a contaminated environment must enter an MTF through a patient decontamination site (PDS).[30] This ensures MTF patients and staff will not become cross-contaminated by arriving contaminated casualties. The principal components of the PDS include:

- an entry control point,

- a triage area,

- an emergency medical treatment (EMT) area,

- a decontamination area, and

- a “hot line” separating the contaminated from clean areas.30,31

Medical personnel should be available to perform triage and emergency care in the contaminated “warm” zone before casualties are decontaminated. Casualties needing emergency care are sent to the warm side EMT. Because patient decontamination involves heavy work that can cause overheating, the decontamination team should be supplemented with nonmedical personnel. A safety officer must be appointed to observe PDS workers and manage work/rest cycles. Medical facilities must consider environmental variables such as wind direction and water run-off when establishing a decontamination site.30,31

BIOLOGICAL WARFARE AGENTS

In late March 1979, at a Soviet army biological research facility on the outskirts of Sverdlovsk, USSR, in the foothills of the Ural Mountains, a technician removed a clogged filter in the anthrax drying plant, briefly allowing spores to escape. Approximately 1 g of a powerful weaponized strain, anthrax 836, was released into the cold night air. In a few days all the night shift workers in a plant across the street, in the direct path of the wind, had fallen ill, and within a week almost all were dead. Over the next 6 weeks at least 66 persons died from inhalational anthrax, and farm animals died up to 50 km within a narrow zone downwind from the factory.[32] The outbreak, a “biological Chernobyl,” demonstrated the power of anthrax as a biological weapon and clearly showed that the USSR was producing offensive biological weapons, in violation of the 1972 Biological Weapons Convention.[33]

Prior to 1969, the United States had an active biological warfare program that included research, development, and stockpiling of offensive biological weapons. Under President Nixon, the United States unilaterally renounced the development and production of biological weapons. From that time forward, US efforts in biological warfare have been restricted to research and development of vaccines, drugs, and diagnostics as defensive measures against biological weapons.[34] While the United States offensive biological warfare program included open-air testing using simulants thought to be nonpathogenic, the US military has never used biological weapons.34,35 In contrast to the United States, the USSR (and Russia) had a massive offensive biological weapons program until 1992, and Iraq maintained some offensive biological weapons capacity until 2003.33,34,36

There have been two large-scale bioterrorist attacks in the United States: the 1984 Rajneeshee salmonella attack, which resulted in 751 cases of infection, and the 2001 anthrax mailings, which resulted in 22 cases of infection, 5 deaths, and approximately 10,000 suspected exposures to patients who were offered postexposure prophylaxis.37,38 Published reports suggest that the threat of biological terrorism continues to increase, and the use of biological weapons in both large- and small-scale attacks against US military and civilians continues to be actively explored by nations and terrorist groups.34,39 In 2001 a team of virologists in Germany and France constructed an Ebola virus from three strands of complimentary DNA using reverse genetics, with technology described by the National Scientific Advisory Board for Biosecurity as “readily accessible, straightforward, and a fundamental tool used in current biological research.”40,41 However, MMOs should understand that while many biological agents can cause illness in humans, few are capable of affecting public health and medical infrastructures on a large scale, like anthrax and Ebola.

The Centers for Disease Control and Prevention (CDC) has been designated the lead agency for overall national public health planning and response to biological terrorism. It has prioritized high-risk biological agents based on their overall threat to civilians (Table 35-3).[42] This chapter focuses on Category A agents and their relevance to the MMO. MMOs must maintain a high index of suspicion and be prepared to evaluate both symptomatic patients and asymptomatic “suspected exposed” military and civilian patients referred from syndromic surveillance systems.

Bacterial Agents

Anthrax

Inhalational anthrax in the United States under normal circumstances is so unusual that a single case should prompt an investigation for bioterrorism. Naturally occurring anthrax is primarily a disease of herbivores. The causative agent of anthrax is a gram-positive sporulating rod, Bacillus anthracis, and spores are the usual infective form.[43]

In New York City on September 29, 2001, a 7-month-old infant was noted to have a painless red papule with swelling on his upper arm. During the next 24 hours his arm became increasingly edematous, the papule evolved into a painless macule, and a slight serous drainage began. His pediatrician began antibiotics for presumed cellulitis, but the infant soon required admission for increased swelling and difficulty tolerating oral medication. By hospital day 2 the arm showed massive non-pitting edema with a dark red macule 3 cm in diameter. The working diagnosis was “spider-bite.” The infant continued to deteriorate. On hospital day 13 he was diagnosed with cutaneous anthrax by skin biopsy and blood testing for B anthracis. Eventually the infant made a full recovery on appropriate antibiotics. It was later determined that the day before his symptoms began, the infant had spent an hour in his mother’s office at a national news organization, where anthrax spores were subsequently found.[44]

Cutaneous anthrax had never before been diagnosed in an infant in New York. The first case of inhalational anthrax associated with the anthrax mailings was not recognized until October 4. Earlier diagnosis of cutaneous anthrax in this case would have alerted the medical community to the impending danger and prevented further delay in diagnosis of other symptomatic patients.

Anthrax presents as three distinct clinical diseases in humans determined by the route of entry of the spores: inhalational, cutaneous, and gastrointestinal (GI). The most severe of these is inhalational anthrax, which presents as a nonspecific febrile illness after a 1- to 6-day incubation period.[43] The inhalational anthrax syndrome may include nausea, vomiting, nonproductive cough, fever, malaise, headache, and chest discomfort.45,46 Physical findings are nonspecific early in the course of disease. Evidence of mediastinal widening (hemorrhagic mediastinitis) or pleural effusions may be seen on chest x-ray or computed tomography (CT) scan.[47] Prominent hilar adenopathy is characteristic.[43] The patient will progress to respiratory distress, septic shock, and death unless provided aggressive intensive care.[43] Due to the fulminant course of inhalational anthrax, prompt antibiotics are essential for survival, and monotherapy is not acceptable.[48] More advanced therapies are available under Investigational New Drug (IND) authorization subject to Food and Drug Administration (FDA) regulations.[48]

Direct person-to-person spread does not occur, and standard universal patient precautions are recommended. Anthrax is detectable in early stages via blood culture or polymerase chain reaction (PCR) and later stages via Gram stain of blood, cerebral spinal fluid (CSF), or pleural fluid.[43] B anthracis culture requires biosafety level (BSL) 2 lab precautions.

TABLE 35-3

CRITICAL BIOLOGICAL AGENT CATEGORIES FOR PUBLIC HEALTH PREPAREDNESS

Biological Agents*

Disease

Category A: moderate to high potential for large-scale dissemination; greatest potential for production of mass casualties and major impact on public health

Variola major

Smallpox

Bacillus anthracis

Anthrax

Yersinia pestis

Plague

Clostridium botulinum (botulinum toxins)

Botulism

Francisella tularensis

Tularemia

Filoviruses and arenaviruses (eg, Ebola virus, Lassa virus)

Viral hemorrhagic fevers

Category B: some potential for large-scale dissemination; cause less illness and death and expected to have lower public health impact

Coxiella burnetii

Q fever

Brucella species

Brucellosis

Burkholderia mallei

Glanders

Burkholderia pseudomallei

Melioidosis

Alphaviruses (VEE, EEE, WEE)

Encephalitis

Rickettsia prowazekii

Typhus fever

Toxins (eg, ricin, staphylococcal enterotoxin B)

Toxic syndromes

Chlamydia psittaci

Psittacosis

Food safety threats (eg, Salmonella species, Escherichia coli O157:H7)

Water safety threats (eg, Vibrio cholerae, Cryptosporidium parvum)

Category C: could emerge as a future threat; not believed to be a significant public health threat at present

Emerging threat agents (eg, Nipah virus, Hantavirus, multidrug-resistant tuberculosis, SARS, MERS)

*The categories of agents should not be considered definitive and may change as new information is obtained.

EEE: Eastern equine encephalomyelitis; MERS: Middle East respiratory syndrome; SARS: severe acute respiratory syndrome; VEE: Venezuelan equine encephalomyelitis; WEE: Western equine encephalomyelitis

Reproduced with permission from: Rotz LD, Khan AS, Lillibridge SR, et al. Public health assessment of potential biological terrorism agents. Emerg Infect Dis. 2002;8(2):225-226.

Biothrax (Anthrax Vaccine Adsorbed [AVA]; Emergent BioSolutions, Gaithersburg, MD) is a safe vaccine licensed for the prevention of anthrax.[43] It is included in the Strategic National Stockpile and indicated for postexposure prophylaxis (PEP).[48] Antibiotics and AVA are indicated for PEP; all patients exposed to anthrax should receive prophylactic antibiotic treatment for 60 days.[48] Anthrax is thought to be the most likely biological agent to be used in future bioterrorism attacks.[45] Anthrax spores were weaponized by the United States, the USSR, and Iraq, among other countries.49,50 During the Persian Gulf War, US military members carried ciprofloxacin to be used prophylactically in the event of an anthrax attack on US forces.[43]

Plague

Yersinia pestis is a gram-negative bacterium that causes plague, a naturally occurring disease spread from rodents through direct contact or contact with infected fleas. Plague is endemic to the US southwest, but naturally occurring pneumonic plague is rare. Three pandemics of plague occurred in the 6th, 14th, and 19th centuries, killing millions of people.[51] The highly contagious nature of plague via person-to-person transmission makes it an attractive high-threat biological terrorist weapon, and it was weaponized by the United States and USSR.[52]

Plague appears in three forms in humans: pneumonic, septicemic, and bubonic. Pneumonic plague would be the disease form expected after aerosol dissemination and presents as a severe respiratory illness of sudden onset 1 to 6 days after exposure.[52] Classic symptoms include high fever, headache, and cough with hemoptysis.[52] Death results from respiratory failure, circulatory collapse, and bleeding diathesis.[51] Plague should be suspected by the MMO if a large number of previously healthy individuals present with severe pneumonia with hemoptysis. The MMO can establish a presumptive diagnosis by identifying gram-negative coccobacilli in sputum. A definitive diagnosis requires culturing the organism, which usually takes 48 to 72 hours. PCR and direct fluorescent antibody tests may be available in certain reference labs.[53]

Early treatment with antibiotics is required for survival, ideally within 1 day of symptoms, although naturally occurring antibiotic-resistant strains exist.[53] Patient management requires respiratory droplet precautions because pneumonic plague is easily spread person-to-person via aerosol, yet this has not occurred in the United States since 1925.[51] All individuals who come within 2 m of a patient with pneumonic plague should receive PEP with antibiotics.[53] No vaccine has been available since 1998, and the previously available vaccine was not effective against pneumonic plague.51,53

Tularemia

Francisella tularensis, the causative agent of tularemia, is a small, naturally occurring, hardy, and extremely virulent gram-negative coccobacillus. F tularensis can be stabilized and aerosolized to make an effective offensive weapon, and it has been associated with multiple environmental biosurveillance alerts in the United States since 2001.[54] As a result, the MMO could see “suspected exposed” patients referred via bioterrorism aerosol surveillance programs.[54]

Tularemia is acquired primarily through contact with rabbits, ticks, or fleabites. It was weaponized by the United States and the USSR and has a very low infectious dose; exposure to approximately 10 organisms will cause disease.[55] A high index of suspicion is needed to make an early diagnosis of tularemia. After aerosol inhalation and an incubation period of 3 to 6 days, the disease manifests as abrupt onset of fever, headache, malaise, myalgia, and prostration, followed by pleura-pneumonia.[56] F tularensis is difficult to culture with standard lab media, and isolation of the organism requires a BSL-3 level containment lab.[57]

The initial treatment is with intravenous antibiotics. There has been no known human-to-human transmission of tularemia, so only standard precautions are required.[55] Since there is no licensed vaccine available, PEP is managed with antibiotics and should be continued for 14 days.[57]

Viral Agents

Viruses, as intracellular parasites requiring host cells for replication, cannot be cultivated in synthetic nutrient materials. The MMO should recognize that some viruses are well suited as bioweapons.

Smallpox (Variola)

Smallpox, caused by the variola virus, was declared eradicated by the World Health Organization in 1980. The United States ended routine civilian vaccination in 1972 and routine smallpox military vaccination in 1989.[58] Two repositories for the smallpox virus exist in the United States and Russia; however, the extent of clandestine stockpiles as a biological weapon is unknown, and the possibility of its reemergence exists. Smallpox was easily cultured, very stable, and successfully weaponized.[59] Large stockpiles of this agent existed in the USSR, where it was viewed as a strategic weapon of opportunity. Since routine civilian immunization ended, there is now a large immunologically naïve population.33,58

The initial diagnosis of smallpox is clinical. The MMO must differentiate smallpox from other papulovesicular lesion-producing diseases. The clinical manifestations of smallpox appear in a series of distinct phases that are uniquely characteristic, and its rash may be confused with chickenpox. Lesions appear first on the face and hands, then spread to the extremities, and finally the trunk. Classically, lesions remain synchronous in their stage of development throughout the body during each clinical phase. Microscopy cannot distinguish between the orthopox viruses, but PCR may distinguish variola.[58] The MMO may fail to recognize patients with immunocompromise who develop different, non-classic forms of disease, and human monkeypox may look indistinguishable from smallpox.[58]

To the MMO, any case of smallpox should be considered a public health emergency. There is no FDA-approved chemotherapy, but antiviral drugs for use against smallpox are under investigation.[60] Individuals with successful smallpox vaccination within 3 years that resulted in a confirmed clinical take (progression from papule to vesicle to pustule to scab at the inoculation site) are considered immune to smallpox; however, routine revaccination of all potentially exposed individuals would be prudent in the face of significant exposure risk.[60]

Immediate vaccination or revaccination with smallpox (live vaccinia virus) vaccine (ACAM 2000), ideally within 4 days for all exposed personnel, will likely ameliorate or prevent disease.[60] There are no absolute contraindications to postexposure vaccination for high-risk exposures, and vaccinia immune globulin (VIG) is indicated for rare life-threatening complications from vaccinia vaccine, such as eczema vaccinatum and postvaccinial encephalitis.58,59

The MMO must recognize that smallpox is highly infectious; transmission occurs person-to-person by respiratory droplets and is enhanced by coughing.58–61 Infection can also occur from contact with infected clothing or bedding. Patients are infectious from onset of rash until all scabs separate. Infectious patients require isolation with contact, airborne, and droplet precautions.[60] All asymptomatic contacts must be quarantined for 17 days.[60]

PCR testing for smallpox is available under BSL-4 conditions at national laboratories (US Army Medical Research Institute for Infectious Diseases and the CDC) via the Laboratory Response Network. A PCR test that detects all orthopoxviruses may be available via the military area medical laboratory.[60]

Viral Hemorrhagic Fever

On September 25, 2014, a 45-year-old man from Liberia, who had arrived in the US 5 days earlier, went to a Dallas, Texas, emergency department with fever (100.1° F), abdominal pain, and headache. He was treated for possible sinusitis and discharged. He returned to the same emergency department via ambulance on September 28 with fever (101.4° F), abdominal pain, and severe diarrhea. He tested positive for Ebola virus on September 30, the first imported Ebola virus infection diagnosed in the United States. Despite intensive care, the patient died 8 days later. Although PPE and appropriate precautions were used, two nurses caring for the patient subsequently contracted Ebola virus disease (EVD) and required prolonged intensive care; both survived. Multiple community contacts of all patients were either voluntarily quarantined or actively monitored for 21 days, and 12 persons in this group developed fever or other symptoms compatible with EVD, but no other person contracted EVD.[62]

Viral hemorrhagic fever (VHF) is an acute febrile syndrome from a diverse group of tick-, rodent-, and mosquito-borne viral illnesses naturally occurring in specific geographic locations. These diseases are unified by their potential to present as a severe febrile illness with a bleeding diathesis and high mortality rate. The MMO should recognize two VHF viruses, yellow fever and dengue, that have great significance in the history of military medicine.[63] While the VHFs have not been weaponized, they are recognized as having significant potential for aerosol dissemination and weaponization, and the Aum Shinrikyo group attempted to obtain Ebola virus samples from West Africa for development in their bioterrorism program.33,63–65 Aerosol dissemination does not occur naturally.63,64

The clinical presentation of VHF includes various combinations of fever, malaise, myalgia, headache, vomiting, and diarrhea. The initial constellation of symptoms makes VHF difficult to distinguish from other acute febrile illnesses. VHF should be considered by the MMO in any patient presenting with severe acute febrile illness and abnormal bleeding.[66] Differentiating the VHFs is difficult, and making a definitive diagnosis of VHF requires a reference laboratory with BSL-4 advanced bio-containment capability. Rapid enzyme immunoassays and PCR testing exist but may not be readily available for specific VHFs. Lab specimens must be appropriately collected, handled, double-bagged, decontaminated, and shipped to the BSL-4 lab.[66]

Treatment includes intensive supportive care with vigorous fluid resuscitation under strict contact precautions and negative-pressure isolation. Management of the hemorrhagic component mirrors other patient coagulopathies. Intramuscular injections and aspirin and other anticoagulants should be avoided. Airborne precautions must be instituted for procedures that create aerosols. Antiviral therapy may be available on an investigational new drug basis.[64] VHF patients harbor extensive infectious viral load in blood, body fluids, and body secretions,63,64,66 and MMOs must be aware that caring for these patients has proven to be highly risky and labor and staff intensive. Staff treating VHF patients should wear double gloves, impermeable gowns with leg and shoe coverings, eye protection and HEPA (N95) masks or positive pressure air-purifying respirators.[66] Medical staff will experience significant risk from contaminated PPE, in particular during the doffing process, and all waste should be carefully handled and incinerated or autoclaved.

After a presumed bio-warfare attack with unknown VHF agent, the MMO should consider intravenous antiviral drugs for any exposed individual with fever higher than 101° F, until the agent is identified.[66] Yellow fever is the only VHF for which a licensed vaccine is available. Experimental vaccines exist for other VHFs, but are not readily available.[66] Close personal contacts of VHF patients, including medical personnel, should be closely monitored for fever and other symptoms during the established incubation period.

Biological Toxins

Toxins are harmful substances produced by living organisms. By nature they lack volatility (there is no vapor hazard), do not persist in the environment, are not dermally active, and pose no risk for person-to-person spread.[67] Biological toxins have military utility as aerosolized weapons based on the magnitude of their toxicity.[67]

Botulinum

By weight, botulinum toxins are the most toxic substance known. It has been estimated that 1 g of aerosolized botulinum toxin could kill more than a million people.[68] Botulinum toxins are a group of seven related neurotoxins produced by the spore-forming bacillus Clostridium botulinum, which is present in the soil.[67] Botulinum toxin inhibits neurotransmission by preventing acetylcholine release at the nerve terminal.[67] Neurotoxins produced by C botulinum are readily denatured in the environment.[67] There are three forms of naturally occurring botulism: foodborne botulism, wound botulism, and intestinal botulism (infant and adult).

The intentional use of botulinum toxin can be either an inhalational or foodborne threat, and industrial-scale fermentation could produce large amounts of toxin.[67] A large aerosol release would easily overwhelm healthcare capabilities. Botulinum toxin has been weaponized by the United States, USSR, Iraq, and terrorist organizations.67–70 Aum Shinrikyo attempted to dispense botulinum toxin in Tokyo in the mid-1990s.[65] In an outbreak related to an intentional aerosolized release, the MMO should expect patients presenting as afebrile, alert, and oriented, with descending paralysis manifested by cranial nerve palsies, including ptosis, diplopia, blurred vision, dysphagia, and dysphonia, followed by symmetrical descending flaccid paralysis.67,68 Respiratory failure, which may occur abruptly, is the most common cause of death. Symptoms may progress over hours or days depending on the exposure dose. Sensory symptoms do not occur and botulinum toxin does not cross the blood-brain barrier, so altered sensorium should not occur.[71]

Botulism is a clinical diagnosis because laboratory testing can be inconclusive. Mouse neutralization (bioassay) is the most sensitive test and can take up to 4 days; an enzyme-linked immunosorbent assay (ELISA) test also exists.[71] Early administration of antitoxin is critical; antitoxin must never be withheld from the patient, even if treatment is delayed.[71] Postexposure prophylaxis with antitoxin administration, while not recommended, should be considered under extraordinary circumstances after a high-risk exposure.67,71

Ricin

Ricin is a potent cytotoxin derived from the mash of the castor bean. Its mechanism of toxicity is via inhibition of protein synthesis.[72] Ricin has military significance because of the ease with which it can be extracted from the castor bean. It is ideal for small-scale bioterrorism attacks and has been successfully used in several notorious political assassinations.72,73

Ricin’s clinical presentation depends on the dose and route of exposure. It is primarily a threat via aerosol inhalation and ingestion.[72] The MMO should suspect ricin in a large number of geographically clustered cases of acute lung injury, because inhalation causes severe, progressive lung inflammation leading to respiratory failure over days.[74] Ingestion will cause severe GI inflammation and multiorgan failure.[74] The diagnosis of ricin poisoning will be challenging for the MMO because multiple pulmonary pathogens could present similarly to aerosolized ricin. Specific tests exist but are not readily available.73,74

There is no antitoxin to ricin. Treatment for ricin poisoning is supportive, regardless of the route of exposure. Patients should be thoroughly decontaminated with soap and water.72–74 Ricin-induced lung injury will not respond to antibiotics, and ricin ingestion is managed by lavage and cathartics.73,74 Ricin toxicity is not contagious, and protective masks are effective. While vaccines are under investigation, none currently exist.[74]

RADIOLOGICAL AND NUCLEAR EXPOSURES

In 2011, an earthquake with a subsequent tsunami stuck Japan, resulting in flooding of the nuclear reactor plant in Fukushima. The subsequent loss of power caused the reactor to overheat, followed by meltdowns and evacuations from the surrounding area. The event was categorized as level 7 on the International Nuclear and Radiologic Event Scale, and is estimated to involve 10% of the exposure that occurred at Chernobyl, Russia, in 1986.[75] The Chernobyl accident is the largest nuclear disaster in history, causing 30 immediate deaths and the evacuation of over 300,000 people. Reports of health issues related to radiation exposure continue.[76]

Three types of devices pose a risk of radiation exposure to military personnel: (1) a radiation exposure device (RED); (2) a radiological dispersion device (RDD); and (3) an improvised nuclear device (IND). An RED has a radioactive source within a container or sealed source for the purpose of exposing those nearby to high doses of radiation. Various military and civilian/industrial supplies and equipment contain radioactive material that could be used to create an RED or RDD to employ as a weapon or cause exposure due to improper storage or handling. RDDs are intentionally engineered to disperse radiation but without a nuclear blast. Dispersal may be through a plume or contamination of the food and water chain.

INDs, designed to deliver a nuclear detonation at either full or partial yield, are the most catastrophic of these devices. INDs expose individuals to a high level of external radiation, blast and thermal injury, and subsequent radiation exposure through inhalation of particulate matter and ingestion of contaminated materials. The primary effect of an IND is the blast effect. The medical management of blast injury from both nuclear and non-nuclear explosive devices is discussed in detail later in this chapter. Unique to INDs is an intense thermal wave of energy known as the nuclear flash. Individuals in the immediate vicinity will be incinerated. Surviving individuals will suffer burns on the side exposed to the blast or from secondary fires ignited by the thermal wave. The other principal output from a nuclear blast is radiation, in both primary and secondary exposures.

Radiation Effects

Radiation effects can be divided into two categories, acute external exposure and internal contamination. Both an RDD and an IND can cause an immediate release of radiological material leading to acute radiation syndrome (ARS). Acute external exposure usually involves beta and gamma particles. Internal contamination can occur via inhalation, ingestion, or absorption from a contaminated wound. Internal contamination can be due to any isotopes, of which there are over 8,000. Radioactive decay from isotopes creates ionizing radiation whose properties can vary (Table 35-4). Internal contamination is unique from external exposure and ARS because isotope identification is crucial in medical management.

External Exposure

ARS is the result of high-level (> 0.7 Gy) exposure to ionizing radiation. Exhibit 35-1 lists conditions that can result in ARS. A characteristic constellation of clinical events results from radiation damage to cells that occurs within seconds of exposure. The organ systems and cell lines with the highest turnover are the most sensitive to radiation exposure. ARS follows a predictable course through four phases: prodromal, latent, well-defined illness, and finally recovery or death. The transition time between phases depends on the dose of radiation received. The prodromal phase, which can last minutes to days, is characterized by nausea, vomiting, diarrhea, mild fever, and transient skin erythema. The patient then may appear well for a few hours, or even a few weeks, during the latent phase, which is characterized by silent cell and tissue destruction. This destruction is later manifested clinically as one or more of the syndromes described below. Death can occur within days for extremely high doses but may not occur for weeks to months. Recovery can take up to 2 years.

TABLE 35-4

PROPERTIES AND EFFECTS OF IONIZING RADIATION

Type

Source

Properties

Clinical Concern

Alpha particles

Charged particles from heavy nuclei

Travel short distance, shielded by clothes/skin

Wound absorption

Beta particles

Electrons from fallout or certain isotopes

Travel short distance in tissue

Can cause radiation burns, damaging if internalized

Gamma rays

Photons from nuclear detonation, fallout, or nuclear decay

High energy and pass through matter easily

Whole body effects from both external exposure and internalization

Neutrons

Uncharged particles emitted from fission

High energy and pass through matter easily

Same effects as gamma rays with more significant damage

EXHIBIT 35-1

CONDITIONS REQUIRED FOR ACUTE RADIATION SYNDROME

- Dose must be large (>0.7 Gy).

- Dose must be external.

- The radiation must be penetrating (x-rays, gamma rays, neutrons).

- The entire body must be exposed.

- The dose must be delivered in a short time.

___________________

Adapted from: Centers for Disease Control and Prevention. Acute radiation syndrome: a fact sheet for physicians. https://emergency.cdc.gov/radiation/arsphysicianfactsheet.asp. Updated August 23, 2017. Accessed July 4, 2018.

There are three classic ARS syndromes: (1) hematopoietic, (2) GI, and (3) neurovascular. The hematopoietic syndrome, also known as the bone marrow syndrome, occurs with doses above 0.7 Gy. Hematopoietic progenitors are unable to divide, resulting in bone marrow failure and lymphopenia or pancytopenia. Destruction of cell lines leads to infection, bleeding, and poor wound healing. Survival depends on dose, concomitant injuries, and access to supportive care. The mean lethal dose required to kill 50% of humans within 60 days, LD50/60, is about 3.5 to 4 Gy. Providing medical therapy including antibiotics, transfusions, and cell line stimulation can improve survival at higher exposure doses.

The GI syndrome occurs in conjunction with the hematopoietic syndrome at doses higher than 6 Gy. This level of radiation causes damage to the small intestine, targeted at intestinal crypt cells that have a high turnover rate. This syndrome has the typical flu-like prodromal phase, and diarrhea is often characteristic. The overt clinical phase involves malaise, anorexia, severe diarrhea, and fever. The diarrhea can lead to dehydration and electrolyte imbalance. Loss of GI integrity can lead to malabsorption and nutritional disorders. Bacteria can translocate across the damaged epithelial lining of the intestinal wall and lead to gram-negative sepsis. More severely affected patients can present in renal failure or cardiovascular collapse. While aggressive supportive care can extend the survival period, death usually occurs from sepsis and multiorgan failure.

The most severe and rapidly fatal of the syndromes, due to doses higher than 12 Gy, is the neurovascular syndrome. High radiation exposure will result in an immediate burning sensation, followed by nausea and vomiting, fever, hypotension, and neurologic dysfunction such as ataxia and confusion. Symptoms are rapidly progressive and severe; death typically occurs in 24 to 48 hours. Recovery is not expected in patients with this syndrome.

Knowing that the clinical syndromes are dose dependent, markers to estimate radiation dose early in the evaluation of exposed patients can be very useful. Radiation dose can be estimated using the medical history, serial blood counts, and the time to emesis. Medical history should include the circumstances of suspected exposure, taking note of location relative to the incident, sheltering, and any other pertinent exposure details, in addition to clinical symptoms. Serial blood counts are one of the most readily available and useful methods to characterize exposure. An initial complete blood count followed by serial measurements three times a day for 2 to 3 days will facilitate determination of the slope of lymphocyte decline. A drop in lymphocyte count by more than 50% in the first 24 hours indicates a potentially lethal exposure. Time to emesis can be used in the absence of laboratory support or as an adjunct to lymphocyte count. Emesis within 1 to 2 hours of exposure carries a poor prognosis.

The chromosome-aberration cytogenetic bioassay (specifically lymphocyte dicentrics) is considered the gold standard in estimating dose. However, samples must be obtained within 24 hours of exposure, and results may not be available for 2 to 3 days, so time to emesis and lymphocyte counts remain the most useful tools in the initial assessment period. It is helpful to remember that if an individual has not vomited within 8 to 10 hours of exposure, it is unlikely he or she was exposed to a dose over 1 Gy.77,78 The Armed Forces Radiobiology Research Institute Biodosimetry Assessment Tool is a software package that can help providers assess exposure and guide therapy. The tool has a complimentary package for first responders called the First Responders Radiologic Assessment Triage. These useful tools can facilitate optimization of a standardized framework for the response to nuclear or radiological catastrophe.[79]

Triage and Treatment of Radiation-Injured Patients

Radiation-injured patients are emergently treated for life, limb, or eyesight injuries regardless of contamination. A radiological detonation produces casualties with a combination of blast injury, thermal injury, and various wounds—all requiring medical attention. Triage of patients with combined injury should follow trauma protocols. If the only injuries are radiation injuries, then triage should consist of assessment of dose rate, prodromal symptoms, and specimen collection for biodosimetry. Contaminated patients pose little threat to healthcare personnel, and treatment of emergent conditions should not be delayed due to concerns of contamination. Decontamination is a time-consuming and resource-intensive process, so patients should be stabilized prior to decontamination. Fortunately, removing clothing, bandages, and personal effects removes 90% of contamination, so exposure for trauma management begins the decontamination process. Further decontamination involves washing the skin with soap and water (preferred over 0.5% hypochlorite solution) without irritating the skin. Standard hospital PPE (gown, cap, double gloves, and shoe covers) is adequate when decontaminating patients. If possible, irrigation effluent should be collected and disposed of deliberately.

Decontamination should be confirmed with radiation detection, indication, and computation (RADIAC) counters such as the AN/VDR-2 and the AN/PDR-77; refer to Table 35-5 for decontamination standards. To minimize local tissue injury and systemic contamination, particulate matter with alpha or beta emitters should be removed from wounds, and then the wound should be thoroughly irrigated. However, aggressive surgical debridement to eliminate particulate matter is not recommended and may cause more damage to tissue than would be posed by the radiation risk. Similarly, burns should be irrigated and cleaned while leaving blisters intact and minimizing damage to the skin. Once wounds and burns have been cleaned, they should be reexamined with a RADIAC counter.

After life-threatening injuries have been addressed and decontamination is complete, attention can be given to treatment of ARS. Therapy is determined by signs and symptoms, and laboratory parameters help guide treatment. Antibiotic agents and possibly antifungals and antivirals can be used in neutropenic patients to prevent infection. Fluoroquinolones with streptococcal coverage are most appropriate in the radiation-poisoned patient. When the patient is not neutropenic, antimicrobial therapy should be targeted to the specific infection. Supportive care such as anti-emetics, fluid therapy, electrolyte replacement, and analgesics can provide significant relief. Vomiting is common and, as described above, can be a prognostic indicator. While prophylaxis is not indicated, anti-emetics should be given once vomiting has begun. Serotonin receptor antagonists have well-documented efficacy for nausea and vomiting in radiation-treated patients, and thus should be useful in the setting of radiation poisoning. Fluid resuscitation should address losses due to trauma, burns, and GI symptoms. Patients with early onset multiorgan failure should be managed as expectant with the goal of providing comfort care coupled with psychological support.

TABLE 35-5

DETECTION LIMITS*FOR DECONTAMINATION

Type of Radiation

Limit

Alpha particles

< 1,000 disintegrations/minute

Beta particle

< 1 mR/h

Gamma rays

< 2 × local background level

*Upper limit of radiation that must be reached to consider an individual thoroughly decontaminated. If an individual is above these levels, decontamination efforts should be continued until detectable radiation is below these limits.

For patients with low to moderate exposure and manifestation of the hematopoietic syndrome, attention should be given to support of cell lines. For exposures greater than 3 Gy, hematopoietic colony stimulating factors (CSFs) are recommended. For pediatric, geriatric, or polytrauma patients, the threshold for therapy should be lower. Therapy should be started as soon as biodosimetry or clinical signs and symptoms suggest this threshold exposure level. More severe exposures, over 7 Gy, may require transfusion therapy and even stem cell transplantation in addition to prolonged therapy with CSFs. Survival from acute effects in partial body exposures over 10 Gy is possible with hematopoietic support and early use of CSFs. Adjunctive therapies become necessary as ARS develops over days to weeks.

In addition to medical therapy, it is important to recognize the psychological injuries that may occur as a result of nuclear or radiological injury. It is likely that the fear and anxiety associated with exposure outweighs the actual medical effects. Attention should be given to the immediate psychological response, combat stress effects, and long-term sequela of such a psychological stress such as posttraumatic stress disorder. A responsive, competent, compassionate, and confident medical response will do much to alleviate immediate anxiety and fear. Information flow should be accurate and timely. Anticipating the need for mental health support will help ensure resources are available to mitigate adverse psychological outcomes.77,78

Internal Exposure

Ingestion, inhalation, or contamination of wounds with radioactive material are mechanisms of internal exposure. Isotope identification is crucial in the determination of medical management. An in-depth discussion of specific isotope management is beyond the scope of this chapter; however, some general principles apply to the care of these patients, based on reducing ongoing exposure. Available methods of reducing internal contamination include dilution, chelation, and chemically altering the isotope. Absorption in the GI tract can be reduced by lavage or cathartics; pulmonary load can be reduced by bronchoalveolar lavage; and contamination in wounds can be excised. Further treatment should be directed at decorporation of the isotope. Treatment for some of the more common isotopes is listed in Table 35-6.[78]

Internal radiation exposure and ARS with associated physical and psychological injuries form a complex medical picture that requires optimization of decision-making and resource management to maximize medical outcomes. Survival can be greatly affected by wise therapy and supportive care, underscoring the importance of understanding the evaluation, triage, and medical management of radiological exposure.77,78

TABLE 35-6

TREATMENT OPTIONS FOR SELECTED RADIOISOTOPES

Radionucleotides of:

Treatment

Plutonium 239

Zn-DTPA or Ca-DTPA

Yttrium 90

Zn-DTPA or Ca-DTPA

Uranium

Sodium bicarbonate

Cesium 137

Prussian blue

Strontium

Calcium or aluminum phosphate

Radioidodines

Potassium iodide

Zn-DTPA: zinc diethylenetriamene pentaacetate

Ca-DTPA: calcium diethylenetriamene pentaacetate

EXPLOSIVE (BLAST) INJURIES

Blast injury can involve a complex array of injuries with various wounding mechanisms. Care of the blast victim can be especially challenging because the provider may be faced with several life-threatening injuries that must be addressed simultaneously. The magnitude of blast effects is influenced by several factors. For example, pressure generated in water moves more quickly and dissipates more slowly than pressure waves in air, so underwater blasts may lead to more injury. As distance from the blast increases, injury risk decreases, and shielding can provide significant protection. On the other hand, being in a confined space, or being close to a surface that reflects the propagating pressure wave, may result in magnification of the blast effects.

Mechanisms of Blast Injury

Explosions cause injury by several mechanisms. The initial gas expansion causes a blast wave with high winds that can cause displacement of people or objects. This is followed by a pressure differential created by the blast wave, and then a negative pressure phase occurs before air pressures return to normal. Heat generation, fragmentation, and collapse of infrastructure can all contribute to injury. Blast injuries are thus characterized as primary, secondary, tertiary, and quaternary injury. Although this is a simplified taxonomy, it can be useful to theoretically organize the anticipated effects.

Primary blast injury is a result of the blast overpressure and the forces it exerts upon the body. The pressure differential created by alternating overpressure and underpressure leads to both local tissue and systemic effects. Air-filled organ systems such as the GI, pulmonary, and auditory systems are the most sensitive, but blast effect can also cause musculoskeletal tissue damage, central nervous system injury, and even visual and cardiovascular effects. Injury is not isolated to local tissue effects. Cardiovascular collapse may occur as the result of pressure effects on the vagus nerve and dysfunctional vasoconstriction in response to diminished cardiac output.

Flying debris displaced as a result of the blast wave and winds causes secondary injury in the form of both penetrating and blunt trauma. Secondary injury is seen more commonly than severe primary injury, and these injuries can be devastating. Tertiary injury occurs with structural collapse or when forces displace a person who then sustains blunt trauma such as fractures or a closed head injury. While tertiary injury may have a high mortality rate at the site of the explosion, it only represents a small portion of overall deaths. Lastly, the term quaternary injury captures all the other miscellaneous injuries that may occur as a result of explosions, such as burns, asphyxia, toxic (including chemical and radiological) exposures, and psychological sequela. Evaluation and management of secondary, tertiary, and quaternary injuries follows routine trauma management principles, so the following discussion will be limited to primary blast injury.80,81

Evaluation and Management of Primary Blast Injury

Due to their large amount of air-filled tissue, the lungs are susceptible to primary blast injury. The pressure differential causes disruption of lung tissue with damage to the alveolar-capillary interface. Blast lung may be complicated by pneumothorax, hemothorax, pulmonary contusion, pulmonary hemorrhage, pulmonary emboli, mediastinal air, and subcutaneous air, all of which contribute to difficulty in oxygenation due to ventilation/perfusion mismatch. A chest x-ray done as part of routine trauma management will help identify pulmonary injuries. However, radiographic findings may be delayed, so observation for 4 to 6 hours may be necessary in symptomatic patients. A CT may also be useful because some injuries may be missed on chest x-ray. Bilateral pulmonary infiltrates are commonly noted. Pneumothorax or hemothorax can be treated with tube thoracostomy. Severe injury resulting in impaired ventilation and oxygenation may require mechanical ventilation. Minimizing peak inspiratory pressures and allowing permissive hypercapnia may help minimize the risk of air emboli. To avoid volume overload, fluid use should be judicious. Similarly, cardiovascular collapse (described above) is best treated with inotrope support instead of aggressive fluid administration.

Much like the lungs, the GI tract is susceptible to injury due to air-filled viscus. Bowel injuries including contusion, ischemia with the risk for necrosis, or perforation are uncommon but possible results of blast waves. Body armor may help prevent secondary injury but cannot fully protect against pressure effects on the bowel. Bowel injury may be delayed in presentation; therefore, a high index of suspicion should drive evaluation. CT can be useful to evaluate for injuries, but it lacks sensitivity for contusions and mesenteric injury. Thus, serial exams are an important part of ensuring such injuries, or delayed development of hematoma or perforation, are not missed. Perforation, necrosis, and even severe ischemia are indications for laparotomy and likely resection.

The tympanic membrane (TM) is highly susceptible to blast injury, and the absence of TM injury makes it less likely there is significant injury to the lungs, GI tract, or CNS in otherwise asymptomatic patients. Sensorineuronal deafness and tinnitus can occur in addition to TM rupture. The blast wave may cause displacement of the ossicles or damage to sensory structures. Small, isolated TM ruptures will likely heal without surgical treatment, but larger perforations and other injuries should be referred for surgical evaluation. Patients with TM rupture should be evaluated closely for concussive brain injury.

While traumatic brain injury (TBI) is more commonly associated with secondary and tertiary mechanisms, it can be caused by primary blast injury. Cerebral concussive syndromes are common and may result from oxidative injury and neuronal cell death caused by the blast. Standardized assessment tools such as the Military Acute Concussion Evaluation (MACE) can help collect baseline and follow-up comparisons to risk-stratify patients and guide referral for further evaluation and therapy. Fortunately, most patients are categorized as mild TBI and recover quickly with conservative care.

Myriad other injuries have been described as a result of blast injury, including ocular injuries such as globe rupture, conjunctival hemorrhage, and hyphema, and cardiac injuries such as myocardial wall contusion, hemorrhage, and atrial rupture. Clearly, explosions can cause a complex array of blast effects that present clinical challenges. Understanding blast effects in an effort to make sound diagnostic and therapeutic decisions is important for the MMO. The evolution of modern warfare has underscored the importance of expertise in caring for victims of explosion.

CONCLUSION

The MMO must remain vigilant against a host of CBRNE threats while forward deployed as well as in garrison. Today’s unpredictable environment includes the risk of either traditional CBRNE attacks or for asymmetric engagements with novel methods such as the use of industrial chemicals as weapons. A substantial knowledge base and constant surveillance are required to quickly identify and respond to these possible events. Clinical practice guidelines (CPGs) relevant to the care of the CBRNE patient in the DoD environment can be found at http://jts.amedd.army.mil/index.cfm/PI_CPGs/cpgs. The MMO should be familiar with the various CBRNE threats and means to mitigate such threats, possess the knowledge to recognize an exposure when it occurs, be able to conduct appropriate decontamination, and be familiar with management of CBRNE casualties.

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Chapter 36

ACUTE PAIN MANAGEMENT IN THE DEPLOYED ENVIRONMENT

CHESTER “TRIP” BUCKENMAIER III, MD*

INTRODUCTION

HISTORY OF MILITARY PAIN MANAGEMENT

PAIN “CHRONIFICATION” AND THE POLYTRAUMA TRIAD

THE ACUTE PAIN SERVICE

PAIN MANAGEMENT ON THE MODERN BATTLEFIELD

Role 1: Immediate First Aid Delivered at the Scene

Role 2: Forward Surgical Care

Role 3: Combat Support Hospitals

Roles 4 and 5: Medical Centers Outside the Theater

PAIN MEASUREMENT

CONCLUSION

*Colonel (Retired), Medical Corps, US Army; Professor of Anesthesiology, Department of Military Emergency Medicine, Uniformed Services University, Rockville, Maryland

INTRODUCTION

“What an infinite blessing.”

—General Thomas Jonathan “Stonewall” Jackson (1824–1863)

General “Stonewall” Jackson and his Confederate army were in the process of routing the Union army during the Civil War battle of Chancellorsville, Virginia, on May 2, 1863, but he had run out of time and daylight for the attack. The general and his staff were riding in front of Confederate lines, reconnoitering the situation in hopes of pressing an evening attack to break the Union lines, when Confederate sentries mistook the scouting party for the enemy and opened fire with muskets. General Jackson was wounded in the left arm and right hand. He was removed from the battlefield by a horse-drawn field ambulance, receiving whiskey to ease the pain of his wounds. He was taken to the Confederate II Corps field hospital of Dr Hunter McGuire, where more whiskey was provided and morphine administered to further ease the general’s suffering. Early the following morning, Dr McGuire performed a left arm amputation while the general was anesthetized with chloroform. As the effects of the anesthetic took hold, the general was reported to have murmured, “What an infinite blessing.”[1]

General Jackson was most likely referring to the “blessing” of battlefield pain relief following his wounding. Contrary to popular cinematic depictions of Civil War medicine that suggested soldiers suffered surgery with little or no analgesia, morphine was in fact widely available and often used to ease the suffering of wounded soldiers. Military physicians during the war were advised to carry morphine and brandy in their pockets as their primary medications for the management of casualties.[2] Then as now, those responsible for providing care to Americans defending this nation have sought innovative ways to ease the suffering of battle casualties. This chapter provides the foundation for the military medical officer (MMO) to successfully implement a pain management strategy for wounded service members in the deployed environment.

HISTORY OF MILITARY PAIN MANAGEMENT

The primary active compound in opium was first isolated by the German physicist Friedrich Sertürner in 1806, and the medication was given the name “morphine” after the Greek god Morpheus. The invention of the syringe and hollow needle followed soon after in the 1850s, providing a suitable delivery system for the drug and paving the way for its use as a surgical analgesic.[3] The combination of these two medical advances just prior to the American Civil War was fortuitous in light of the masses of battlefield casualties from this particularly brutal chapter in American military history. Before these advances, wounded soldiers requiring surgery had little hope of avoiding significant suffering under the knife of a surgeon. In the Revolutionary War medical text, Diseases Incident to Armies,[4] John Ranby, a prominent English surgeon, is quoted:

In regard to the wounded, you should act in all respects as if you were entirely unaffected by their groans and complaints; but at the same time I would have you behave with such caution, as not to proceed rashly or cruelly, and be particularly careful to avoid unnecessary pain.[4]

In short, before the advent of the hypodermic needle and morphine, those wounded in America’s wars could hope for little more than a speedy surgeon willing to avoid unnecessary pain. Prior to the Civil War, anesthesia and analgesia for soldiers was at best rudimentary. The lack of adequate pain control served as a significant impediment to battlefield surgical development; operations were reserved for the direst of circumstances and the surgery was often as deadly as the inciting wound. As General Jackson so eloquently noted, the ability to manage the pain of combat wounds was indeed a blessing. The miracle of analgesia with morphine and other opioid medications was certainly a significant advancement in battlefield surgical management, although this therapy would prove to have a decidedly unhealthy side. Serious consequences associated with chronic opioid use for pain were recognized following the Civil War. In their 1928 book, The Opium Problem, Terry and Pellens noted that “following the Civil War the increase in opiate use was so marked among ex-soldiers as to give rise to the term ‘army disease,’ and today in more than one old soldiers’ home are cases of chronic opium intoxication which date from this period.”[5] It has been suggested that the widespread use of morphine, during and long after the Civil War, gave rise to the first large-scale drug addiction problem within the United States. Spikes in drug abuse have followed every major US conflict since.[2]

Interestingly, the Civil War provided some classic descriptions of chronic pain conditions, such as “phantom limb pain” and “causalgia” (termed “complex regional pain syndrome” today). S. Weir Mitchell, a neurologist, insisted his patients had a form of physical illness, manifested by the strange pain behaviors noted above, that seemed to persist long after their wounds had healed. Unfortunately, this viewpoint changed by the 1920s with the development of “specificity theory,” which postulated the experience of pain had to be associated with a specific noxious stimulus. Pain sufferers who did not meet these strict criteria were presumed to be malingerers or drug abusers.[6] At this point, morphine was highly regulated, and chronic pain patients were often limited to psychotherapy or neurosurgical procedures (resection or ablation of nerves) with poor and often debilitating results.[6]

Although attitudes regarding the treatment of acute and chronic pain continued to evolve, morphine remained the gold standard for battlefield analgesia during World War II. Henry K. Beecher, an anesthesiologist in the US Army who served in the North African and Italian campaigns, provided the first wartime clinical investigations specifically on the issue of pain from battlefield wounds.[7] Dr Beecher made several salient observations related to morphine use at the point of battlefield injury, during initial casualty care, and its impact on casualty outcomes. First, Beecher noted that at the point of injury, medics routinely administered morphine prophylactically, versus the administration after an assessment of a casualty’s actual complaint of pain. Beecher noted that this approach might adversely impact casualties as their treatment continued, particularly those who were hypovolemic. He observed that intramuscular injection of morphine in patients with low blood pressure from wounding often failed to decrease pain, prompting additional dosages. When the patient was eventually warmed and normal circulation reestablished at the field hospital, the unabsorbed deposits of morphine in the muscle entered the circulation, resulting in morphine toxicity. Furthermore, while advocating for the more responsible use of morphine on the battlefield, Beecher developed the first concept of multimodal pain management in battlefield casualties by recognizing the importance of regional nerve blocks, proper splinting and bandaging, and emotional care as all being important components of pain management in the wounded.

As World War II ended, a young anesthesiologist named John Bonica was struggling to run an anesthesia service at the newly built Madigan Army Hospital in Washington State. Bonica observed a growing number of returning soldiers with healed wounds but baffling “lesionless” chronic pain problems. He was astonished at the general lack of information on the management of these pain conditions either in the literature or from experienced colleagues in other medical specialties. Dr Bonica took it upon himself to read anything he could find on chronic pain and instituted regular meetings with colleagues to discuss the management of pain patients.[8] This postwar experience thoroughly convinced Dr Bonica that complex pain problems required a coordinated, multidisciplinary approach, which later led to his establishment of the first pain clinic at the University of Washington, in 1961.[9] Dr Bonica is further credited with the first comprehensive textbook on pain management, The Management of Pain,[10] now in its fourth edition. It would not be an overstatement to suggest that the modern practice of pain medicine was forged in the minds and experience of those caring for American war wounded.

Although innovation in battlefield surgery and anesthesia progressed rapidly following World War II, scant attention was afforded casualties with pain on American battlefields beyond the provision of morphine. Prevailing attitudes considered acute pain a natural symptom of wounding that would be alleviated through appropriate management, healing, and rehabilitation. Perhaps this explains why the evolution of pain management on the American battlefield stalled with morphine, a solution from the Civil War. The recognition that acute pain influences the development of chronic pain is a relatively recent concept, and the mechanisms involved in the transition of acute to chronic pain, or “chronification” of pain (see below), remain poorly elucidated.[11]

At the onset of the conflicts in Afghanistan and Iraq following September 11, 2001, the American military deployed into a 21st century combat casualty care environment almost exclusively with morphine, a 19th century pain management solution. Although morphine maintained its historical reputation for treating combat trauma pain, it proved to be a poor fit given the recent evolution of modern patient evacuation capabilities and treatment doctrine. Previously, common practice had been to hold the wounded for days in theater until they were clinically stable for transport. Patients today are now being held only long enough to be stabilized for transport to the next node, or role, of higher medical treatment capability. During the Vietnam War, the average time from point of injury back to the United States was 45 days, whereas today the average time is only 4 days.[12] The rapid transition of casualties by evacuation aircraft to higher levels of medical capability has been considered a key factor in the historically low died-of-wounds rate, less than 10%, established in Iraq and Afghanistan.[12]

While the improved aeromedical evacuation chain has been a remarkable success, it resulted in unexpected consequences in terms of pain management. Military aircraft used for casualty transport present difficult environments for administering pain care. Pain experienced from combat wounds tended to be exacerbated in the loud, vibrating, cramped, and bouncing interior of an aircraft in flight for extended distances (Figure 36-1). Aeromedical personnel, constrained early in the war to morphine for pain management, were significantly challenged by limitations in monitoring capability, space, and equipment. Managing respiratory complications associated with morphine in this environment can be life threatening; therefore, many patients arrived at their destination with inadequate pain control.[13] In 2003, the US Army surgeon general, Lieutenant General James Peake, called for innovative pain solutions to address a number of wounded soldiers reportedly arriving in Landstuhl, Germany, from Iraq and Afghanistan in “agony.” Peake’s directive resulted in the first deployment of medical personnel and equipment with the express mission of improving evacuation pain management.[14]

Figure 36-1. Inside a C-17 Air Force medical evacuation flight from Afghanistan.

For some time prior to September 11, 2001, military anesthesia leaders had been considering an expanded role for regional anesthesia (RA) and local anesthetics on the modern battlefield. Although its utilization in civilian medicine was limited to several academic medical centers, recent RA advances with new needle and peripheral nerve catheter technology, peripheral nerve stimulation, and microprocessor-driven infusion pumps had enhanced the value of RA as a viable battlefield anesthetic and analgesic. Furthermore, the military’s use of RA was expanding for routine surgery in the United States, while military medical missions to underserved regions of the world were recognizing other benefits of RA. Specifically noted were improved patient hemodynamic stability, safety, small logistic and equipment support requirements, and profound perioperative analgesia, especially when continuous peripheral nerve block (CPNB) catheters were utilized.[15]

Based on the military’s initial experience with RA and a review of casualty data, initial efforts to improve casualty evacuation pain management were centered on bringing advanced RA to the modern battlefield. In a query of wound types in 3,102 casualties from October 2001 to January 2005, 54% were orthopedic extremity wounds recognized as particularly suited for RA and CPNB management.[16]

In 2003, the first CPNB was placed in an American casualty who had sustained extensive injury to his left calf from a rocket-propelled grenade (Figure 36-2). Despite intravenous administration of morphine sulfate, 18 mg titrated over 60 minutes, the patient complained of the highest level of pain on a verbal analog scale (10 out of 10) upon arrival at the 21st Combat Support Hospital (CSH) in Balad, Iraq. As part of his operating room anesthetic management, continuous left lumbar plexus and continuous sciatic nerve catheters were placed, reducing his pain to zero, and debridement of the wound was performed under light sedation with the patient spontaneously ventilating. Following this first operation, the patient traveled to Walter Reed Army Medical Center in Washington, DC, via Landstuhl Regional Medical Center (LRMC), Germany, with the majority of his analgesic needs handled through continuous infusions of 0.2% ropivacaine through the CPNB catheters. The CPNB catheters placed in the Iraq CSH were maintained for 16 days and used to establish surgical level blocks for four additional operations.[14] This first experience led, within a few years, to routine use of RA and CPNB in Iraq and Afghanistan in hundreds of casualties. Although a complete description of RA and CPNB use on the battlefield is beyond the scope of this chapter, an excellent resource for understanding RA on the modern battlefield can be found in the Military Acute Pain Management in the Deployed Environment Advanced Regional Anesthesia and Analgesia handbook, the first military medical text devoted to the acute pain management of battlefield casualties.[17]

Figure 36-2. Typical wound managed with continuous peripheral nerve blocks at a combat support hospital.

RA, while transformational for the pain management of extremity wounds, is not appropriate for many other injuries that were left with morphine as the sole analgesic option. However, in the process of fielding RA in the evacuation system, the door was opened for an expanded evaluation of acute pain management across all roles of care. Medical officers from all three uniformed services, spurred by the need to improve pain care for the wounded, ill, and injured, began to work through their inter-service differences to develop a synchronized strategy to address pain management. This was fortunate because the general lack of historical attention to casualty pain management and the overreliance on morphine monotherapy for pain on the battlefield was contributing to later recuperation problems for service members and veterans at home as they continued their rehabilitation and recovery.[18]

PAIN “CHRONIFICATION” AND THE POLYTRAUMA TRIAD

Although relief of pain and suffering following wounding has always been considered a noble act and ethically sound medical practice, pain has historically been understood to be an acute symptom of wounding or disease that would resolve as the casualty recovered and rehabilitated. Woolf[19] proposed that pain be divided into two broad categories: adaptive and maladaptive. Adaptive pain is protective against injury, promotes survival when injury has occurred, and is self-limiting. Maladaptive pain, on the other hand, is a pathologic response by the nervous system to noxious stimuli and is a manifestation of pain as a disease. Only in the past few decades have physicians begun to understand that poorly managed acute pain (adaptive) can have a negative impact on recovery and lead to debilitating chronic pain (maladaptive). Evidence is mounting that endogenous and exogenous factors can influence pain signal descending pathway modulation within the spinal cord and possibly influence “chronification” of acute pain into chronic pain.[20] Individuals who exhibit symptoms consistent with pain chronification develop common brain changes in areas known to manage nociceptive input or pain regulation. It has been suggested that these brain changes represent a pain chronification signature that should be reversible with adequate pain management.[21] However, the myriad influences impacting the chronification of pain remain incompletely and poorly understood. Rollin Gallagher, MD, editor of Pain Medicine, has modeled the chronification of pain as a cycle that begins with acute injury and cascades into a series of pathological central nervous system aberrant changes. These changes can be mutually reinforcing in a vicious circle and lead to the disease process of chronic pain with its attendant physical, psychological, and social disability (Figure 36-3).

The impact of pain chronification on a wounded service member’s recovery and rehabilitation is often devastating. Moreover, unlike the obvious disability associated with amputation, broken bones, and wounds that engender public sympathy, the burden of chronic pain is often invisible to the public; those carrying this burden often do so alone with little public or professional empathy. Development of chronic pain can further exacerbate other common wartime injuries such as posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), which are often described as signature injuries from the recent conflicts. Lew et al[22] recently examined the medical records of 340 consecutive veterans being treated for polytrauma to determine the incidence of chronic pain, PTSD, and TBI in this population. They noted that 81.5% of this population complained of chronic pain (compared to 68.2% with PTSD and 66.8% with TBI). Furthermore, 41.2% of the cohort had all three conditions simultaneously. This group suggested that the association of chronic pain, PTSD, and TBI represents a polytrauma clinical triad, and most patients diagnosed with one condition will have the others in combination. However, although considerable attention and investment has been directed towards PTSD and TBI research and treatment, comparatively little investment has been afforded chronic pain in the same period, even though it is the more common complaint among trauma victims.

THE ACUTE PAIN SERVICE

The fact that opioids have historically served (and continue to serve) in the modern era as a cornerstone of pain management following combat wounds is understandable, because this class of medications has few peers in terms of the speed and intensity of the analgesia produced. As noted earlier, the use of this medication has had a long association with military medicine, and more severely wounded veterans are surviving than at any time in history. Unfortunately, the consequences of opioid monotherapy for pain management is becoming a problem as significant, and in many cases worse, than the pain condition being treated. Beyond the usual acute side effects of nausea, constipation, dependence, and potentially deadly respiratory depression, the use of opioids for protracted periods can lead to a host of other issues. Chronic opioid use has been associated with reductions in sex hormones in men, termed opioid-induced androgen deficiency (OPIAD), that can result in significantly higher levels of depression, fatigue, and sexual dysfunction.[23] Other conditions associated with long-term opioid use include osteoporosis, immune function suppression, and cognitive impairment.[24]

Figure 36-3. “Chronification”: the chronic pain cycle.
Reproduced with permission from: Gallagher RM. Pharmacologic approaches to pain management. In: Ebert M, Kerns R, eds. Behavioral and Psychoparmacologic Pain Management. New York, NY: Cambridge University Press; 2011:139.

Obviously these conditions significantly detract from the recovery and rehabilitation of a casualty from combat trauma. Even more disconcerting is the mounting evidence that ongoing use of opioids for pain may paradoxically decrease the threshold for a patient’s tolerance of noxious stimuli. Although the exact mechanism for this phenomenon is incompletely understood, it is likely a combination of both peripheral and central nervous system changes influenced by chronic opioid therapy.24,25 Mirroring the national opioid misuse and abuse trends, the military has experienced an increase in opioid-related problems that have likely been magnified by the stress associated with the last 18 years of conflict.[26] The medical community’s continued overreliance on opioids as a single approach for managing pain has created an epidemic of prescription medication abuse and diversion within the United States. In 2009, the rate of deaths due to unintentional drug overdoses surpassed those caused by motor vehicle crashes.[27]

As evidence has become increasingly unfavorable toward opioid monotherapy on the battlefield, coupled with recent successes in managing complex trauma with CPNB and local anesthetics, the need for a systematic approach to pain for casualty evacuation has become more apparent. While CPNB catheters have clearly demonstrated efficacy in the management of polytrauma pain without the significant side effects associated with opioids, RA techniques and other advanced pain management options require trained medical personnel and logistics support at all roles of care in the evacuation chain.[28] Fortunately, as chronification of acute pain increasingly became considered as a disease process, efforts in both military and civilian medicine began establishing acute pain management infrastructure through establishment of an acute pain service (APS).

The APS provides the training, medical logistics, and organizational framework for physicians, nurses, and other support personnel to diagnose and treat acute pain as a pathophysiologic ailment.[29] Most importantly, the APS infrastructure facilitates the use of multimodal analgesia for patients based on their individual problems, within the context of increasingly complex pain issues associated with trauma and the modern perioperative environment. Multimodal analgesia is defined as the use of two or more medications or techniques that produce analgesia by different mechanisms. The advantage of this approach is that the overall analgesia is superior to what would have been achieved using any single drug or procedure (monotherapy), while the unwanted side effects of any one treatment element are minimized because of reduced reliance, and thus a smaller dose, of any one element.30,31

Concurrent with the improvements in managing acute pain through APS establishment in major US hospitals has been the realization that aggressive and effective acute pain management reduces postoperative morbidity.[32] Furthermore, effective control of acute pain reduces the cascade of unwanted physiologic consequences (see Figure 36-3) associated with unmanaged nociception, which adversely impact recovery and rehabilitation and can induce chronic pain.33,34 Persistent postsurgical pain, defined as pain lasting 3 to 6 months after surgery, is present in 10% to 50% of surgical patients, and can lead to debilitating chronic pain in 2% to 10% of these patients.[35]

Despite this alarmingly high incidence, little is generally known or accepted on who is at risk for developing chronic pain following trauma or surgery, or how to effectively manage acute pain to avoid chronification. It is understood that acute pain chronification is a complex problem involving many patient factors in the perioperative and recovery periods that contribute to persistent postsurgical pain and, in some patients, chronic pain.[36] Certainly a patient’s genotype is an important determinant of susceptibility to chronic pain development, but epigenetic modifications of gene expression that are influenced by exposure to toxins, medications, diet, and other physiologic and psychologic stressors can also impact a patient’s unique predisposition to developing chronic pain after trauma or surgery.[37] This emerging understanding of the complexity and importance of effective pain management in a patient’s overall healing, along with the requirement to address the needs of the wounded, ill, and injured from the Afghanistan and Iraq wars, has led to a reemphasis on the management of pain in war casualties on 21st century battlefields.

PAIN MANAGEMENT ON THE MODERN BATTLEFIELD

In 2009, following increasing reports of prescription medication abuse and diversion among the Army wounded assigned to the Warrior Transition Units, as well as continued concerns with the lack of a clear pain management strategy, the Army surgeon general, Lieutenant General Eric Schoomaker, chartered the Tri-Service Pain Management Task Force (PMTF). Its mission was to review military pain management capabilities and practices and develop recommendations for a comprehensive pain management strategy. The resulting PMTF report (2010) outlined over 100 recommendations for a pain management strategy that is “holistic, multidisciplinary, and multimodal in its approach, utilizes state of the art/science modalities and technologies, and provides optimal quality of life for soldiers and other patients with acute and chronic pain.”[38] This effort has further increased the military health system’s reemphasis on pain management, both acute and chronic, throughout the casualty evacuation chain and within military treatment facilities.

Casualty care on the modern battlefield is organized into four roles of care (previously known as levels) that denote increasing medical capability from point of injury back to the United States (see Chapter 14, Introduction to Health Service Support).[39] A discussion of improvements in pain management of casualties from recent conflicts is best described within this framework of the roles of care.

Role 1: Immediate First Aid Delivered at the Scene

Role 1 care is at point of injury and focused on self-aid and buddy aid. One of the most basic and important actions the individual soldier can undertake to reduce the impact of pain and enhance resilience following wounding is through efforts directed at achieving better personal health and fitness prior to deployment (see Chapter 19, The Evolution of Human Performance Optimization and Total Force Fitness). This concept is embodied by the Army Medical Command’s Performance Triad campaign, which is designed to establish healthy lifestyle habits with focus on physical activity, appropriate nutrition, and adequate sleep.[40] Essentially, a healthy person will be better prepared to tolerate the physical and psychological stress associated with acute pain, and thus better able to resist pain chronification.

While morphine continues as the primary, gold standard analgesic for combat medics, there have been significant changes to the Role 1 approach to analgesia. One example is the inclusion of a chapter on pain assessment and control (Chapter 30, Basic Medical Skills) in the Special Operations Forces Medical Handbook, 2nd edition, which serves as a primary medical information source for combat medics.[41] This resource provides information on the analgesics taken by medics into battle, along with the “dos” and “don’ts” of analgesic management in this complex and dangerous environment. The primary annual skills sustainment courses for medics and corpsmen still have a heavy focus on morphine as the primary analgesic. However, Tactical Combat Casualty Care (TCCC) guidelines, endorsed by the Department of Defense, offer a much broader range of analgesic options.

A number of recent developments have occurred in acute pain management of combat casualties far forward on the modern battlefield. One of the more novel approaches, developed by US Special Forces, involved issuing individual first aid kits with combat pill packs to be used in the event of wounding in the combat environment. Essentially, soldiers were instructed to self-administer the medications as soon as practical if painfully wounded and alert enough to open the pack, while remaining in the fight. The packs contained a cyclooxygenase-2-selective nonsteroidal antiinflammatory drug (NSAID), meloxicam 15 mg, and acetaminophen 650 mg, in addition to the antibiotic gatifloxacin.[42] Neither of the pain medications impact platelet function when given as single doses, and therefore do not impede clot formation following wounding.43,44 With brilliant simplicity, this approach granted the casualty instant access to pain management at the point of injury without reliance on another, likely otherwise occupied, soldier. Additionally, these medications have no clinically relevant impact on cognition, allowing the wounded soldier to “stay in the fight” while still establishing a non-opioid analgesic foundation that can be built upon through the roles of care when the casualty is evacuated. While the pill packs are not currently carried by all soldiers, many combat medics and corpsmen have these medications available to treat battlefield casualties at the point of injury.

For casualties in pain who are unable to fight and do not require intravenous access, oral transmucosal fentanyl citrate (OTFC), 800 µg transbuccal (a “fentanyl lollipop”), is frequently used by combat medics in the field.[42] Kotwal el al[45] studied 22 hemodynamically stable casualties with uncomplicated orthopedic trauma and concluded that OTFC was an effective, rapid-acting analgesic alternative for trauma in the combat or austere environment. The ability to administer the medication via the oral mucosa, negating the need for vascular access, is a definitive advantage. One patient in this series did experience hypoventilation, which remains the primary issue of concern for all opioid medications in this environment. Therefore, medics continue to be advised to monitor patients closely following any opioid administration while keeping naloxone readily accessible.[46] The most common side effect associated with this approach, as with other opioid-based methods, is nausea.[47] Although OTFC has demonstrated significant efficacy in managing acute trauma pain, like morphine, the risks associated with opioid medications are not resolved with this delivery method.

One of the most interesting developments from the recent conflicts is the use of ketamine as an analgesic alternative to morphine on the battlefield. In the same class of drugs as phencyclidine (PCP), ketamine is termed a dissociative anesthetic and has been described as producing a cataleptic state, amnesia, and intense analgesia without depression of the respiratory rate or blood pressure at low doses.48,49 Additionally, ketamine is a noncompetitive antagonist of the N-methyl-D-aspartate (NMDA) receptor, which is activated by peripheral nociception, leading to hyperexcitability of dorsal root neurons, which is thought to contribute to central sensitization and the chronification of pain.49,50 The most common side effects associated with ketamine administration are psychedelic emergence phenomena, including feelings of floating, vivid dreams, hallucinations, and delirium.51,52 These issues can be minimized or eliminated if the infusion dose of ketamine utilized is low (< 2.5 µg/kg/min) and certainly these issues are not as troublesome as those associated with opioid or NSAID use.[53] Eastridge et al, in a review of 4,596 Iraq and Afghanistan combat casualties from October 2001 to June 2011, identified hemorrhage as responsible for 90% of deaths from potentially survivable wounds and recommended “providing a battlefield analgesia option that does not cause respiratory depression or exacerbate hemorrhagic shock.”[54] Ketamine has many attributes that fulfill these conditions.

The flexibility of ketamine as the principle anesthetic in military situations was demonstrated during the Somalia civil war in 1994 and in north Uganda in 1999. The conditions in these conflicts were so austere that patient monitoring during surgery consisted of counting respirations and the heart rate while adjusting the ketamine drip rate based on established parameters every 3 to 5 minutes. This was accomplished with ancillary staff of variable anesthesia training and experience.[55] In the author’s own experience in 2009, while deployed as an anesthesiologist at Camp Bastion, Afghanistan, two options were available for providing analgesia during initial trauma assessments: morphine and ketamine. In every case where I was the lead trauma anesthesiologist, I selected ketamine over morphine to provide analgesia due to its consistent analgesic effectiveness without the hemodynamic complications of respiratory depression and hypotension associated with morphine. Ketamine was also extremely useful when a chemical restraint was indicated to prevent patients from injuring themselves, or in support of procedures or imaging studies where a comfortable and motionless patient was desirable. In the recent conflicts, ketamine has been determined to be at least as effective as morphine for providing analgesia at point of injury and during initial evacuation.[56] In a study of 48 healthy volunteers who were asked to perform common military tasks after exposure to morphine 10 mg versus ketamine 25 mg given intramuscularly in the deltoid muscle, ketamine was associated with more reports of side effects (dizziness, poor concentration, or feelings of happiness generally), although performance decrements between the two medications were minimal.[57] Intranasal delivery of ketamine has also been evaluated, removing the need for vascular access.[58]

These properties of ketamine make it an ideal Role 1 analgesic, and recent changes to the TCCC guidelines for pain management now include ketamine for the first time.[59] Ketamine, either 50 mg intramuscular or intranasal, or 20 mg intravenous or intraosseous (administered slowly), is recommended as an additional option to opioid therapy for moderate to severe pain in Role 1 conditions. In a review of 228 Afghanistan casualties evacuated from the battlefield by rotary aircraft from October 2012 to September 2013, the most common analgesic used was ketamine, closely followed by morphine; when two analgesics were employed, ketamine and morphine were most often used.[60]

Role 2: Forward Surgical Care

Role 2 facilities provide enhanced resuscitation services compared to Role 1, with the important addition of surgical assets to provide damage control resuscitation and surgery, as well as casualty collection and sorting efforts. These facilities are the first level of care where blood and blood products are available for trauma resuscitation.[61] Analgesic options at this level are similar to Role 1, with the addition of general anesthesia and single injection RA when indicated.

An interesting development from the recent conflicts is the use of acupuncture in the management of acute pain and stress issues in the far-forward Role 1 and 2 environment. Working in the deployed military environment is stressful and hard on the body, without even considering conditions experienced in actual combat. From wearing 40 pounds of body armor and equipment, to walking or riding in difficult terrain, and being constantly on alert for danger, among many other taxing wartime events, soldiers have plenty of reasons to develop painful conditions. Military healthcare providers have found acupuncture to be a safe and useful therapy in pain and stress management for soldiers on the modern battlefield.[62] Acupuncture requires minimal equipment to perform, is associated with minimal (mostly minor) side effects, and has no abuse potential. The increased use of acupuncture, particularly auricular acupuncture, in the care of soldiers has been a unique feature of the medical response to the wars in Iraq and Afghanistan. A battalion aid station serving 500 Seabees deployed to Iraq from September 2006 through March 2007 managed 132 individual patients with acupuncture for a variety of issues, and 80% of these patients required no additional medications such as antiinflammatories or analgesics.[63] These attributes have prompted some medical leaders to suggest acupuncture training and services should be a routine component of the military response to disaster or war.[64]

Despite published and anecdotal reports of the successful application of acupuncture on the modern battlefield, the general consensus is that an appropriate evidence base to support standard acupuncture care protocols in the military is lacking.[65] This is not to suggest a lack of evidence to support acupuncture in the management of a variety of conditions; rather, there remains a general dearth of experience and system support within the military to develop an understanding of acupuncture’s role in military medicine. This situation is changing as the military seeks non-opioid options for analgesic care in austere conditions. Although acupuncture has been used sporadically throughout the military since the 1980s, there has been a major educational and clinical transformation in the use of acupuncture during the past decade.[66] Initial investment into DoD-wide acupuncture training and credentialing has been through the introduction of battlefield acupuncture (BFA), an auricular acupuncture protocol for pain that is taught to all levels of provider within the military.[67] BFA is a series of five auricular points, called cingulate gyrus, thalamus, omega 2, point zero, and shen men (Figure 36-4), in which semipermanent needle studs are placed to reduce pain and stress.[68] This program was designed to socialize both patients and providers to the use of acupuncture in military care settings while adding a nonpharmaceutical complementary method for treating pain. Although considerable additional research and experience is needed before acupuncture in the military can be considered routine, it is the most developed integrative medicine approach within the federal medicine system today and will likely be a common approach to managing pain in the future.

Figure 36-4. Battlefield acupuncture auricular points. Points are usually placed in the following order: cingulate gyrus, thalamus, omega 2, point zero, and shen men (CTOPS). Photograph courtesy of Richard C. Niemtzow, MD

Role 3: Combat Support Hospitals

The goal of both Role 1 and 2 care efforts is the stabilization of the casualty for evacuation to a Role 3 facility within the war theater. Role 3 facilities have the major surgical specialties represented, full anesthesia capability, intensive care, diagnostic imaging, laboratory, and blood bank services available. Role 3 represents the highest level of care within the war theater and the first opportunity for restorative care, including comprehensive pain management.

Perhaps one of the most significant concepts to develop from the recent wars is the realization that effective pain management begins at point of injury, must operate as a continuum throughout the roles of care, extends into the casualty’s evacuation to the United States, continues through rehabilitation in medical centers, and stretches into the rest of their lives.[69] This is a considerable responsibility for any healthcare system, but shirking this effort can, and often does, destroy the quality and productivity of the life that was saved on the battlefield. (This is not to suggest that military healthcare providers have ignored pain and suffering in the past; in fact, pain management has been considered the general responsibility of every healthcare provider. Superficially this approach may appear to be a reasonable, but when everyone is held responsible, no one can be held accountable when pain is an issue for the wounded soldier.)

Despite contemporary understanding of the detrimental impact of inadequate pain management on rehabilitation and recovery following trauma or surgery,[70] adequate and continuous pain management remains a significant challenge for the military, particularly in the deployed or evacuation environment. Sophisticated management of pain, beyond the application of opioid monotherapy, requires establishment of an APS of dedicated physicians, nurses, and support personnel who are both responsible and accountable for casualty pain management within the CSH. Through a collaboration between US and United Kingdom military medical services, a demonstration APS was established at the Camp Bastion, Afghanistan, CSH in 2009.[71] The British CSH leadership established pain management as a key indicator of care quality at the facility during the project. APS personnel consisted of a physician leader with specialty training in acute pain management and RA, as well as pain nurse champions within each care ward in the hospital. The team was augmented with specialized equipment dedicated to pain management, including pain infusion pumps, RA catheters and equipment, peripheral nerve stimulators, and a portable ultrasound machine.

During this particular demonstration, approximately 455 trauma cases were managed by the CSH trauma team, and the APS physician rounded daily with the team as the pain consultant. Unusual or difficult acute pain cases were managed directly by the APS, although all casualties received a multimodal pain care plan. Table 36-1 outlines the frequency of intravenous and oral analgesic medications that were used in this patient cohort. Of the 71 casualties managed directly by the APS in this project, 51 (71.8%) received RA as part of their multimodal pain plan. The majority of these patients had traumatic amputations or limb injuries. The average improvement in pain scores (for those able to report), based on the casualties’ recall estimate of their pain at point of injury, was 51.9% (± 31.2). A general survey of healthcare providers at the CSH during the project period was also performed to evaluate their perceptions of the value of the activity to overall care.[72] The survey consisted of items designed to appraise staff impressions of APS outcomes, complexity of care, decision-making support, and pain management education. Generally the survey revealed considerable enthusiasm for the establishment of the CSH APS. Respondents agreed that soldiers managed by the APS reported reduced levels of pain (64.8%) and obtained greater relief (73.9%). The staff generally agreed (73.5%) that the APS had a positive overall impact on patient outcomes.

TABLE 36-1

FREQUENCY OF INTRAVENOUS AND ORAL ANALGESIC ADMINISTRATION

Medication

No. of Patients

Frequency (%) of Patients

Paracetamol (IV)

66

93.0

Diclofenac (IV)

59

83.1

Morphine (IV)

30

42.3

Oramorph SR (PO)

19

26.8

Codeine (PO)

5

7.0

Ketamine (IV)

5

7.0

Ketorolac (IV)

5

7.0

Ibuprofen (PO)

4

5.6

Tramadol (PO)

4

5.6

Acetaminophen (PO)

1

1.4

Amitriptyline (PO)

1

1.4

Co-codamol (PO)

1

1.4

Methocarbamol (PO)

1

1.4

IV: intravenous

PO: per os (by mouth)

Reproduced with permission from: Buckenmaier C III, Mahoney PF, Anton T, Kwon N, Polomano RC. Impact of an acute pain service on pain outcomes with combat-injured soldiers at Camp Bastion, Afghanistan. Pain Med. 2012;13:919–926.

The Camp Bastion APS also provided opportunities for innovation in dealing with difficult clinical pain situations. For example, ventilator beds within the CSH intensive care unit were limited, and failure to wean patients efficiently from this constrained resource impacted the CSH’s mission readiness. Patients who sustained abdominal wounds were notoriously difficult to remove from the ventilator following a laparotomy due to poor respiratory drive secondary to severe abdominal pain. Epidural catheters infusing local anesthetics are a possibility in these patients, although patient positioning and anticoagulation issues often precluded this option. To overcome this clinical dilemma, APS staff employed a bilateral continuous transversus abdominis plane block to provide sufficient abdominal wall analgesia to allow patients to be weaned off ventilator support faster. This was one of the first descriptions of this technique being used within a war theater for this purpose.[73]

As previously discussed, rapid evacuation of wounded by aircraft has contributed greatly to the increased survival of casualties in recent conflicts. A specific advantage of a functioning APS within the CSH is the ability to prepare patients, from a pain management perspective, for long evacuation flights to medical centers outside the conflict theater.[74] The use of advanced pain control technology on air evacuation flights, such as patient controlled analgesic infusions, CPNBs, and novel analgesic medications, depends on APS efforts at the CSH for the safe application and transfer of these modalities onto the medically austere aircraft environment. APS services must also be established at the receiving facility for appropriate care plan communication and safe management of pain care modalities at the receiving medical center.

Recognition of the importance of pain management within the roles of care and evacuation chain has resulted in the establishment of a Joint Theater Trauma System Clinical Practice Guideline on Pain, Anxiety and Delirium, most recently updated in March 2017 (http://jts.amedd.army.mil/assets/docs/cpgs/JTS_Clinical_Practice_Guidelines_(CPGs)/Pain_Anxiety_Delirium_13_Mar_2017_ID29.pdf). This document provides a doctrinal basis for the need and establishment of an APS in Role 3 and above medical treatment facilities. It also outlines many of the innovations in pain care that have been established during current conflicts. Even with the creation of this wartime practice guideline, organization of APS services in current CSH settings remains inconsistent. General medical command understanding and emphasis of the importance of pain management in combat casualty care is required to make this guideline a standard of practice in the next war.

Roles 4 and 5: Medical Centers Outside the Theater

Role 4 facilities are full-service military hospitals located outside the war theater of operations. LRMC has served as the primary evacuation hospital for both Iraq and Afghanistan and is the current epitome of Role 4 care. The success of new pain technologies established in Role 3 depended on the establishment of an APS presence at LRMC early in the conflicts. During the course of the conflicts, Walter Reed Army Medical Center anesthesiology residents performed month-long training rotations at the LRMC APS in support of the activity and to gain practical experience in the acute pain management of war casualties. The investment in this training experience by military graduate medical education highlights the importance of the APS activity to casualty management at the critical LRMC casualty evacuation node.

Role 5 military medical centers located within the United States represent the final and most capable expression of military medicine. Recovering wounded remain weeks to months in these rehabilitation facilities, undergoing physical and psychological restoration. The APS service and effective management of pain is, again, a key component of care at this level. Collection of actionable patient-reported outcome data in this complex environment becomes even more critical to provide the needed evidence to drive innovation in pain diagnosis and treatment.

PAIN MEASUREMENT

The LRMC APS provided opportunity for some of the only research on casualty pain levels since Beecher’s efforts from World War II. A survey of 110 wounded from July 2007 to February 2008 revealed that pain scores in this cohort tended to be high during evacuation flights (>4 on a numeric rating scale), and respondents often failed to receive a 50% reduction in their pain despite recent advances in inflight pain care.[28] Unfortunately, this small survey represents one of the very few attempts to quantify and track casualty pain during the recent years of conflict, representing a missed opportunity to better understand the impact of pain on the recovering casualty. There is a fundamental need for better pain data, collected throughout all roles of care, to enhance the understanding of how pain on the modern battlefield can best be managed to enhance overall patient outcomes.

One of the primary findings and recommendations from the PMTF 2010 report was the need for an improved pain assessment tool able to measure pain intensity, mood, stress, biopsychosocial impact, and functional impact across all roles of care.[38] In response, the Defense and Veterans Pain Rating Scale (DVPRS)[75] was developed and validated to provide a standardized measure for pain in all manner of military treatment facilities (Figure 36-5). The DVPRS scale is unique in its employment of functional language labels for each pain measurement number on the zero-to-ten scale, along with pain faces and colored pain intensity bars to assist patients in rating pain intensity. The use of functional language anchors for each pain intensity number reduces response variability and enhances consistency of the pain question throughout the care system. The addition of questions on the impact of pain on activity, sleep, mood, and stress emphasizes the important biopsychosocial variables that influence the overall pain experience. Adaptation of the DVPRS as the federal pain question standard through all roles of care could standardize pain data and improve understanding of the clinical impact of pain management treatments. The lack of quality, standardized, patient-reported outcome data on pain has been a major source of inertia in the development and adoption of novel pain care modalities on the modern battlefield. Pain data of this type will become even more vital if the promise of genomics guiding future medical care is to be realized.76,77

The PMTF also recommended the development of a Pain Assessment Screening Tool and Outcomes Registry (PASTOR) to inform clinical care visits and provide comprehensive data on treatment effectiveness. PASTOR utilizes the Patient-Reported Outcomes Measurement Information System (PROMIS) developed through the National Institutes of Health (NIH).[78] Although a complete discussion of PASTOR is beyond the scope of this chapter, the program leverages computer adaptive technology and validated NIH measurement domains (anxiety, depression, fatigue, sleep impairment, among others) to create a detailed clinician summary report on pain with far more clinically useful information than what is obtained with the standard numeric (0–10) pain rating scale currently used in most clinical situations. Furthermore, this data, along with patient demographic and treatment information, goes into a registry to support process improvement research.

Figure 36-5. Defense and Veterans Pain Rating Scale.

CONCLUSION

MMOs have a long history of alleviating acute pain and suffering; it is one of the greatest blessings bestowed on the battlefield. Recent focus has been on alternative strategies for acute pain management specific to the various roles of care, branching out with an expanded armament of medications, as well as nonpharmacologic adjuncts such as RA and acupuncture. The need for the APS system and standardized patient-reported pain outcome data collection cannot be overemphasized as novel medications and technologies continue to be developed for use in the military environment. There is also a developing understanding about the chronification of pain. The APS system provides a vital link between acute pain care and specialty chronic pain services, which is crucial when chronic pain complicates recovery.

Acute pain chronification is a complex disease process that defies a single medication or procedural solution. Although development of a system approach to pain through the APS may be challenging in the currently taxed medical environment, the elements for establishing APS services are already inherent to deployed and fixed medical facilities. Command emphasis on pain management is required as a key indicator of patient care quality within all military treatment facilities. This emphasis must be continuously validated through collection of pain care data as patients pass through all roles of care. Investment in this pain care system will establish the infrastructure required to maintain advancements achieved in the present conflicts and stimulate research and innovation in the next conflict. As John Bonica observed in The Management of Pain, “The proper management of pain remains, after all, the most important obligation, the main objective, and the crowning achievement of every physician.”[10] In the author’s own experience, few things in life are as personally rewarding as relieving the pain of a wounded soldier.

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Chapter 37

COMBAT AND OPERATIONAL STRESS CONTROL

JAMES C. WEST, MD,* AND CHRISTOPHER H. WARNER, MD†

INTRODUCTION

PHYSIOLOGY AND PSYCHOLOGY OF HUMAN STRESS RESPONSE

COMBAT AND OPERATIONAL STRESSES

RESILIENCY AND CHARACTERISTICS OF HEALTHY INDIVIDUALS AND UNITS

Individual Resilience and Vulnerability

Unit Resilience and Vulnerability

REACTIONS TO COMBAT AND OPERATIONAL STRESS

PRINCIPLES OF COMBAT AND OPERATIONAL STRESS ASSESSMENT

PRINCIPLES OF COMBAT AND OPERATIONAL STRESS CONTROL

MANAGEMENT OF COMBAT AND OPERATIONAL STRESS REACTIONS IN INDIVIDUALS

Psychotherapy in Theater

Medication Management in Theater

Restoration Centers

Management and Disposition of Severe Reactions and Psychiatric Illness

MANAGEMENT OF COMBAT AND OPERATIONAL STRESS REACTIONS IN UNITS—TRAUMATIC EVENT MANAGEMENT

SUMMARY

*Captain, Medical Corps, US Navy; Assistant Professor of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Colonel, US Army Medical Corps; Psychiatry Consultant to The US Army Surgeon General, USA MEDDAC-Fort Stewart, Fort Stewart, Georgia

INTRODUCTION

Military operations are inherently stressful, whether due to the stress of combat or the more insidious operational stresses of the operating environment. Combat and operational stress control encompasses practices that promote individual and unit resilience and ameliorate negative stress reactions. Combat and operation stress control is the collective responsibility of all unit personnel. The unit military medical officer (MMO) plays a key role in enhancing leadership efforts in promoting unit resiliency. MMOs also have responsibility to evaluate and treat members impaired by combat and operational stress injuries. This chapter will provide an overview of fundamentals of combat and operational stress control for the unit MMO.

PHYSIOLOGY AND PSYCHOLOGY OF HUMAN STRESS RESPONSE

In order to understand the role of the MMO in promoting resilience and evaluating and treating combat and operational stress casualties, it is necessary to first consider fundamental principles behind the human stress response. The human stress response system functions to maintain homeostasis in the presence of external threats and environmental changes. It does so by causing protective behaviors such as “fight, flight, or freeze” in the face of a threat. The stress response system also promotes rapid recall of past threat information. Under extreme stress these reaction and recall systems can generate behaviors and symptoms out of proportion to the threat.

The primary brain systems involved in stress response include the amygdala, hippocampus, and prefrontal cortex.[1] These regions all process sensory information, but do so in different ways and at different speeds. The amygdala receives direct sensory input from the thalamus and rapidly identifies threats. In the presence of threat, the amygdala generates signals for appropriate fight, flight, or freeze responses. The hippocampus and prefrontal cortex receive the same sensory information, but pathways to these brain areas are slower and designed to incorporate additional memory and context information. In healthy, non-stressed individuals these pathways modulate or inhibit amygdala response. Prolonged or extreme stress can shift the balance of the amygdala–prefrontal cortex–hippocampus system to produce a persistent threat response. In other words, the amygdala becomes hyperactive and the prefrontal cortex hypoactive and unable to sufficiently modulate the fight/flight/freeze response. An affected individual is hyperresponsive and less able to self-regulate stress responses. In the combat environment some hypervigilance and enhanced reactivity is typically adaptive, but excessive hyperarousal is impairing.

A useful paradigm recently adopted by the Department of Defense is the Stress Response Continuum, shown in Figure 37-1.[2] This model places individual responses along a continuum of ready-reacting-injured-ill. Ready individuals demonstrate effective coping and are adapting to any stress without significant distress or impairment. Under stress many individuals will demonstrate mild distress or impairment and would be considered otherwise healthy but reacting. Under significant stress, a percentage of individuals will go on to be injured, meaning that they experience possibly transient severe distress or impairment, but also are at significant risk for persisting negative alterations. Finally, some individuals may experience true illness under extreme stress and develop a mental disorder or diagnosis. This distinction is usually made after a significant period of impairment, arbitrarily about 60 days.

COMBAT AND OPERATIONAL STRESSES

Combat operations present a variety of stresses to deployed personnel. Direct exposure to killing and death are significant and psychologically toxic.[3] If the exposed individual experiences horror or helplessness, the exposure to killing and death becomes much more traumatic. Examples of severe exposures include witnessing fellow soldiers burn to death in a vehicle and being helpless to intervene; close proximity to the sudden death of a teammate, as in an improvised explosive device blast; or engagement in which troops find themselves outnumbered or defenseless. Handling human remains or cleaning blood and brains from vehicles or buildings are also potentially traumatic events. The act of killing enemy combatants is potentially traumatic, and inadvertent killing of noncombatants even more so. Patrolling or defending in a sustained and unpredictable threat environment even in the absence of killing can generate severe or persisting stress responses.

In addition to stress associated with death and killing, all individuals must manage the stresses of the operational environment.[4] At the simplest level, living in austere conditions with exposure to the elements and diminished access to regular physical comforts is an operational stress. Cold, heat, dirt, noise, and unpleasant smells all take a cumulative toll on forward personnel. Separation from family or other primary social supports can present significant stress, as can living in a confined environment with fellow soldiers for a prolonged period of time. Combat operations typically occur around the clock, with significant risk of fatigue as an additional stress. Table 37-1 summarizes common combat and operational stresses the MMO should consider.

Figure 37-1. The combat and operational stress continuum model with its four color-coded stress zones.
PTSD: posttraumatic stress disorder
Reproduced from: Nash WP. US Marine Corps and Navy combat and operational stress continuum model: a tool for leaders. In: Ritchie EC, ed. Combat and Operational Behavioral Health. Fort Detrick, MD: Borden Institute; 2011: Figure 7-1.

RESILIENCY AND CHARACTERISTICS OF HEALTHY INDIVIDUALS AND UNITS

“Some of the most potent factors which contribute to high morale in military groups are confidence in their own ability, faith and trust in their leaders and a sureness of purpose.”

—Captain Francis Braceland, 1946[5]

Prevention is the best medicine. Commanders of military units are charged with developing and training combat-ready units. The unit MMO plays a key role in fostering an environment that promotes a unit’s ability to withstand stress. Resilience represents a state in which members of a unit are able to tolerate significant stress and react constructively to diminish that stress. By understanding factors in individuals and units that promote resilience, the MMO can be a vital advisor to unit leadership.

Individual Resilience and Vulnerability

Every individual brings strengths and vulnerabilities into military service. Resilient individuals possess a stable sense of self. From a military perspective, this is an individual who has a clear sense of identity as a soldier, sailor, airman, or marine and whose experiences in the military reinforce that identity. Resilient individuals also show use of adaptive coping mechanisms such as recognizing areas of control, positive cognitive appraisal, and engaging social support.[6] Past exposure to trauma has a variable impact on individual resilience. There is significant evidence to support that risk of psychological injury is related to the burden of childhood trauma.[7] Individuals with significant home-front stress demonstrate worse overall psychological health.[8] Members of elite combat units typically show greater resilience, and this is believed to be a combination of selection factors for membership and ongoing high-intensity training to promote resilience.

Unit Resilience and Vulnerability

Group dynamics can both promote and detract from individual resilience. The most consistently cited protective factor against psychological injury in combat is unit cohesion.[9] Key elements of cohesion are a sense of attachment to members in the unit and viewing other members as a source of emotional support. Conversely, units with significant internal distrust or a perceived disregard for individual welfare are less resilient and may put their members at risk under stress. Leadership is another key element of unit resilience. Units gain resilience when leaders communicate a clear sense of mission and recognize the contribution of all members of the unit.[10]

TABLE 37-1

EXAMPLES OF COMBAT AND OPERATIONAL STRESSORS

PHYSICAL STRESSORS

MENTAL STRESSORS

Environmental

- Heat, cold, wetness, dust, vibration, noise, blast

- Noxious odors (fumes, poisons, chemicals)

- Directed-energy weapons/devices

- Ionizing radiation

- Infectious agents

- Physical work

- Poor visibility (bright lights, darkness, haze)

- Difficult or arduous terrain

- High altitude

Cognitive

- Information (sensory overload or deprivation)

- Ambiguity, uncertainty, unpredictability

- Time pressure or waiting

- Difficult decisions (rules of engagement)

- Organizational dynamics and changes

- Hard choices versus no choice

- Recognition of impaired functioning

- Working beyond skill level

- Previous failures

Physiological

- Sleep deprivation

- Dehydration

- Malnutrition

- Poor hygiene

- Muscular and aerobic fatigue

- Overuse or underuse of muscles

- Impaired immune system

- Illness or injury

- Sexual frustration

- Substance use (smoking, caffeine, alcohol)

- Obesity

- Poor physical condition

Emotional

- Being new in unit, isolated, lonely

- Fear and anxiety-producing threats (of death, injury, failure, or loss)

- Grief-producing losses (bereavement)

- Resentment, anger, and rage-producing frustration and guilt

- Inactivity producing boredom

- Conflicting/divided motives and loyalties

- Spiritual confrontation or temptation causing loss of faith

- Interpersonal conflict (unit, buddy)

- Home-front worries, homesickness

- Loss of privacy

- Victimization/harassment

- Exposure to combat/dead bodies

- Having to kill

Adapted from: US Department of the Army. Combat and Operational Stress Control. Washington, DC; DA; 2006. Field Manual 4-02.51.

REACTIONS TO COMBAT AND OPERATIONAL STRESS

Prolonged or extreme stress can leave units or individuals with significant impairment. Such emotional reactions or behaviors are referred to as combat and operational stress reactions or injuries. These reactions tend to fall into distinct categories, and more than one type of reaction may occur within any individual or in reaction to particular stressors. Patterns of combat and operational stress reaction include acute stress reactions, operational fatigue, traumatic grief, and moral injury.[4]

Acute stress reactions represent a maladaptive psychological and physiologic reaction to an extreme stress. This is typically a single severe traumatic event, but acute stress reactions can also occur after a series of severe traumas. Emotional manifestations of acute stress reactions include restlessness, panic, irritability, rage, and sometimes numbing. Cognitive responses include confusion, memory problems, and traumatic amnesia. Physical complaints can include fatigue, loss of bowel and bladder control, insomnia, palpitations, and shortness of breath. Dissociation, in which an individual becomes detached from their surroundings or experiences amnesia, represents a severe form of acute stress reaction. Acute stress reaction should not be confused with posttraumatic stress disorder. Even though many symptoms are shared, an acute stress reaction is a time-limited response to psychological trauma.

Combat and Operational Stress Control Operational fatigue occurs in the presence of less intense but prolonged stresses. Throughout history this condition has received names such as “soldier’s heart” and “old sergeant’s syndrome.” Such reactions are characterized by a persistent and constant anxiety or depressed state. Affected individuals may experience irritability or depressed mood, persistent anxiety or restlessness, changes in appetite or energy, insomnia, concentration difficulties, muscular tension, or tremor.

Traumatic grief is a disruption in the normal grieving process brought on by sudden or traumatic loss. Normal grieving is the healthy process by which individuals allow themselves to experience emotional reactions associated with loss and engage in the cognitive process of adapting to a world without the deceased individual. Losses experienced in combat, by their abrupt and violent nature, tend to promote traumatic grief reactions. Significant complications of traumatic grief involve distorted beliefs about the causes and implications of the death. An affected member may present with problems with excessive guilt and sense of responsibility over the death. Conversely, an individual may externalize their guilt through acting out or undermining leaders.

Moral injury refers to psychological reactions stemming from real or perceived transgressions of moral codes by self or others and betrayals of trust.[11] Modern warfare increasingly puts individuals in ambiguous circumstances where the distinction between hostile combatant and innocent civilian is blurry. A well-intended soldier may fire on a presumed insurgent only to discover that he has killed a noncombatant. In the same vein, individuals may engage in intentional acts while in the heat of battle that later produce intense feelings of shame or anger. As a result, individuals can respond with symptoms of intense anger, revenge fantasies or acts, intense feelings of shame and guilt, and self-destructive or avoidant behaviors.

PRINCIPLES OF COMBAT AND OPERATIONAL STRESS ASSESSMENT

Assessment of combat stress control casualties is a core competency of the MMO. The tasks of assessment involve gathering relevant history, inquiring about individual and unit factors promoting or detracting from individual resiliency, screening, establishing appropriate differential diagnosis, and communicating disposition. The simplified goal of a combat and operational stress control assessment is to identify where the individual is along the stress response continuum. Exhibit 37-1 summarizes important elements of a combat stress control evaluation.

Relevant history entails focus on the presenting symptoms and circumstances. By constructing a narrative of the events, thoughts, and feelings immediately preceding presentation, the MMO gains valuable insight into the nature of the problem. For instance, an individual presenting with 24 hours of restlessness, irritability, insomnia, and intrusive images of a firefight immediately following the event suggests a combat stress reaction or acute stress injury. An individual presenting with 6 weeks of insomnia and irritability in the context of concerns that his wife is having an affair back home suggests an adjustment disorder. In both individuals it is essential to identify the number and significance of potentially traumatic exposures in the current deployment to promptly identify risk for acute stress injuries.

In assessing individual and unit resilience, it is important to identify and assign weight to each factor contributing to or detracting from resilience. Does the soldier identify a sense of purpose or meaning to their current job? Does the identity of their unit or military occupational specialty reconcile with their sense of who they are? Do they view their leaders as effective and having the best interest of unit members in mind? Once the breadth of resiliency factors are considered and weighed against each other, a clearer picture of an individual’s prognosis emerges. Members with significant questions about the usefulness of their job, uncertainty in their ability to effectively complete it, disconnection from peers, or a distrust of leadership they view as inept are less likely to be resilient and therefore at higher risk for persisting combat stress reactions. Further, they are less likely to respond favorably to typical combat stress control interventions and may require significantly more intervention to restore capability.

Differential diagnosis should first exclude the presence of mental or medical illness. A major depressive disorder should not be confused with a combat fatigue reaction, and the principle of expectancy, or prompt recovery and return to duty, would not be appropriate. Intoxication or withdrawal from substances is another important consideration. Although access to alcohol and other substances of abuse is greatly restricted in the combat environment, they are not impossible to obtain. The evaluator also needs to consider exposure to environmental toxins or side effects of medications. An important example of this is development of anxiety symptoms following prophylaxis with mefloquine for malaria. If combat stress reaction is present, the provider should characterize the type of the reaction. Significant distress or impairment in response to home-front stressors typically represents adjustment disorder, but in more severe or prolonged cases, such distress may represent a depressive or anxiety disorder.

EXHIBIT 37-1

ELEMENTS OF COMBAT STRESS CONTROL EVALUATION

History

- Circumstances of presentation

- Current symptoms and impairment

- Trauma exposure

Resilience factors

- Individual: sense of self, purpose, home-front concerns

- Unit: cohesion, leadership, communication

- Environmental factors

Screening

- Psychiatric illness

- Medical conditions

- Medication and supplements

Mental status examination

Safety assessment

PRINCIPLES OF COMBAT AND OPERATIONAL STRESS CONTROL

The principles of combat and operational stress control were first developed by the British and French forces during World War I. These principles were characterized as “PIES”: proximity, immediacy, expectancy, and simplicity.[12] While these principles were more recently modified into a new acronym, “BICEPS” (brevity, immediacy, contact/centrality, expectancy, proximity, simplicity), the basic forward psychiatry principles initially established during World War I continue to serve as the cornerstone to modern deployed mental health care.[10]

The concept of brevity in forward psychiatry treatment is that the care provided for the treatment of a combat operational stress reaction should be time limited. In US military doctrine there is some variance as to the time limit, but all guidelines state that if symptoms do not improve within 72 to 96 hours, then the service member should be evacuated to a higher level of care. Immediacy refers to psychiatric casualties being treated as soon as possible. Embedded military mental health providers are available throughout the operating theater to ensure readily accessible care. The principle of contact involves keeping the service member connected to his or her unit. A key aspect to this step is the importance of ensuring that the service member continues to feel an important part of the unit and a vital contributor to the unit’s mission success.

Expectancy refers to facilitating the service member’s expectation of returning to duty. In essence, the MMO must make clear early that the treatment goal is for the service member to return to duty in the combat role. Once service members assume the identity of “injured” or “patient,” they make a cognitive shift in role and expected outcome. It is therefore important to address service members by their military title and refrain from using the term “casualty” or “patient.” Prior reports have noted that in past operations failure to pay close attention to labeling and to set expectations resulted in a contagion effect and an increased number of soldiers evacuated from the battlefield.[13]

Proximity refers to psychiatric casualties being treated geographically close to operating units in order to reinforce attachment to their unit. Since World War I, US military forces have pushed medical and mental health resources toward the front lines to facilitate this principle. Since the early 2000s, the Army and Marine Corps have embedded psychiatrists, social workers, nurse practitioners, and psychologists at the brigade and regimental levels both in combat and during peacetime. This has not only facilitated adherence to the principle of proximity, but has also increased the chance that service members are treated by providers assigned to their unit, thus providing consistency and greater availability of provider staff.

Simplicity refers to using brief and straightforward treatment focused on the basics to emphasize the normality of the service member’s experience rather than implying some significant level of mental illness.[14] The concept of simplicity in treatment is best exemplified by the “five R’s”: (1) rest, (2) rehydration and replenishment of nutrients, (3) restoration of confidence through meaningful work, (4) reassurance that recovery is likely, and (5) return to duty.[10]

The effectiveness of forward psychiatry principles remains controversial, primarily associated with the desired effect of the treatment. Since World War II, return to duty rates have been cited at levels greater than 70% to 80%.[15] However, critics note that studies find varying rates of combat stress relapse associated with forward psychiatry, and that some symptomatic service members are eventually evacuated from the combat theater despite forward psychiatric treatment.[13] Another key question concerns the long-term psychological benefit from forward psychiatry treatment. Israeli researchers noted that evacuation of individuals with mild combat operational stress injuries worsened their prognosis and further complicated their recovery.[16] However, a recent RAND report[15] noted that service members who had a combat operational stress reaction were more likely to later develop posttraumatic stress disorder. Thus, despite the widespread acceptance of forward psychiatry principles, the effectiveness of this treatment to both return service members to duty and to prevent long-term psychological health outcomes remains inconclusive.[13] Further studies are needed to determine the overall short- and long-term effectiveness of forward psychiatry.

MANAGEMENT OF COMBAT AND OPERATIONAL STRESS REACTIONS IN INDIVIDUALS

While forward psychiatry principles represent the base of combat operational stress treatment and may be the only level of care available during high-intensity combat, the recent wars in Iraq and Afghanistan have shown that higher levels of care can be delivered in a mature theater.

Psychotherapy in Theater

The most common reasons service members seek mental healthcare during a deployment are family stressors, combat exposure, and difficulties with the unit leadership.[17] Common focus areas of treatment include relationship stress, grief and loss, anger and aggression, depression, anxiety and panic symptoms, and managing traumatic events. Psychotherapeutic interventions can be very effective for these complaints. Providing effective psychotherapy during a deployment can be challenging. Service members’ time and availability may be limited, and there is a consistent expectation that they remain combat effective during treatment. Service members seeking mental health intervention typically present for only one visit while deployed.[18] Therefore, treatment approaches used in garrison may need to be adjusted. In order to be effective, interventions must be focused and brief.

Given the large overlap of physiological and psychological symptoms experienced in response to deployment stress, targeting physical symptoms of stress can be highly effective. Relaxation training, incorporating abdominal breathing, progressive muscle relaxation, guided imagery, and self-hypnosis are skills that an MMO can teach quickly and that can provide significant benefit in an environment likely to remain continuously stressful.[19]

Abdominal breathing promotes slow and deep breathing by encouraging expansion of the abdomen rather than the chest. This is easily taught by having the individual place a hand on their chest and abdomen while breathing in slowly. The provider encourages the individual to move the abdominal hand and slow breathing through counting.

Progressive muscle relaxation involves intermittently flexing or engaging tension in specific muscle groups for 7 to 10 seconds, followed by relaxation. The provider guides the individual through this pattern of tension and relaxation, starting with the most peripheral muscles and ending with core muscles. In guided imagery, the provider talks the individual through a mutually agreed-on peaceful scene with a combination of verbal prompts and periods of silence. The individual keeps their eyes closed throughout the process and visualizes the scene described.

Self-hypnosis requires the individual to focus intensely on an internal stimulus such as breath counting or a neutral word or phrase. This intense focus induces a relaxation response.

Brief cognitive interventions are also available to the MMO and can help distressed service members cope and adapt to overwhelming stress. Cognitive interventions target distorted thoughts common in distressed individuals (eg, “It’s all my fault, I always mess up,” or “I know he/she is leaving me”). Simple intervention involves helping the individual identify their distorted thoughts and consider possible alternatives that are less distressing.

Mental health providers need to keep in mind that they must be available at all hours of the day to respond to an emergent situation or traumatic event, and these events, along with enemy engagements, can result in both the provider and the service member being unable to meet as scheduled. Thus, trying to schedule treatment times with military personnel is difficult, making the ability to capitalize on brief treatment modalities key. Providers should adapt their treatment to single-session models because they may not have another opportunity for intervention. If the provider determines that long-term, in-depth psychotherapy is required, a risk assessment should be conducted and consideration for transfer to a higher level of care considered.

Medication Management in Theater

Prior to the operations in Iraq and Afghanistan, mental health treatment focused on triage and non-pharmacological interventions aimed at normalizing and minimizing combat stress. Medications were generally used only in emergency situations to treat acute psychosis or agitation, typically as chemical restraint while awaiting evacuation. With the development of selective serotonin reuptake inhibitors (SSRIs) in the 1990s, providers gained the ability to prescribe medications without requirements for laboratory monitoring, concern for significant side effects, or risk of overdose. This led to more common medication use in theater, either because service members deployed already taking psychotropic medications, or they were prescribed in theater.

For service members with previously identified mental health conditions, the US Department of Defense specifies minimum mental health requirements for deployment. Specific conditions such as bipolar and psychotic disorder and classes of medications such as lithium or anticonvulsants can disqualify service members from deployment, while some may require a waiver.[20] Factors to consider for deploying service members with mental health conditions include the ongoing ability to access care, the risk of worsening symptoms, and continuity of care. A recent study showed that when a continuity of care plan is put in place prior to deployment, the risk of worsening symptoms, mental health evacuation, and serious events are decreased.[21]

Generally, combat and operational stress reactions do not require treatment with medications other than possibly short-term use of sleep aids. Those service members who develop significant mood, anxiety, or trauma- and stress-related disorders while deployed may benefit from medication. Factors affecting the decision to prescribe medications in the deployed environment include availability of medication, access to follow-up, and potential side effects. The MMO must balance these factors against an individual’s operational assignment, tempo of operations, and location.

There is no standardized mechanism for medication management in theater. The proximity of mental health provider and pharmacy resources, as well as the comfort level of the primary care provider in managing psychotropic medications, will significantly impact the process. Common patterns of care are either evaluation and follow-up with a psychiatrist, or initial prescribing by a psychiatrist with follow-up by a primary care provider (with or without telephonic consultation with a psychiatrist). Despite these variables, certain factors remain constant. Providers should generally prescribe medication infrequently, ensure a reliable follow-up mechanism, and evacuate service members with prolonged or more than moderate-level symptoms. The most common medications prescribed by theater mental health providers during the Operation Iraqi Freedom were SSRIs (40% of patients seen) and sleep aids (38% of patients seen).[18]

The decision whether or not to prescribe psychotropic medications will be driven by the ability of the provider to safely and effectively care for their units. Providers must recognize the limitations of their resources, capabilities, and situation, and make the decision to treat in theater, return service members to their home station, or delay treatment until the service member returns home as scheduled. The key factors that impact this decision include symptom severity, current level of occupational dysfunction, response to treatment, duty limitations due to the medications, and the responsibilities the service member is expected to perform.

Restoration Centers

Treatment of a service member with a combat and operational stress reaction is meant to be short in duration and should be carried out in close proximity to the unit. The majority of combat and operational stress reactions should be treated locally, with a maximum of 1 to 2 nights away from their unit, typically at the aid station or headquarters. However, if symptoms are severe or persist beyond 72 to 96 hours, the MMO should consider evacuation of the individual to a higher level of care. In recent conflicts, theater commanders have established specialized restoration centers to meet this need.

Restoration centers are located in the theater of operations but generally not close in proximity to the unit or the front lines. These centers are staffed by specialized mental health personnel and provide service members with intensive outpatient treatment for up to a week. Typical interventions include cognitive and occupational therapy, with a focus on expectancy and return to duty. All interventions occur within a highly structured military environment to reinforce the concepts of contact and expectancy.[10] Service members whose symptoms do not improve within 1 week are normally evacuated from theater and returned to their home station for more intensive psychiatric care. It is important to note that restoration centers are not inpatient facilities; they do not have the capacity to manage severely behaviorally disturbed or dangerous patients other than for acute stabilization and transport. In general, inpatient capabilities are very limited in a deployed environment.

Management and Disposition of Severe Reactions and Psychiatric Illness

Regardless of prevention and resiliency efforts, there will be a small percentage of patients with severe and dangerous reactions and persisting psychiatric illness. Acute psychosis and mania can render individuals dangerous due to unpredictable behavior and ready access to weapons and live ammunition. Individuals with suicidal ideation, whether in the context of acute stressors or psychiatric illness, should be similarly managed with extreme caution. Those suffering severe symptoms placing them at risk for suicide or unpredictable behavior require evacuation from theater. MMOs must ensure continuous positive control of such patients.

Once a service member with acute suicide risk or unpredictable behavior is identified, the MMO must ensure that the individual stays under direct observation in a safe environment at all times until safely evacuated. This may involve holding the person in the aid station with or without the use of sedative medications or physical restraints. Releasing the individual to a “unit watch” should only be considered when there is a reliable command representative educated on the individual’s condition, and never as an alternative to evacuation. The unit must designate a specific individual to take responsibility for the soldier and understand the specific risks their condition presents. Finally, the unit must ensure the at-risk individual is not allowed access to weapons while awaiting evacuation.[22]

MANAGEMENT OF COMBAT AND OPERATIONAL STRESS REACTIONS IN UNITS—TRAUMATIC EVENT MANAGEMENT

Exposure to combat-related potentially traumatic events in which service members experience intense feelings of terror, horror, helplessness, or hopelessness is one of the principal risk factors for behavioral health problems in a combat setting.[23] Examples of combat-related potentially traumatic events include being ambushed by the enemy, being in close proximity to an improvised explosive device or booby trap attack, or having a unit member seriously injured or killed. Traumatic event management (TEM) describes a process of intervention after a potentially traumatic event to prevent, identify, and manage combat operational stress reactions in individuals and units as early as possible.

It is important to recognize that TEM is a continuous process and not an acute intervention. Prior to a potentially traumatic event, leaders should be trained to understand what events are potentially traumatic, how to activate a TEM response, and what TEM services are available. Following a potentially traumatic event, leaders must ensure their service members are safe and in a secure location, that the basic needs of the service members are met, and that a TEM response team is notified. Unit MMOs and ministry personnel are a key link in identifying units at risk and experiencing signs of psychological distress, as well as initiating the chain of response.

A TEM team comprised of embedded mental health providers and unit ministry personnel works in conjunction with the unit leadership to proactively manage the psychological effects of the traumatic experience. The TEM response begins with a general needs assessment to determine the overall health of the unit and whether service members need immediate mental health care for combat operational stress reactions. Mental health personnel also provide consultation and education to unit leaders and service members regarding available services and how to access mental health care. It is important throughout this process that the TEM response team work in close cooperation with the unit leadership to reinforce the perception that leaders are requesting intervention on behalf of the unit.

A key event during the initial response phase is the leader-led after action review. This review is not a psychological debriefing but rather a military process that assists in encouraging service members to talk about the event. In healthy units this review is part of the innate battle rhythm and not a special event when a potentially traumatic event occurs.

Historically, the military mental health provider in conjunction with the unit leader determined if a group psychological debriefing should be conducted. There are numerous psychological debriefing models; however, each model focuses on recognizing the trauma and processing reactions to it. These debriefings differ from military after action reviews in that the focus is on individual’s psychological reactions and is conducted by a trained counselor. Most debriefing models derive from the work of Marshall during World War II.[24] Of note, Marshall’s sessions were not intended to provide psychological benefits but rather to gather historical data for military record keeping; however, he noted that the process provided clarity of events and support for the participants. He surmised that these debriefings helped to decrease the development of combat stress reactions.[24]

The effectiveness of psychological debriefings continues to be debated by both military and civilian mental health providers. Few research studies have focused specifically on the effectiveness or risk/benefit of psychological debriefings in military populations. In contrast, civilian studies of victims are mixed with some demonstrating benefits as well as negative outcomes.25–29 A recent Cochrane analysis recommended against using psychological debriefings citing that the risks outweighed the benefits based on the civilian literature.[29] A key limitation to both the civilian data and the Cochrane review is the lack of a standardized TEM debriefing process. There are multiple models practiced commonly in TEM debriefings including critical event debriefing (CED), critical incident stress debriefing (CISD), psychiatric debriefing, historical debriefing, and intelligence debriefing. A lack of consistent standardized protocols for TEM debriefing group formation and execution limits the ability to assess its effectiveness and the conclusions that can be drawn from such studies.

In spite of all of the concern about potential risk and lack of effectiveness, psychological debriefings remain a tool frequently employed by military mental health providers as military leaders are attuned to the long-term risks of exposure to potentially traumatic events. As such, MMOs and mental health providers should pursue the most up-to-date evidence on TEM. The current US Army Combat Operational Stress Control field manual provides a guideline for TEM operations but leaves the decision to conduct a psychological debriefing and the method of debriefing open to the mental health provider.[10] A recent review of practices used among NATO forces in Afghanistan indicated that some sort of group intervention remains the norm, but that the term “debriefing” is generally avoided.[30]

SUMMARY

Combat and operational stress control is a collective effort of individuals, unit leaders, medical, ministry, and mental health personnel. It requires understanding of the fundamentals of human stress response, and knowledge of the predictable patterns of stress injury. The MMO has an obligation to promote psychological resilience within their unit and is a key source of surveillance and recommendations for unit leaders. When properly managed, the majority of individuals suffering even the most severe acute stress injuries will likely recover with simple PIES/BICEPS interventions and return to duty. The MMO can initiate many of these interventions with or without the assistance of mental health personnel. Finally, when potentially traumatic events occur, the MMO should understand the principles of traumatic event management and be prepared to request mental health assistance.

REFERENCES

1.   Mora F, Segovia G, Del Arco A, de Blas M, Garrido P. Stress, neurotransmitters, corticosterone and body-brain integration. Brain Res. 201;1476:71–85. doi: 10.1016/j.brainres.2011.12.049.

2.   Nash WP. US Marine Corps and Navy combat and operational stress continuum model: a tool for leaders. In: Ritchie EC, ed. Combat and Operational Behavioral Health. Fort Detrick, MD: Borden Institute; 2011: Chap 7.

3.   Grossman DA. On Killing: The Psychological Cost of Learning to Kill in War and Society. New York, NY: Back Bay Books/Little Brown and Company; 2009.

4.   Nash WP. Combat/operational stress adaptations and injuries. In Figley CR, Nash WP, eds. Combat Stress Injury: Theory, Research, and Management. New York, NY: Routledge; 2007: Chap 3.

5.   Braceland F. Psychiatric lessons learned from World War II. Am J Psychiatry. 1947;103(5):587–593.

6.   Gibbons SW, Shafer M, Aramanda L, Hickling EJ, Benedek DM. Combat health care providers and resiliency: adaptive coping mechanisms during and after deployment. Psychol Serv. 2014;11(2):192–199. doi: 10.1037/a0033165.

7.   Agorastos A, Pittman JO, Angkaw AC, et al. The cumulative effect of different childhood trauma types on self-reported symptoms of adult male depression and PTSD, substance abuse and health-related quality of life in a large active-duty military cohort. J Psychiatr Res. 2014;58:46–54. doi: 10.1016/j.jpsychires.2014.07.014.

8.   Mulligan K, Jones N, Davies M, et al. Effects of home on the mental health of British forces serving in Iraq and Afghanistan. Br J Psychiatry. 2012;201(3):193–198. doi: 10.1192/bjp.bp.111.097527.

9.   Sundin J, Jones N, Greenberg N, et al. Mental health among commando, airborne and other UK infantry personnel. Occup Med (Lond). 2010;60(7):552–559. doi: 10.1093/occmed/kqq129.

10.   US Department of the Army. Combat and Operational Stress Control. Washington, DC; DA; 2006. Field Manual 4-02.51.

11.   Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695–706. doi: 10.1016/j.cpr.2009.07.003.

12.   Rock NL, Stokes JW, Koshes RJ, Fagan J, Cline WR, Jones, FD. US Army combat psychiatry. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes JW, eds. War Psychiatry. Washington, DC: Office of the Surgeon General of the Army, Borden Institute; 1995: Chap 7.

13.   Jones E, Wessely S. “Forward psychiatry” in the military: its origins and effectiveness. J Trauma Stress. 2003;16(4):411–419. doi: 10.1023/a:1024426321072.

14.   Jones DR. US Air Force combat psychiatry. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes JW, eds. War Psychiatry. Washington, DC: Office of the Surgeon General of the Army, Borden Institute; 1995: Chap 8.

15.   Helmus, TC, Glenn RW. Steeling the Mind: Combat Stress Reactions and Their Implications for Urban Warfare. Santa Monica, CA: RAND Corporation; 2005.

16.   Belenky GL, Tyner CF, Sodetz FJ. Israeli Battle Shock Casualties: 1973 and 1982. Washington, DC: Walter Reed Army Institute of Research; 1983.

17.   Warner CH, Breitbach JE, Appenzeller GN, Yates V, Grieger T, Webster WG. Division mental health in the new brigade combat team structure: part I. Predeployment and deployment. Mil Med. 2007;172(9):907–911.

18.   Schmitz KJ, Schmied EA, Webb-Murphy JA, et al. Psychiatric diagnoses and treatment of U.S. military personnel while deployed to Iraq. Mil Med. 2012;177(4):380–389.

19.   Bourne EJ. The Anxiety and Phobia Workbook. 5th ed. Oakland, CA: New Harbinger Publications Inc; 2010.

20.   US Department of Defense. Deployment-Limiting Medical Conditions for Service Members and DoD Civilian Employees. Washington DC: DoD; 2010. DoD Instruction 6490.07.

21.   Warner CH, Appenzeller GN, Parker JR, Warner CM, Hoge CW. Effectiveness of mental health screening and coordination of in-theater care prior to deployment to Iraq: a cohort study. Am J Psychiatry. 2011;168(4):378–385. doi: 10.1176/appi.ajp.2010.10091303.

22.   Payne SE, Hill JV, Johnson DE. The use of unit watch or command interest profile in the management of suicide and homicide risk: rationale and guidelines for the military mental health professional. Mil Med. 2008;173(1):25–35.

23.   Fontana A, Rosenheck R. Psychological benefits and liabilities of traumatic exposure in the war zone. J Trauma Stress. 1998;11(3):485–503. doi: 10.1023/a:1024452612412.

24.   Koshes RJ, Young SA, Stokes JW. Debriefing following combat. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes JW, eds. War Psychiatry. Washington, DC: Office of the Surgeon General of the Army, Borden Institute; 1995: Chap 11.

25.   Adler AB, Castro CA, McGurk D. Time-driven battlemind psychological debriefing: a group-level early intervention in combat. Mil Med. 2009;174(1):21–28.

26.   Jacobs J, Horne-Moyer HL, Jones R. The effectiveness of critical incident stress debriefing with primary and secondary trauma victims. Int J Emerg Ment Health. 2004;6(1):5–14.

27.   MacDonald CM. Evaluation of stress debriefing interventions with military populations. Mil Med. 2003;168(12):961–968.

28.   Mitchell SG, Mitchell JT. Caplan, community, and critical incident stress management. Int J Emerg Ment Health. 2006;8(1):5–14.

29.   Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2002(2):Cd000560. doi: 10.1002/14651858.cd000560.

30.   Vermetten E, Greenberg N, Boeschoten MA, et al. Deployment-related mental health support: comparative analysis comparative analysis of NATO and allied ISAF partners. Eur J Psychotraumatol. 2014;5. doi: 10.3402/ejpt. v5.23732.

Chapter 38

TRAUMATIC BRAIN INJURY IN THE MILITARY

RENEE PAZDAN, MD*; THERESA LATTIMORE, MSN†; EDWARD WHITT, MS‡; AND JAMIE GRIMES, MD§

INTRODUCTION

BACKGROUND AND SCOPE

DEMOGRAPHICS AND EPIDEMIOLOGY

Department of Defense Definition of Traumatic Brain Injury

Severity Range: Mild, Moderate, Severe, and Penetrating

Defining Postinjury Periods

Military Incidence by Numbers, Severity, and Service

Incidence Among Civilians

MANAGEMENT IN DEPLOYED SETTINGS

Concussion Management in the Deployed Setting

Traumatic Brain Injury With Polytrauma

CONCUSSION MANAGEMENT IN NONDEPLOYED SETTINGS

Algorithms for Garrison Concussion Management

Return to Play: High School, College, and State Requirements

Progressive Return to Activity

MANAGEMENT OF POSTCONCUSSIVE SYMPTOMS

Clinical Practice Guideline for the Management of Concussion/Mild Traumatic Brain Injury

Patient-Centered Care

Assessments for Common Postconcussive Symptoms

Neuroimaging Beyond the Immediate Period

RESEARCH AND FUTURE CONSIDERATIONS

SUMMARY

*Captain, US Public Health Service; Director of Traumatic Brain Injury, Warrior Recovery Center, Fort Carson, Colorado

†Director, Army Traumatic Brain Injury Program, US Army Office of The Surgeon General, Falls Church, Virginia

‡Master Sergeant (Retired), US Army; Senior Health Policy Analyst, Defense Health Agency, Falls Church, Virginia

§Colonel, Medical Corps, US Army; Chair, Neurology Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

Traumatic brain injury (TBI) sustained in battle was described as early as Homer’s Iliad, written approximately 3,000 years ago, before the Hippocratic era.[1] Homer is believed to have discussed at least 147 neurological injuries in the Iliad, of which 78% were fatal, ranging from lethal penetrating brain injury to fully survivable events such as concussion and syncope.[1] TBI remains a significant issue in modern warfare, with frequent diagnosis in both combat and training environments. The primary concerns for operational forces are the acute management of symptoms, impact on warfighting tasks, and susceptibility to secondary injury. Additionally, because of the logistical challenges associated with management of any injury or disease in an operational environment, the military continues to invest in improving the state of the science and delivering optimized TBI care in a modular and scalable fashion. The Department of Defense (DoD) requires “Readiness of the Force,” which relies on prevention of TBI, early and effective clinical management, and constant pursuit of advances in understanding and treating the condition.

BACKGROUND AND SCOPE

The DoD’s Defense and Veterans Brain Injury Center (DVBIC) tracks and reports the number of active duty service members (SMs) worldwide who sustain a TBI for the first time. Tracking began in 2000 and continues, with an overall annual peak incidence in 2011 at 32,829. Numbers have declined since then, with the most recent annual incidence of 17,707 in 2017. In total, from 2000 through 2017, at least 379,519 TBIs were sustained by active duty, guard, and reserve members of the armed forces.[2]

DoD Instruction 6490.11, DoD Policy Guidance for Management of Mild Traumatic Brain Injury/Concussion in the Deployed Setting,[3] published in 2012, and updated in 2018, provided unified guidelines to all the services for management of mild TBI in the deployed setting. Previously, the DoD relied on SMs to report symptoms; with this policy, the DoD shifted to event-based reporting instead of patient-based presentation for evaluation of concussion. The DoD now uses event-driven protocols to maximize the chances of identifying a TBI or a potential TBI. No longer does the SM need to self-identify as having symptoms; rather, if an event is deemed potentially concussive, a medical evaluation is mandated (Exhibit 38-1). The Military Acute Concussion Evaluation (MACE), selected as a screening tool, provides guided questions to determine whether or not a concussion occurred. While the requirement for a potentially concussive event (PCE), or the role of policy to mandate concussion evaluation, could change in the future, the goal is to build systems that do not rely on self-identification by the SM.

DEMOGRAPHICS AND EPIDEMIOLOGY

Department of Defense Definition of Traumatic Brain Injury

In 2007, the DoD published a definition and injury stratification for TBI that was consistent with the Centers for Disease Control and Prevention, the National Institutes of Health, and the World Health Organization. This memorandum was updated and re-signed by the Assistant Secretary of Defense for Health Affairs in 2015.[4] As data rapidly emerges from the TBI research portfolio, most groups are considering new ways to define and stratify TBI. However, the current DoD definition of TBI is as follows: “A traumatically induced structural injury or physiological disruption of brain function, as a result of an external force, that is indicated by new onset or worsening of at least one of the following clinical signs immediately following the event:

1. any period of loss, or a decreased level, of consciousness;

2. any loss of memory for events immediately before or after the injury (posttraumatic amnesia);

3. any alteration in mental state at the time of the injury (eg, confusion, disorientation, slowed thinking, alteration of consciousness/mental state).”[4]

The Department of Veterans Affairs (VA)/DoD Clinical Practice Guideline[5] (CPG) includes the above and the following two items:

4. neurological deficits (eg, weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia) that may or may not be transient; or

5. intracranial lesion.

The definitions also say that, among other external forces, a blast or explosion may be considered a cause of TBI.

EXHIBIT 38-1

MANDATORY REPORTING FOR POTENTIALLY CONCUSSIVE EVENTS

Events Requiring Concussion Evaluation

- Involvement in a vehicle collision or rollover.

- A blow to the head during activities such as training, sporting/recreational activities, or combatives.

- Within 50 meters of a blast (inside or outside).

Command-Directed (Examples)

- Repeated exposures to the events listed above.

- In accordance with protocols for environmental sensors (eg, helmet sensor, blast gauge).

Severity Range: Mild, Moderate, Severe, Penetrating

Severity of TBI, per the DoD definition, is determined by the presence and duration of an altered state, which can include alteration of consciousness, loss of consciousness, or posttraumatic amnesia at the time of injury (Table 38-1). In the DoD definition, concussion is synonymous with mild TBI; these terms will be used interchangeably in this chapter. It should be noted that mild TBI can in some cases result in significant persistent symptoms and functional impairment, despite having the “mild” label. While penetrating head injury can be readily categorized as such by physical examination, closed head injury can be subtler, and severity categories are further defined by the parameters in Table 38-1.

Defining Postinjury Periods

There is variability in the literature about timing and definitions after head injury. The VA/DoD CPG[5] for mild TBI uses the following stages, based upon work group consensus. These definitions will be used throughout this chapter:

- Immediate period: 0 to 7 days postinjury.

- Acute period: 1 to 6 weeks postinjury.

- Post-acute period: 7 to 12 weeks postinjury.

- Chronic: more than 12 weeks postinjury.

Of note, the Berlin consensus statement on concussion in sport (see discussion below) uses different terminology, as well as different time frames—namely, the use of the term “persistent symptoms,” defined as the period beyond which normal clinical recovery is expected, and identified as over 10 to 14 days in adults and over 4 weeks in children.[6] This re-characterization of acute and post-acute concussion with a shorter timeline, as described in the Berlin consensus statement, is consistent with the direction that the DoD and many other groups are moving toward. For the DoD, this shift toward shorter timelines first appeared in the 2014 clinical recommendation on progressive return to activity,[7] with timelines that deviated from DoD Instruction 6490.11.[3] When reviewing literature on concussion, it is therefore imperative to be aware of how TBI, severity levels, and duration of postconcussion symptoms are defined, and that this aspect of concussion characterization is evolving rapidly based on emerging science.[8] Greater standardization of definitions and terminology over time will not only improve communication about direct patient care, but also allow research to move forward in a more synchronized fashion.

TABLE 38-1

DEPARTMENT OF DEFENSE TRAUMATIC BRAIN INJURY SEVERITY CRITERIA

Mild/Concussion

Moderate

Severe

CT scan

Normal (CT is not indicated for most mild TBI patients)

Normal or abnormal structural imaging

Normal or abnormal structural imaging

Loss of consciousness

0–30 minutes

>30 minutes and <24 hours

> 24 hours

Alteration of consciousness

A moment–24 hours

>24 hours (if >24 hours, severity is based on other criteria)

Posttraumatic amnesia

0–1 day

>1 day < 7 days

> 7 days

CT: computed tomography; TBI: traumatic brain injury

Military Incidence by Numbers, Severity, and Service

The vast majority of TBI in the military, as in the civilian setting, is mild TBI (concussion), and as of February 2017 accounted for 85.9% of TBI in the DoD (Table 38-2). Although incidence has some correlation with operational tempo and troop volume, including the 2011 peak, TBI diagnoses have not returned to the numbers seen before Operations Enduring Freedom and Iraqi Freedom.[3] This may be indicative of not just an increased rate, or higher risk exposures, but also of increased awareness by patients and clinical providers in conjunction with the mandatory DoD reporting requirements. However, these composite numbers do not tell the full story because each SM is counted in the surveillance data only once per lifetime, which likely results in some level of underreporting of TBIs within the DoD. Further, the often mentioned ratio of 80% of DoD TBIs occurring in the nondeployed (garrison) environment is based on the assumption that the injury occurred where and when the diagnosis was made. This likely skews data toward more injuries occurring in garrison than in the combat environment, despite the surveillance methodology that counts diagnoses made within 30 days of a deployment as occurring during deployment.

TABLE 38-2

DEPARTMENT OF DEFENSE WORLDWIDE TRAUMATIC BRAIN INJURY NUMBERS, 2000–2016

Severity

Air Force

Army

Marine Corps

Navy

Total

Penetrating

560

3,119

766

620

5,065

Severe

439

2,251

627

453

3,770

Moderate

4,370

18,060

5,396

5,125

32,951

Mild

42,167

172,366

42,643

40,302

297,478

Not classifiable

1,602

15,632

2,127

2,467

21,828

Total

49,138

211,428

51,559

48,967

361,092

Data source: Defense and Veterans Brain Injury Center.

Regasa et al reported that prior studies indicated a TBI rate during deployment ranging from 12% to 22.8%.[9] However, the researchers went on to demonstrate that analysis of the data showed SMs were 8.4 times as likely to be diagnosed with a TBI in the 4 weeks after deployment as compared to predeployment.[7] The risk decreased over the next 40 weeks, then leveled off at 1.7 times the predeployment rate. This correlation is not causal, and the authors note it could result from underreporting in theater or increased injury rates for unknown reasons after deployment. Another analysis of military TBI data from the Armed Forces Health Surveillance Branch, published in the Medical Surveillance Monthly Report (MSMR),[10] divided TBI diagnoses by occurrence (prior to, during, or after deployment) and found that injury rates during deployment were 1.5 times that of predeployment, and 1.2 times that of the postdeployment group. This data is consistent with the work of Regasa et al, showing an increased prevalence both during and after deployment. The MSMR article further showed that combat-specific and armor/motor transport occupations had a higher postdeployment prevalence than other jobs when compared to predeployment. It is important to note that diagnoses in the 4 weeks after redeployment coincide with mandatory screening and may represent increased recognition of the injury rather than increased incidence. Additional research is needed to better understand the timing and location of these injuries.

Incidence Among Civilians

The Centers for Disease Control and Prevention estimates that from 2002 to 2006, TBI caused 1,365,000 emergency department visits, 275,000 hospitalizations, and 52,000 deaths.[11] However, it also reports that only 1 in 9 concussions are believed to be captured by typical surveillance methods. Falls represented the highest percentage (35.2%) of external cause of injury in the general population in this time period. Motor vehicle injuries were the most common cause of TBI-related deaths, with the greatest numbers occurring in those aged 20 to 24. Also noted in this time period was a 62% increase in fall-related TBIs among children seen by emergency departments. This data might represent influences such as public awareness that were also represented in the DoD data.

MANAGEMENT IN DEPLOYED SETTINGS

Concussion Management in the Deployed Setting

This section will focus on the challenges of managing concussion, especially with growing awareness of the complexity and evolving nature of TBI in the acute period. Moderate, severe, and penetrating TBIs are managed in accordance with protocols defined by Tactical Combat Casualty Care (TCCC) clinical practice algorithms (discussed later in this chapter). An emerging concept in the immediate/acute assessment of concussion is understanding the neurometabolic cascade and its manifestation in multiple domains, including cognitive, vestibular, and oculomotor. However, the timing of metabolic demand and injury/recovery curves within the brain are not fully understood. As described in 2014 by Giza et al,[12] the neurometabolic cascade is a complex process of ionic, metabolic, and physiologic events, including an acute outpour of K+ and influx of Ca++, with drops in glucose and cerebral blood flow, leading to altered neurotransmitters and glutamate, and chronic pathophysiology with axonal injury, inflammation, and toxic accumulations.

Consequently, multiple domains must be tested, and evaluations must be repeated after the brain is provided an opportunity to rest. In the military, this challenge is met through a combination of concussion management algorithms. A medical staff member may initiate the assessment, or per DoD policy, operational commanders may be required to refer an SM who was exposed to a PCE (see Exhibit 38-1). The algorithms start with “red flag” signs and symptoms (Exhibit 38-2). Separate red flags geared toward combat medics or corpsmen, rather than to providers, allow for a lower threshold for consultation or evacuation. Surveillance for these red flags is conducted secondary to TCCC protocols and may lead to provider consultation or hospital transport. Importantly, the DoD has invested in capabilities for point-of-injury assessment and monitoring (discussed further in the research section of this chapter). At the provider level, the red flags define the need for neuroimaging (noncontrast head computed tomography [CT] in the immediate injury period) or referral to specialty services.

If there are no red flags, the MACE is initiated (Figure 38-1). The MACE is a standardized screening and assessment document performed on all SMs who experienced a PCE, with a section for a scripted history of the event. This section of the MACE is critical not only for documentation within the health record, but also for the SM’s records as he or she transitions from active duty service. As discussed earlier, accurate entry into the electronic health record using the most current International Classification of Diseases (ICD) code is also important for maintaining good surveillance data. If the MACE determines that a concussive event occurred, then the additional sections are completed. Assessment and treatment of other injuries and symptoms is initiated per standard medical protocols. (The MACE pocket card is available at the Defense and Veterans Brain Injury Center website, https://dvbic.dcoe.mil/material/mace-military-acute-concussionevaluation-pocket-card.) The next (forthcoming) version of the MACE, the MACE 2, will complement the Sport Concussion Assessment Tool edition 5 (SCAT 5), a product of the Berlin consensus work group.[6] The MACE 2 will be a multimodal assessment capability, and aid in standardized assessment of all the known concussion symptom clusters or subtypes. The most significant additions are supported by questions and assessments, targeting identification of symptom manifestations of vestibular effects, oculomotor effects, migraine, and anxiety, similar to those seen in sports concussion management.[8]

EXHIBIT 38-2

RED FLAGS FOR TRAUMATIC BRAIN INJURY AS LISTED IN DEPARTMENT OF DEFENSE CLINICAL MANAGEMENT ALGORITHMS

Red flags for TBI are different at the corpsman/medic level than provider level, with a lower threshold for consultation or evacuation.

Corpsman/Combat Medic Red Flags

- Loss of consciousness

- ≥ 2 potentially concussive events within 72 hours

- Unusual or combative behavior

- Unequal pupils

- Seizures

- Repeated vomiting

- Double vision/loss of vision

- Worsening headache

- Weakness on one side of the body

- Unable to recognize people/disoriented to place

- Abnormal speech

Provider Red Flags

- Progressively declining level of consciousness

- Progressively declining neurological status

- Pupillary asymmetry

- Seizures

- Repeated vomiting

- Clinically verified GCS <15

- Neurological deficit: motor or sensory LOC >5 minutes

- Double vision

- Worsening headache

- Cannot recognize people or disoriented to place

- Slurred speech

- Unusual behavior

___________________

GCS: Glasgow Coma Scale

LOC: loss of consciousness

TBI: traumatic brain injury

Figure 38-1. Military Acute Concussion Evaluation pocket card.
Reproduced from: https://dvbic.dcoe.mil/material/mace-military-acute-concussion-evaluation-pocket-card.

Once a concussion diagnosis is made, results of the MACE are used to continue through the concussion management algorithms, and treatment depends on the clinical findings. However, at a minimum, all SMs exposed to a PCE in a deployed location are evaluated with the MACE and provided 24 hours of rest/recovery time, symptom management, and reevaluation (including exertional testing) once they are symptom free.

This initial management of concussion may be conducted by a medic or corpsman in conjunction with a licensed provider. However, the algorithm presents a stepwise approach for progressive levels of care, from medic/corpsman through primary care, to specialty providers (eg, neurology, physical/occupational therapy, neuropsychology) within the deployed environment. If an SM does not recover within the anticipated timelines, as detailed by the algorithms, they are referred to a specialty provider for comprehensive management. Current DoD policy and clinical guidance require any SM sustaining more than one concussion within a 12-month period to be managed with more conservative protocols. If diagnosed with a second concussion, the SM receives a minimum of 7 days of recovery following symptom resolution, and then must pass exertional testing prior to return to duty. For a third concussion within 12 months, the SM undergoes a “recurrent concussion evaluation” prior to return to duty. This comprehensive evaluation is conducted by a multidisciplinary team of providers and includes a history and examination, including balance assessment; neuroimaging (as necessary); neuropsychological assessment; and a functional assessment.

Vignette 38-1. A 19-year-old male Army soldier, military occupational specialty11B (infantry), was involved in an improvised explosive blast that directly hit his Humvee while out on patrol. The soldier recalled seeing a flash of light and debris, and was thrown against the side of vehicle, then felt dazed and confused for about 10 minutes. He developed a moderate-severity holocranial headache along with nausea, photophobia, and a constant ringing in his ears. He was able to ambulate independently but felt off balance and reported feeling “not quite right.” Initial evaluation at the forward operating base 2 hours after the blast by the 68W (medic) was done according to the concussion algorithm, and because no red flags were present, the MACE protocol was followed. Concussion was confirmed and the score was 23/green/B (cognitive/neurological/symptoms). The soldier was educated about acute concussion and expectation for recovery, and given a handout with information about concussion symptoms and recovery. His platoon leader was notified that the soldier would be required to have a minimum of 24 hours of rest after becoming symptom free. The following day, the soldier was evaluated by the unit’s physician assistant and felt much better after a good night’s sleep. His headache and nausea had resolved and his balance and hearing were back to baseline. His MACE score was now 26/green/A, and exertional testing was performed without any recurrence of symptoms. He was progressed over the next 5 days through the return-to-activity stages without difficulty and returned to full duty.

Traumatic Brain Injury With Polytrauma

Prehospital trauma care performed on the battlefield can differ markedly from that performed in the civilian sector. The TCCC guidelines were developed as a result, adjusting the previous Advanced Trauma Life Support model to meet the specific considerations of combat wounds, such as early use of the extremity tourniquet for exsanguination and allowing patients suffering from uncontrolled hemorrhage to remain in a permissive hypotensive state. (Refer to Chapter 33, Tactical Medicine, for a complete discussion about TCCC principles in the operational environment.) TCCC guidelines are maintained by the Joint Trauma System (JTS), which serves as the DoD’s Center of Excellence for Trauma. The JTS and associated committees meet frequently to update the guidelines, which specifically include discussion of moderate, severe, and penetrating TBI. The algorithm for the management of concussion/mild TBI in the deployed setting is generated by the DVBIC, but it is included with the other TCCC guidelines and is used in conjunction with the MACE. The JTS uses the DoD Trauma Registry to conduct performance improvement projects that guide the committees on recommendations and updates to both CPGs and equipment.

Treating TBI in the prehospital environment begins with an understanding of the mission, including the probability of injuries, as well as limitations when operating austerely and outside of a medical treatment facility. Many factors must be considered to develop a unique mission plan that includes specific equipment needs. Planning is key to providing optimal care, especially in the most complex conditions; it is the foundation for the best possible outcomes achievable, even with minimal equipment. When planning for possible head injuries, the provider should know the location and capabilities of DoD, partner nation, and host nation medical facilities within the area of operations, particularly the location of neurosurgical assets and neuroimaging, which will not be available at all evacuation points. Providers should conduct independent research to learn about the area of operations, such as reviewing TRAVAX.com,[13] a website providing location-based health information, and other independent information sources. Following mission planning, it is essential to become familiar with, and pack for, the available prehospital medical equipment (Class VIII). Deployable units have unit-level packing lists that serve as the minimal required equipment to treat trauma casualties; special provisions should be considered to plan for head injuries and the Class VIII equipment required to treat them in the prehospital setting.

Hemorrhage is the number one cause of preventable death on the battlefield,[14] and the TCCC guidelines place significant emphasis on first responder actions and skills to stop bleeding. Hemorrhage and the associated treatments can be a confounding factor to the treatment of TBI in the prehospital setting, particularly in polytrauma patients when the TBI is triaged secondary to addressing massive hemorrhage. As a result, providers receiving patients throughout the continuum of care must realize TBI may not have been addressed until the patient is hemodynamically stabilized, which may not have occurred by the time a patient arrives to the next level of care.

The prehospital provider’s challenge is to administer lifesaving care while taking into account all considerations to prevent or reduce the possibility of secondary brain injury. The TCCC guidelines allow patients with uncontrollable hemorrhage to remain in a hypotensive state, permitting the patient’s systolic blood pressure to remain at 90 mm Hg by palpation, or evaluation of perfusion through mentation. However, recent literature[15] suggests that allowing moderate to severe TBI patients to remain in a hypotensive state is associated with increased probability of secondary brain injury and sequelae. Even a single episode of hypotension during the prehospital or early hospital phases of TBI management is associated with dramatic increases in mortality.

These findings refocus the prehospital provider on the importance of perfusion and the brain’s immediate and enduring requirement for oxygenation. The role of supplemental oxygenation is not entirely clear in this population. While some animal studies have shown worsened axonal injury in simulated aeromedical evacuation after TBI,16,17 the impact on functional outcomes in humans is not fully known. Multiple factors must be weighed when determining timing of transport to definitive care, and monitoring the posttraumatic inflammatory response (both local and systemic) may be helpful in timing determinations and prevention of secondary brain injury.[18] Operational considerations such as working at altitude in mountainous environments must also be integrated into medical decision-making. For example, at Fort Carson, an Army post at 6,000 feet elevation at the base of 14,000-foot mountains, a mild TBI patient who has otherwise recovered after concussion may experience recurrence of symptoms with increased exertion, particularly at higher altitudes.

After the initial trauma survey is complete, the provider will conduct a comprehensive head-to-toe evaluation, and TBI red flags should alert the provider to immediate necessary actions. Serial follow-on clinical assessments should be performed and documented. Early assessment is critical if increased intracranial pressure is clinically suspected. While the benefits of neuroimaging are well accepted, it is typically unavailable in the forward military operating environment, so use of the Glasgow Coma Scale (GCS) (Table 38-3) guides early determination of TBI severity. It is important to capture both the initial and a postresuscitation GCS score because resuscitation interventions can change the patient’s status.

Identification of pupillary asymmetry can be an indicator of elevated intracranial pressure, providing a high index of suspicion for brain stem compression on the third cranial nerve with impending herniation. Bruising behind the ears (Battle sign) or around the eyes (“raccoon eyes”), as well as cerebrospinal fluid otorrhea and rhinorrhea, are typically associated with basilar skull fractures. Blunt trauma and falls should prompt consideration of manual spinal immobilization during treatment and application of a rigid cervical collar. If clinical evidence supports immobilization with a spinal board, additional precautions should be considered to pad the board and casualty because pressure necrosis may take place within hours of initial immobilization. Elevating the head of the bed between 30 and 60 degrees is optimal for casualties with suspected elevated intracranial pressure.

TABLE 38-3

GLASGOW COMA SCALE*

Response

Score

Eye response (E)

4 = spontaneous

3 = to sound

2 = to pressure

1 = none

Verbal response (V)

5 = oriented

4 = confused

3 = words

2 = no words, only sounds

1 = none

Motor response (M)

6 = obeys commands

5 = localizing

4 = normal flexion

3 = abnormal flexion

2 = abnormal extension

1 = none

Key: Severe: GCS 3–8; Moderate: GCS 9–12; Mild: GCS 13–15

*The Glasgow Coma Scale (GCS) scoring assessment is currently in transition: the pain stimulus has been replaced with pressure at the finger tip, trapezius, or supraorbital notch. The impact of this change to protocols and guidelines has yet to be determined. The modification can be found on the GCS website: https://www.glasgowcomascale.org/. Additionally noted is the rating of non-testable (NT), which is applied when there is an identifiable limiting factor.

CONCUSSION MANAGEMENT IN NONDEPLOYED SETTINGS

Algorithms for Garrison Concussion Management

In 2013, the Army began requiring parallel efforts (event-driven protocols) to evaluate and manage concussion in the garrison environment, using a set of algorithms from point of injury through 7 days.[19] Unlike the deployed practice that includes a comprehensive concussion algorithm beyond the initial 7 days, the garrison version uses the VA/DoD CPG[5] after the first week. An additional difference is that in the garrison algorithms, only SMs with a diagnosed concussion have mandatory downtime, while in the deployed environment all SMs exposed to a PCE are given 24 hours downtime. However, consistent with changes captured in the Berlin consensus statements, all concussion management in the DoD is moving toward the progressive return to activity guideline[7] in combination with the MACE 2, as discussed above, and updated clinical management guidelines for both deployed and garrison settings. This is a shift from the total rest required in the 2012 policy, and initiates individualized rehabilitation plans based on the patient’s unique presentation.

Return to Play: High School, College, and State Requirements

While sports concussion has some notable differences from combat-acquired TBI, there are many similarities, and much of the research done on sports concussion has been applied to military injuries. Guidance on return-to-play after sports concussion has evolved in the past 5 to 10 years, with increasing utilization of progressive return to play and normal activity. The guidance initially focused on slowing return to sports; later, increased attention was paid to the impact of cognitive stress on recovery from concussion, particularly as it pertained to student athletes. All 50 states and Washington, DC, now have some form of “when in doubt, sit them out” concussion laws, and many states now have guidance or laws requiring preseason education for athletes, parents, coaches, and teachers.[20] Capabilities range from little leagues, with limited availability of clinical providers and associated funding, to high school systems that leverage athletic trainers, to the National Collegiate Athletic Association, which often mirrors professional sports with increasing capabilities from sideline to hospital system integration.

These trends are consistent with international guidance, most recently in 2017 with the 5th International Consensus Conference on Sports Concussion, held in Berlin, Germany.[6] This guidance calls for supportive care during the initial recovery period, with gradual return to sport and school, based on symptom resolution and progressive increase in activity levels. The consensus also recommends referral to specialty rehabilitation care for persistent postconcussion symptoms, defined as those remaining after 10 to 14 days for adults or after 4 weeks for children. For these patients, providers should individualize an exercise program, target therapy toward specific disorders, and use cognitive behavioral therapy for any mood component.

Progressive Return to Activity

In 2014, the DVBIC published a clinical recommendation on progressive return to activity (Table 38-4) following acute concussion or mild TBI.[7] Based on published literature and expert opinion, the guidelines are similar to the International Consensus[6] on graduated return to sport. To monitor postconcussion symptoms and assess patients for graduated return to activity, the Neurobehavioral Symptoms Inventory (NSI), a self-report survey, is used throughout the DoD and VA. It asks concussed individuals to rate 22 symptoms from 0 to 4, with 0 as “rarely or never present” and 4 as “very severe.” The recommendation then provides for six stages of recovery. Stage 1 is Rest (see Table 38-4), intended to minimize physical and cognitive exertion for the first 24 hours after concussion. Progression through the six stages occurs incrementally every 24 hours if symptoms are rated as none or mild (0–1). A critical component of the protocol is early education and expectation for recovery, which has proven to be effective in reducing the number and duration of symptoms.[21] As noted previously, progressive return to activity complements updated assessment tools such as the SCAT 5 and MACE 2, used in combination to individualize rehabilitation plans.

TABLE 38-4

STAGES OF THE PROGRESSIVE RETURN TO ACTIVITY PROCESS

Stage

Description

Objective

1

Rest

Symptom resolution

2

Light routine activity

Introduce and promote limited effort

3

Light occupation-oriented activity

Increase light activities that require a combined use of physical, cognitive, and/or balance skills

4

Moderate activity

Increase the intensity and complexity of physical, cognitive, and balance activities

5

Intensive activity

Introduce activity of duration and intensity that parallels the service member’s typical role, function, and tempo

6

Unrestricted activity

Return to pre-injury activities

MANAGEMENT OF POSTCONCUSSIVE SYMPTOMS

Clinical Practice Guideline for the Management of Concussion/Mild Traumatic Brain Injury

The TBI CPG, initially developed in 2009 and updated in 2016,[5] provides evidence-based recommendations to help guide clinical decision-making. In addition, despite a lack of randomized clinical trials for treatment of postconcussive symptoms, best practices based on literature reviews, expert consensus, and common clinical practice are included to help guide management where evidence is insufficient for a definitive recommendation. The CPG provides algorithms for management of symptoms persisting more than 7 days, as well as detailed information on clinical symptom management on multiple co-occurring conditions, including headache, dizziness and disequilibrium, visual symptoms, fatigue, sleep disturbance, cognitive symptoms, persistent pain, hearing difficulties, smelling changes, nausea, changes in appetite, and numbness. An evidence table is also provided, outlining the level of medical evidence for the various recommendations. The full guidelines are provided in great detail, with over 100 pages of text. Additional useful tools include a clinician summary, patient summary, and pocket card.[5]

Patient-Centered Care

Postconcussive symptoms are often broken down into physical, cognitive, and emotional/behavioral categories. Key to caring for individuals with postconcussive symptoms in the acute, postacute, and chronic time periods is patient-centered care. A patient’s issues and symptoms can be as unique and complex as the individuals themselves. Severity of injury (mild, moderate, or severe) does not always correlate to severity of symptoms; outcomes are determined by individual factors in addition to the initial severity of injury. Moderate and severe brain injuries are most often cared for in inpatient hospital and rehabilitation center settings with subsequent outpatient rehabilitation care. Postconcussive care, however, is usually primary care based, with rehabilitation providers and other consultants treating only those with prolonged symptoms not responding to usual care, or those with significantly complex comorbidities. In recent years, the military has increased use of intensive outpatient programs for complex mild TBI patients, utilizing multiple disciplines, including rehabilitation, behavioral health, and complementary and alternative modalities, to address multiple issues in a time-intensive, focused manner, with the goal of improving functional outcomes.

Postconcussive symptoms are not specific to concussion; they are seen in a variety of other medical conditions, particularly psychological conditions that are often comorbid with chronic postconcussive symptoms.[22] In fact, all of the symptoms listed on the NSI are seen at some percentage at baseline in a normal (nonclinical) population: rates of moderate or more severe symptoms in a nonclinical civilian sample who took the NSI ranged from 2.7% for taste/smell changes, to as high as 50% for fatigue, and 43% for concentration.[23] Misattribution of all symptoms to TBI can lead to unnecessary anxiety or other medical conditions being overlooked.

Most individuals will recover relatively quickly after concussion; however, previously reported recovery rates of 80% to 90% within 7 to 10 days after injury[24] may have been optimistic and skewed due to group data rather than individual outcomes. Despite a minority of patients with prolonged symptoms, most recover within 1 month, and those with chronic symptoms (>12 weeks) should have a multidisciplinary evaluation and treatment to aide recovery. Progressive return to activity, combined with individualized rehabilitation plans built around symptom clusters,[8] can help minimize exacerbation of symptoms and avoid repeat injury during the early recovery phase. Those with prolonged symptoms require individualized progression of activity because extended strict rest can also lead to increased social isolation and deconditioning, and may potentially exacerbate symptom reporting rather than improve recovery.[25]

Data for Army soldiers suggests a different recovery trajectory after a concussion sustained during deployment. The Warrior Strong Study, which sampled soldiers returning from deployment in Afghanistan or Iraq to Fort Carson and Fort Bragg between 2009 and 2014, found that nearly 50% of those who had a deployment-related mild TBI reported one or more severe or very severe symptoms on the NSI 3 months after redeployment, compared to 25% of those without a concussion on that deployment.[26] The most common symptoms were sleep problems (30%), forgetfulness (21%), irritability (17%), and headaches (15%). Traditionally, vestibular and oculomotor symptoms were not assessed early in the course of treatment, which may skew historical data on symptom presentation for acute concussion. However, tools such as the Vestibular and Oculomotor Screening (VOMS), which can identify deficits in vestibular and oculomotor domains in acute concussion, are increasingly being used. These assessments, combined with individualized rehabilitation plans in the acute setting, are beginning to demonstrate earlier symptom recovery in both acute and chronic concussion.[8]

From the civilian literature, risk factors for prolonged symptoms and slower recovery include prior concussions,27,28 prior history of headaches,[28] and extremes of age (youngest[28] and oldest[29]). Findings on gender are mixed, though several studies suggest a female predominance for prolonged symptoms, and a recent systematic review of the literature suggested that the teenage years were the most vulnerable time period, greater in girls than in boys.[30] Pre-injury mental health disorders are also a risk factor for prolonged symptoms.[30]

In the military setting, comorbid posttraumatic stress has consistently been correlated with increasing persistence of postconcussive symptoms.[31] In one systematic review the frequency of posttraumatic stress disorder (PTSD) in those with probable mild TBI ranged from 33% to 39%.[32] The directionality of the interaction between mild TBI and PTSD is unclear; however, clinical experience shows that both conditions must be addressed for best outcomes. In military concussion centers, the behavioral health component is often embedded within the concussion clinic to provide interdisciplinary care. Two other factors associated with ongoing prolonged symptoms noted in the Warrior Strong Study were combat exposure and noncephalic pain.[26]

Assessments for Common Postconcussive Symptoms

Sleep problems after concussion are common and can present in various ways. In a meta-analysis, 50% of patients experienced some form of sleep disturbance after TBI, including higher than normal population rates of insomnia (29%), hypersomnia (28%), and sleep apnea (25%).[33] These sleep disturbances are important to evaluate and address early. In the case of insomnia, early intervention is particularly important to mitigate bad habits that can perpetuate poor sleep onset and sleep maintenance. Circadian rhythm sleep–wake disorders are also seen at higher frequency after concussion. These disorders can manifest as insomnia, hypersomnia, or both, depending on the misalignment between the intrinsic circadian rhythm and the desired sleep–wake cycle (eg, delayed circadian rhythm “night owls” will struggle with evening insomnia and morning hypersomnia in the setting of typical military bedtime and wake time). This problem is particularly salient in a military population of young soldiers because young adults tend to have a more delayed circadian rhythm to begin with, which can be further compounded after concussion. Sleep apnea should also be considered in those with complaints of daytime somnolence, nonrefreshing sleep, or ongoing cognitive complaints. Both obstructive and central sleep apnea are more common in those who have experienced TBI, and the effects of sleep apnea on cognition appear to be amplified in this population, particularly in the areas of sustained attention and memory.34,35

Cognitive symptoms after concussion can be associated with a variety of factors, including poor sleep, distraction from pain (such as headaches) or dizziness, and medication side effects, especially for those with polytrauma or concurrent musculoskeletal injury. Anxiety and mood disorders can significantly affect attention and concentration, which in turn impact memory, and can present as cognitive symptoms. However, comprehensive neuropsychological testing is not recommended in the first 30 days after mild TBI.[5] Per the CPG,[5] those who have ongoing symptoms beyond 30 days may be referred for neuropsychological testing, cognitive assessment for functional limitations, and treatment by rehabilitation therapists with expertise in TBI rehabilitation. Typically in the setting of prolonged cognitive symptoms, other treatable conditions related to memory and attention should be excluded (such as thyroid disorders, vitamin B12 deficiency, syphilis, sleep disorders, structural central nervous system lesions, and mood disorders) either clinically or by appropriate testing. Neuropsychological testing typically includes validity/performance measures, which may include stand-alone or embedded measures to increase confidence in the validity of a test battery and overall assessment. Such measures look for consistency between test behavior or self-reported symptoms and known patterns of performance, such as better performance on difficult tasks than on easy tasks. In the mild TBI population, rates of failure on validity measures (or the confidence that the test is measuring a true concussion deficit versus intentional/unintentional artifact) can range from 17% to 58%,36,37 representing a significant portion of this population. Debate exists about the best approach to this patient population, in which measuring objective deficits and progress poses a true challenge, and concerns about secondary gain (emotional or financial, conscious or subconscious) can also be present. However, a functional approach to patient-centered goals, along with minimizing the perception of disability, is recommended by the VA/DoD CPG. Patients presenting with over-reporting of symptoms or invalid findings on objective testing must not routinely be discounted because the presentation may be subconscious or a “cry for help.” The CPG strategy offers a practical approach to challenging patients, and with buy-in and patient engagement in the rehabilitation process, realistic expectations can be set by the patient and the treatment team.

Comorbid psychological conditions are common after concussion, particularly in cases of combat-related concussion or a traumatic event such as assault or severe injury in an accident. Conditions range from adjustment disorder related to the changes in function after concussion, to frank depression, anxiety, or acute stress reaction/PTSD. Irritable mood can accompany any of these psychological conditions, and irritability can be worsened by poor sleep and aggravated by frontal lobe executive dysfunction. Therefore, early and ongoing monitoring for emotional and behavioral symptoms in the acute, post-acute, and chronic postconcussive periods are critical, as is ensuring appropriate referrals to address these symptoms, most commonly with cognitive behavioral therapy. Medication treatment is guided by the primary diagnosis and applicable CPGs for the condition. Of note, no medications have been approved by the Food and Drug Administration specifically for the treatment of postconcussive symptoms (behavioral or physical). The VA/DoD CPG states, “We recommend that the presence of psychological or behavioral symptoms following TBI should be evaluated and managed according to existing evidence based CPGs, and based upon individual factors and the nature and severity of symptoms.”[5]

Headaches attributed to traumatic injury to the head, by the International Classification of Headache Disorders (3rd edition, beta version), are divided into acute (resolves within 3 months) and persistent (persists >3 months) conditions.[38] For mild TBI, headache onset must be within 7 days of the injury event or after discontinuation of medication that may impair the ability to sense the headache. Some experts expand this window to 30 days after the head injury event, and this longer timeframe was elected for use by the Defense Center of Excellence clinical recommendation for management of headache after concussion.[39] Headaches attributed to TBI may have a variety of clinical presentations. They can mimic any of the primary headache disorders, including (most often) migraine and tension type headaches, and (less often) neuralgic or other headache disorders. Secondary headache disorders unrelated to the concussion must also be considered (Exhibit 38-3 lists red flags for referral). Treatments, based upon the semiology of headache presentation, are the same as for the primary headache disorder.[39] With any chronic headache syndrome, caution should be used to avoid medication-overuse headaches (“rebound headache”), in which frequent analgesic use worsens the headache syndrome. If daily analgesics are required for a prolonged duration (more than a few weeks), consideration should be given to prophylactic headache therapy.

Studies have shown that 20% of patients with TBI and 47% of moderate brain injury patients complain of ongoing dizziness beyond 5 years post-injury.[40] Peterson[40] suggests that independent of severity or mechanism of injury, dizziness, migraine-associated dizziness, exercise-induced dizziness, spatial disorientation, and balance impairment[41] are common complaints among TBI patients, with a rate between 30% and 80%. Patient descriptions of these problems can be challenging for diagnostic purposes; for example, patients may use the terms “woozy,” “light-headed,” “spacy,” or “feeling drunk.” The following four categories describing aspects of dizziness may be more useful to clinicians:

1. vertigo, the illusory sensation of motion;

2. visual disorientation, with complaints such as disorientation or nausea when walking down a supermarket aisle or being in a crowd, and motion sensitivity;

3. light-headedness, the symptom likened to those preceding syncope (a sensation just before fainting or loss of consciousness); and

4. imbalance, feelings of unsteadiness, or being prone to stumbling or falling.[42]

Depending on the presentation and examination findings, additional consultation from neurology, otolaryngology, audiology, or physical therapy may be indicated for complaints of vertigo, visual disorientation, or imbalance. For patients with lightheadedness, further evaluation for syncope or pre-syncope may be necessary, and autonomic dysfunction should be considered along with a cardiovascular evaluation. Along with balance and dizziness symptoms, tinnitus, peripheral hearing loss, or central auditory processing disorder may be present. Central auditory processing disorder, related to central nervous system disturbances can manifest as difficulties understanding what is heard, particularly in busy venues where multitasking or focused attention is required.[43]

EXHIBIT 38-3

HEADACHE RED FLAGS AND INDICATIONS FOR REFERRAL

Red flags in evaluation of posttraumatic headaches for primary care providers to refer for emergency or specialty evaluation.

Indications for Emergency Referral

- Concussion red flags

- Thunderclap headache

- Sudden neurological deficit

- Persistent bleeding from nose, ears, or scalp

- Cranial fracture

- Infection resulting from a penetrating injury

- Cerebrospinal fluid leakage (nose or ears)

- Intracranial hemorrhage on CT

Indications for Specialty Referral

- Presence of systemic symptoms

- Associated neurological symptoms

- Onset after age 50

- Change in pattern of headache

- Valsalva precipitation

- Postural aggravation

- Papilledema

- TMJ disorder

- ENT disorder

___________________

CT: computed tomography

TMJ: temporomandibular joint

ENT: ear, nose, and throat

Reproduced from: Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. DCoE clinical recommendation, management of headache following concussion / mild traumatic brain injury: guidance for primary care management in deployed and non-deployed settings. https://dvbic.dcoe.mil/material/management-headache-following-concussionmild-tbi-guidance-primary-care-management-deploye-0. Published February 2016. Accessed May 24, 2018.

Visual function may also be affected after concussion, with accommodation disturbance and convergence insufficiency most commonly noted.44,45 As with the NSI symptoms, both of these conditions are seen in the general population but may become decompensated after concussion. Such visual disturbances may respond to treatments ranging from prescription lenses to vision rehabilitation in cases of prolonged symptoms.

Vignette 38-2. A 28-year-old male Special Forces soldier with 10 years’ time-in-service and three prior combat deployments was evaluated after a fall while skiing during a training exercise with his unit. His last memory was riding up the chair lift. Witnesses reported that he had a bad landing after “catching air” while going over a small cliff, hit the back of his head, then rolled nearly 100 feet down the steep mountain. During the evaluation, which took place immediately, the soldier opened his eyes and moved all extremities normally, but was disoriented and asked the same questions repetitively. His GCS score was 14. Cervical spine precautions were put in place, and he was then evaluated emergently at a civilian hospital with both CT head and c-spine, which showed no acute findings.

However, he had ongoing musculoskeletal neck pain and headache and was given a week of convalescent leave to recover. Evaluation after the recovery week by his primary care physician noted ongoing symptoms of severe headaches with light sensitivity, sound sensitivity, nausea, and even occasional vomiting, especially with exertion. Progression of activity beyond stage 4 (moderate activity) was not successful even 3 weeks after the concussion, and the soldier became frustrated that he could not exercise to maintain his high level of fitness, nor perform his full work duties. Specifically, when he went to the gym, he was unable to lift weights and run as fast as he had previously, and he could not keep up with his Special Forces peers.

He was referred to the concussion/TBI clinic for further evaluation, where additional history revealed at least five prior concussions, including three prior blast concussions and two related to jumps, as well as a history of playing football in high school. In addition, he had significant blast exposures during a prior deployment in 2009, with hundreds of door breaches without definitive concussions, and he was involved in one ambush where three of his team members were killed in action. Recurrent nightmares and flashbacks were a common occurrence. However, he never reported or sought medical attention for previous symptoms; rather, he simply “soldiered on,” performing well on his team until this recent injury.

Examination showed significant musculoskeletal tenderness in the paraspinal neck muscles and restricted range of motion secondary to pain, along with orthostatic tachycardia and convergence insufficiency. Magnetic resonance imaging (MRI) of the brain was normal, and MRI c-spine showed mild degenerative changes but was otherwise unremarkable. The soldier was referred for rehab services, including physical therapy to address the cervical symptoms, graduated return to exercise, optometry and occupational therapy for vision rehabilitation, and psychology to address his prior trauma as well as current adjustment to physical limitations. Cognitive rehabilitation for memory strategies as well as cognitive behavioral therapy for insomnia was provided to address memory and attention issues that were likely due to poor sleep, pain, and mood.

With these services, medications for his migrainous headaches, and better pacing of his activities, the soldier steadily improved, and 4 months after the ski accident he was able to return to full duty, using only abortive medications for rare headaches. After this experience, he also identified two team members who were also struggling with headaches and mood symptoms, prompting their evaluation and treatment, which resulted in the team becoming healthier and stronger for future missions.

Neuroimaging Beyond the Immediate Period

Neuroimaging is not required for the diagnosis of mild TBI, nor is it required for routine evaluation of mild TBI/concussion in all cases. In concussion, imaging is most often normal. Red flags should be used to guide the need for imaging in the immediate period after TBI, and the modality of choice during this time is a non-contrast CT head. Two common sets of criteria used to determine need for imaging in the immediate period are the New Orleans criteria[46] and the Canadian CT head rule.[47] The goal of imaging immediately after injury is to identify intracranial pathology that might require neurosurgical intervention or closer monitoring for intracranial bleeding that could increase and require urgent evacuation.

After the immediate period, the imaging modality of choice (if available and in the absence of contraindications) is MRI,[48] which is a more sensitive tool for detecting subtle structural lesions than CT head. The goals of imaging beyond the immediate period are to help understand persistent symptoms, guide specialist referral, and ensure accurate diagnosis if evaluation was delayed. MRI should include susceptibility weighted imaging/graded recall echo sequences, which are particularly sensitive for identifying areas of diffuse axonal injury or prior microhemorrhage.[48] Diffusion tensor imaging and functional MRI are modalities that hold promise for future use in subacute and chronic periods of TBI, but they are not yet widely available in routine clinical practice. Nuclear imaging studies such as positron emission tomography and single-photon emission computed tomography scans may be considered in cases where structural imaging is normal, but these modalities are best interpreted in a clinical context and in the setting of specialty neuroscience care.

RESEARCH AND FUTURE CONSIDERATIONS

The DoD research portfolio for TBI is gap-driven and tied to military requirements, meaning that funds are awarded based on the ability to study and answer military-specific research questions or develop a capability. This is different from the way in which most other federal research dollars are spent, such as through the National Institutes of Health (NIH), where the projects are investigator driven. The DoD currently has three general TBI focus areas: prevention (including blast and impact TBI), combat casualty care–related neurotrauma, and rehabilitation. The DoD also coordinates the TBI portfolio closely with the NIH and the VA, particularly in accordance with the National Research Action Plan (NRAP), as directed by a 2012 presidential executive order. Through the NRAP, federal agencies seek complementary, rather than overlapping, portfolios. The NRAP also seeks to maximize successful analysis of data from TBI studies through a requirement to share all data from federally funded studies.

Priority areas within the DoD portfolio include longitudinal studies seeking to understand the progression of TBI and how the injury evolves over time. Point-of-injury screening, diagnosis, and monitoring capabilities are another military focus area. Devices capable of determining at the point of injury whether a closed head injury has resulted in bleeding, equivalent to a positive CT scan, are of particular interest and applicability to battlefield medicine; two devices were recently approved by the Food and Drug Administration for this indication. Simultaneously, the DoD is seeking to better understand the forces (blast or impact) associated with TBI and subclinical exposure to PCEs. The goal of this portfolio is to reduce exposure by modifying tactics, techniques, procedures, and equipment for tasks that put SMs at risk for a potential injury.

SUMMARY

The general management and rehabilitation of patients with TBI has evolved into a process of prevention, immediate identification and assessment, early education, graduated return to activity, and, for those with prolonged symptoms, an interdisciplinary evaluation coupled with progressive and targeted rehabilitation. Even in cases of mild TBI, care has progressed from limited if any treatment, to comprehensive evaluation with progressive advancement in physical and cognitive exertion, with the goal of full reintegration and return to duty. The treatment model has advanced from limiting the severity of symptoms of the injury itself, to individualized rehabilitation based on each person’s presentation, unique strengths, and comorbidities. A person’s psychological, genetic, and physical traits cannot be uncoupled from the injury and its effects. Research on all aspects of TBI has increased since the conflicts in Iraq and Afghanistan began, and it has shaped the way care is provided. Ongoing research and clinical efforts will continue to benefit SMs and veterans in the future.

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39.   Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. DCoE clinical recommendation, management of headache following concussion/mild traumatic brain injury: guidance for primary care management in deployed and non-deployed settings. https://dvbic.dcoe.mil/material/management-headache-following-concussionmild-tbi-guidance-primary-care-management-deploye-0. Published February 2016. Accessed May 24, 2018.

40.   Peterson MD. A case-oriented approach exploring the relationship between visual and vestibular disturbances and problems of higher-level mobility in persons with traumatic brain injury. J Head Trauma Rehabil. 2010;25(3):193–205.

41.   Gottshall K. Vestibular rehabilitation after mild traumatic brain injury with vestibular pathology. NeuroRehabilitation. 2011;29(2):167–171.

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44.   Barnett BP, Singman EL. Vision concerns after mild traumatic brain injury. Curr Treat Options Neurol. 2015;17(2)329.

45.   Pearce KL, Sufrinko A, Lau BC, Henry L, Collins MW, Kontos AP. Near point of convergence after a sport-related concussion: measurement reliability and relationship to neurocognitive impairment and symptoms. Am J Sports Med. 2015;43(12):3055–3061.

46.   Haydel M, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000;343(2):100–105.

47.   Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001:357:1391–1396.

48.   Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. DCoE clinical recommendation, neuroimaging following mild traumatic brain injury in the non-deployed setting. https://dvbic.dcoe.mil/material/neuroimaging-following-mild-tbi-non-deployed-setting-clinical-recommendation. Published July 2013. Accessed May 24, 2018.

Chapter 39

CASUALTY TRANSPORT AND EVACUATION

CHETAN U. KHAROD, MD, MPH*; BRENNA M. SHACKELFORD, MD†; AND ROBERT L. MABRY, MD‡

INTRODUCTION

MILITARY CASUALTY EVACUATION TERMINOLOGY

EVOLUTION OF MILITARY CASUALTY EVACUATION DOCTRINE

Larrey and Letterman

Total War

World War II

EVOLUTION OF AEROMEDICAL EVACUATION

Korea

Vietnam

Late 20th Century

Evacuation Lessons From Iraq and Afghanistan

EVACUATION IN FUTURE CONFLICTS

The Operational Environment

Principles of Evacuation for Future Conflicts

MODEL FOR CASUALTY CARE CONTINUUM SUCCESS

SUMMARY

*Colonel (Retired), US Air Force, Medical Corps, Senior Flight Surgeon; Program Director, Military EMS & Disaster Medicine Fellowship, San Antonio Military Medical Center, JBSA, Fort Sam Houston, Texas

†Consultant Emergency Physician, New Zealand

‡Colonel, Medical Corps, US Army; Command Surgeon, Joint Special Operations Command, Fort Bragg, North Carolina

INTRODUCTION

Casualty evacuation, a key phase of combat casualty care, has evolved along three intersecting vectors of technology: (1) military weapons and tactics, (2) medical care, and (3) transportation. This chapter discusses the historical evolution of casualty evacuation, including lessons most recently learned in Iraq and Afghanistan. This historical perspective is critical to understanding how current US systems developed and provides insight into how casualty care during evacuation can be improved. It discusses the potential challenges future conflicts may bring and provides a set of principles that can be used by military physicians on future battlefields. This is not an in-depth technical manual discussing the nuances of each individual evacuation platform that can be found on the modern battlefield, nor does it substitute for current medical evacuation field and technical manuals. Rather, the chapter’s goal is to provide a conceptual understanding and a set of principles that will enable military medical providers to deliver the best possible care to their patients during evacuation, from point of injury (POI) to definitive care.

MILITARY CASUALTY EVACUATION TERMINOLOGY

To understand the history, evolution, and current state of the science of casualty evacuation and en route care, it is essential to understand the language of this key domain of battlefield medicine.

Casualty evacuation (CASEVAC), in a traditional sense, is rapid, unregulated movement of any casualty at any point along the continuum of casualty care from the POI onward. CASEVAC can take place via personnel carries, vehicles, or aircraft available for transport. Regulated movement of these casualties, with the addition of medical personnel on a medically equipped platform, from both POI to dedicated medical care or a medical treatment facility (MTF), or from one MTF to another, is termed medical evacuation (MEDEVAC). Tactical evacuation (TACEVAC) is the overarching term for both CASEVAC and MEDEVAC, and encompasses the full spectrum of transport from a hostile or austere POI to advanced medical care in a secure environment.

The term en route care is defined by the twin goals of providing medical treatment and sustaining or improving the patient’s medical condition during the evacuation process. It is not based on the movement platform itself. En route care is a dynamic process with the goal of providing the best care possible for patients, by adjusting for patient condition, threat, and mission constraints by selection of appropriate platforms and personnel to accomplish the medical evacuation mission.

Much like modern medicine, these terms are continually evolving, now referring more simply to the platform and regulatory status in which a casualty is moved and less to the nature of personnel on board. A variety of patient movement platforms are utilized for evacuation and en route care. Ground transport can be by standard ambulance, tactical vehicle, bus, or any other available medium. Air assets consist of both rotary and fixed-wing aircraft, including assets of the US Army, Air Force, Navy, and more recently, the Marine Corps.

Unregulated patients are the injured, typically located at or close to the POI, before they have been assigned a patient movement request (PMR). Regardless of platform, the unregulated status of these patients defines their transport as CASEVAC, and their movement is influenced by tactical factors and by triage status. These patients may or may not receive en route care; if they do, it can vary greatly, from flight medics placing a tourniquet and performing needle decompression to critical care teams performing damage control resuscitation en route. An example of an unregulated patient is a casualty thrown from a vehicle in an improvised explosive device blast, dragged to a casualty collection point, and subsequently transported via another military vehicle immediately to the nearest forward medical care.

Once patients receive a PMR, they are termed regulated. PMRs are created by the attending physician at the patient’s location in conjunction with an Air Force aeromedical evacuation liaison team. The PMR is further evaluated and subsequently validated by an aeromedical evacuation control center flight nurse and flight surgeon team, with subsequent preparation for the patient’s airlift and movement requirements. This process requires both time and personnel, which typically means the patient has been stabilized at an MTF prior to movement. Regulated medical evacuation takes into account the availability of air assets, the patient’s clinical status, the nature of the en route care expertise available, and the accepting facility’s space and specific medical capability for the casualty. A casualty with a traumatic amputation of the leg, who has had damage control surgery at a Role 2 MTF and is being transported by Air Force aeromedical evacuation, is an example of a regulated patient. Army MEDEVAC often transports patients in both categories, carrying patients from POI as well as between MTFs when intra-theater transport is necessary.

Dynamic en route care capability is now being positioned on what were traditionally considered CASEVAC air platforms. These medical teams are comprised of highly trained critical care physicians, critical care nurses, and advanced medics, bringing a higher level of medical care closer to the POI and adding flexibility in the rapid deployment of aircraft to move patients via unregulated flight.

EVOLUTION OF MILITARY CASUALTY EVACUATION DOCTRINE

Organized evacuation of battle casualties is a relatively new advancement in the history of warfare. From the times of Greek hoplites and Roman legions until the 1800s, no systematic method of evacuating battlefield casualties existed. Wounded fighters had to evacuate themselves from the line and dress their own wounds, or depend on other soldiers to provide care. If the battle were won, those who were too wounded to march with the army were often quartered locally or in field hospitals constructed to care for these patients. Over time, the wounded would “triage” themselves by recovering and returning to duty, recovering but remaining unable to serve further, or dying. Wounded on the losing side did not fare as well. The lightly injured were captured and ransomed or sold as slaves; the more seriously injured were killed or left to die.[1]

Larrey and Letterman

The Napoleonic Wars of the 19th century produced the “father” of modern military medicine and perhaps the greatest military surgeon who ever lived, Dominique Jean Larrey. Larrey was surgeon-in-chief of the Napoleonic armies from the French campaigns in Italy in 1797 to Waterloo in 1815. Larrey’s chief contribution to military medicine was the systematized evacuation of battlefield casualties using a field ambulance. The term “ambulance” comes from the Latin ambulare, meaning “to walk.” As it was used at the time, the term “ambulance” typically meant the field hospital (or the “walking hospital”) that followed the army. Prior to Larrey’s effort, field hospitals were located 3 miles behind the front. The wounded were typically left on the field until after the battle, sometimes receiving no care for 24 hours or more after injury.[2] Larrey, inspired by the speed and mobility of French artillery wagons, developed a system of medical wagons that were both mobile aid stations and evacuation platforms. These ambulance volantes or “flying ambulances” were staffed for, organized to support, and dedicated to the evacuation of the wounded.

Larrey’s ambulance corps was divided into three divisions of 113 personnel each. Each division was commanded by a chief surgeon and equipped with twelve light carriages and four heavy carriages, with each carriage manned by about seven men. Larrey’s ambulance configuration was both mobile and flexible—different equipment could be carried, and different draft animals (eg, camels in the Egypt campaign) could be used, depending on to the mission and environment.[3] Larrey organized the care and evacuation of wounded like any other military operation: with a staff, chain of command, noncommissioned officers, and enlisted men under the leadership of a medical officer.

Part of Larrey’s philosophy of rapid evacuation was based on his 24-hour principle of wound management. Previous surgical opinions recommended that amputation be performed in a delayed fashion, and only through gangrenous tissue. Larrey felt that in cases where an extremity could not be salvaged, rapid amputation while the soldier was still in shock, and before infection had set in, not only improved survival but also was more humane, especially during transport. He felt that patient movement on horseback or by wagon with a clean, well-dressed amputation was much more comfortable for the patient, causing less pain and fewer complications, than being transported with a shattered limb. Thus, Larrey was the first to recognize that time to treatment after injury was a key factor in casualty outcomes. His system of forward care on the field followed by rapid evacuation to surgical care in the field hospital formed the basis for modern medical evacuation systems.[2]

The defeat of Napoleon at Waterloo brought an end to prolonged war in Europe. A worldwide era of unprecedented industrial innovation and economic growth followed, setting the stage for even larger armies to be deployed during the American Civil War. Advances in transportation such as steamboats, locomotives, and railway lines made it possible for large numbers of troops to be moved rapidly in an orderly manner. Food preservation techniques such as canning and dehydration were improved. Weapons technology was enhanced. The smooth-bore musket of Napoleon’s era was notoriously inaccurate; thus, tactics dictated tight formations exchanging volley fire at close range. During the American Civil War, however, the rifled musket firing the 0.58-caliber minié ball was the principal weapon used by both sides. In contrast to the smooth-bore musket, the rifled musket was accurate up to 500 yards. Unfortunately, military tactics did not take into account the capabilities of these new weapons; American generals on both sides of the Civil War still studied and employed Napoleonic tactics. Maneuvering large, tightly packed, linear formations against fortified positions produced devastating results and caused unprecedented numbers of casualties during Civil War battles.

Likewise, military medical leaders in the US Army did not recognize that the nature of warfare had changed from small frontier engagements to warfare on a massive scale. At the outbreak of the war, the Union Army’s medical department was completely unprepared. Physicians were often graduates of unregulated, 2-year medical schools, and few had any training in surgical care or battlefield injuries. Most military leaders did not anticipate a prolonged, large-scale conflict. Additionally, previous campaigns against Indians and the recent Mexican-American War (1846–1848) had resulted in only a few battle casualties. Most campaigns up until that time were short lived, and most deaths were from disease. All US military conflicts from the Revolutionary War to 1860 had resulted in slightly more than 23,000 killed in action or wounded, whereas in the Civil War, the Union side alone would ultimately suffer 600,000 killed or wounded.[4]

The First Battle of Manassas, or Bull Run, in July 1861, was the first significant ground battle of the war. The medical evacuation plan was essentially improvised at the regimental level.[5] Wagons to carry the wounded were driven by civilian teamsters, many of whom fled from the field at the first sound of gunfire. As a result, many Union wounded were left on the field and along the roadside for several days until they could be recovered. The ensuing scandal led to the eventual appointment of Major Jonathan Letterman, MD, as the medical director of the Army of the Potomac, and Letterman’s establishment of the Ambulance Corps in August 1862.[6] In 1864, Congress approved Letterman’s casualty care plan, with few changes, for adoption by the entire Union Army.

Letterman’s plan, like Larrey’s, authorized an ambulance corps controlled by a physician medical director for each army corps. Wagons were dedicated specifically to the mission of evacuating casualties and were under the control of medical officers, not the quartermaster. Medical directors established standards for personnel, equipment, and training. Casualties were treated close to the field, moved to division- or corps-level field hospitals, and then eventually transported to larger fixed facilities in Philadelphia, Baltimore, and Washington, DC. Although still significantly understaffed and strained throughout the war, Letterman’s system of evacuation through echelons of care from the POI, through division and corps field hospitals, to a fixed brick-and-mortar hospital for definitive care and convalescence, would serve as the model for most industrialized nations into the next century.

Total War

The advancement of military weapons and technology, combined with nearly 40 years of peace among the major powers, set the stage for the horrific numbers of battlefield casualties during World War I. The absence of a major conflict in the preceding decades meant that tactical and operational concepts that accounted for long-range, rapid-fire precision artillery; machine guns; or improved, breech-loading, bolt-action rifles using modern cartridges and smokeless gunpowder had yet to be understood or developed. These military advances, as well as improvements in communication, organization, and transportation, enabled massive numbers of soldiers, inspired by nationalist fervor, to meet in battle armed with new weapons and unprecedented destructive power.

Several medical developments had occurred during the relatively peaceful period between the US Civil War and World War I. Lister’s principles of asepsis were introduced. The individual battle dressing, or field dressing, was developed for issue to individual soldiers. Henry Dunant’s humanitarian-focused Red Cross movement expanded in the United States and Europe. In Britain, the Red Cross partnered with the St John Ambulance Association, a first-aid-focused organization that operated in the major cities teaching first aid concepts to workers in industrial centers and other civilians. World War I was the first major conflict with specially trained “medics” assigned to combat formations who moved about the battlefield rendering aid and evacuating the injured. It was also the first war in which combat deaths outnumbered those from disease.

The destructive firepower of the first modern industrial war quickly resulted in a stalemate at the front. Trench warfare characterized combat on the Western front as combatants sought protection from the powerful artillery barrages and machine gun fire in trenches and bunkers. These emplacements remained relatively static during the war, and both sides suffered incredible numbers of casualties trying to win the new type of warfare.

Casualty care during World War I began at the POI. The wounded soldier performed whatever self-aid he could, or perhaps his comrades would provide initial care. At the company aid post, medics focused on sorting patients (“triage”), bandaging wounds, and splinting any fractures to minimize pain and additional injury during litter transport to the battalion or regimental aid post, located 250 to 500 yards behind the line. Once there, splints and dressings were examined and adjusted if necessary, and morphine and anti-tetanus serum were administered. The patients were wrapped in blankets and given hot drinks to keep them warm. Treatment was noted on a casualty tag attached to the patient.

The wounded were then carried by litter to the ambulance dressing station. These stations were located as far forward as safely possible. During the day this was 3,000 to 6,000 yards from the front, located along a road at a relatively protected point such as a building or cellar if possible. If a litter transport more than 800 to 1,000 yards from the battalion aid post was required, relay stations might be set up where litter teams handed off patients for the next stage. It was often safer to move ambulance dressing stations farther forward at night and evacuate patients under the cover of darkness, saving a long and often dangerous litter transport during daylight.

At the ambulance dressing stations, casualties were re-triaged by medical officers. Casualties in severe shock or those deemed non-transportable were held until they improved or died. From the ambulance dressing stations, casualties requiring further care were evacuated to a field hospital. For the first time in history, large numbers of casualties were transported by motorized ambulance. Ambulances made by Ford, Fiat, Peugeot, and General Motors proved their value in terms of speed and patient comfort under brutal combat conditions.7,8 Overall, in the American Expeditionary Forces, the time from wounding until the arrival at the first triage point was 5 to 6 hours.[8]

Field hospitals, where surgical care was first available, were located 6 to 8 miles from the front, out of artillery range. Time from injury at the front lines until arrival at the first surgical care varied depending on road conditions, intensity of combat operations, visibility, and similar factors. Personnel at field hospitals would evaluate and triage patients once again. Casualties stayed a few hours to a few days at the field hospital, depending on the nature of their wounds and the level of combat and casualty flow. Cases that could not be returned to duty but who were stable for further transport were moved to evacuation hospitals. Those casualties deemed nontransportable (ie, those who were likely to die during further transport without immediate surgical care) were retained at the field hospital. These cases typically included three classes: open (or “sucking”) chest wounds; perforating abdominal wounds; and severe hemorrhage cases. Casualties requiring neurosurgical care tended to stand transportation better before an operation than after and were typically sent forward.[8]

Field hospitals were essentially emergency hospitals or more robust dressing/triage stations, and more intensive medical and surgical care was provided at the evacuation hospital. Army Expeditionary Forces evacuation hospitals were typically 1,000-bed facilities located alongside a railway line between 9 and 15 miles from the front. Casualties reached the evacuation hospital on average 10 to 16 hours following triage at the field hospital. In addition to serving the wounded who required immediate surgical care before they could be transported further, evacuation hospitals served as relay or clearing stations in the hospitalization and evacuation chain. Patients were transported from evacuation hospitals by train to a system of base hospitals and then on to fixed facilities throughout France and England for definitive care and convalescence. At each stage of the evacuation chain, those who would not survive transport would be held until they improved or died. Those with minor injuries were returned to duty, and those who required further care were sent on through the chain.[9]

World War II

The world wars of the 20th century saw the development of the internal combustion engine and motorized ambulances that could carry casualties through “echelons of care.” While the Western front was relatively static in the First World War, World War II was a war of speed and mobility. Armored vehicles, which had emerged in rudimentary forms during World War I, were perfected and integrated into a combined arms strategy using air power, artillery, and infantry. Entire armored and mechanized divisions were fielded. The airplane had advanced significantly during the interwar period and would play a key role in moving men, materiel, and casualties across large distances in both the European and Pacific theaters of war. As surgical care advanced and military aviation developed, large numbers of casualties in World War II were able to receive forward stabilizing surgical care and subsequently be transported to a second hospital by airplane. Blood transfusions, advances in resuscitation science, antibiotics, and improvements in surgical technique revolutionized combat surgery and resulted in a reduction of the hospital case fatality rate in patients with abdominal or visceral wounds from 45% during World War I to 15% in World War II.[10]

Evacuation in World War II operated on similar principles as during World War I. The goals at each stage or echelon of care were to provide only those treatments necessary to save lives and ensure patients were stable for transport to the next level. At each stage, those who could be safely returned to duty were sent back to their units, and those who required further treatment continued through the evacuation chain. Those who could not recuperate within 4 to 6 months in theater were evacuated back to the United States. During the war, fixed-wing aeromedical evacuation became the principal method of transporting patients from forward hospitals to rear area facilities.

EVOLUTION OF AEROMEDICAL EVACUATION

After the invention of the airplane in 1903, militaries around the world began to realize the implications aircraft and aviation would have on warfare. Airplanes would offer unprecedented new opportunities on the battlefield. Likewise, aviation’s implications for combat medicine were not lost on military medical planners. During World War I, several countries experimented with medical evacuation by aircraft, but safety, expense, and limited load capacities did not make casualty transport by aircraft feasible on a large scale until World War II. Large, fixed-wing aircraft functioned in the same role as the casualty trains of World War I. Intra-theater patient movement was accomplished on planes such as the Curtiss C-46 Commando or the Douglas C-47 Skytrain, while intertheater transport required larger planes with greater range, such as the Douglas C-54 Skymaster. These planes would move more than one million casualties from forward evacuation hospitals to base hospitals in the rear.[11] In total, more than 1.34 million patients were aeromedically transported during the war.[12]

The helicopter was introduced toward the end of World War II. Initially used to rescue the crew of a downed aircraft in the jungles of Burma, the first evacuation of combat casualties under fire by helicopter was done in Manila in 1945, when 75 to 80 soldiers were evacuated one or two at a time.[13]

Korea

Helicopter evacuation came to the fore during the Korean War. The Bell H-13 Sioux helicopter, an adaptation of the Bell commercial Model 47 was used to evacuate more than 20,000 casualties.[14] These helicopters were crude as evacuation platforms and lacked advanced navigation or communication capabilities. Because patients were in pods located outside the crew compartment, no medical care could be given during flight. Pilots sometimes received ad hoc medical training from surgeons at the receiving hospitals, but the pilot had to land the helicopter to render any aid.

Helicopter evacuation in the US Army evolved with a focus on speed of casualty transport to surgical care. For the first time, casualties could be taken from a remote, rugged location near the POI, and transported rapidly to surgical care, bypassing the intermediate stops through echelons of ground-based evacuation. Helicopter evacuation spared patients prolonged litter or ground ambulance transports over rough terrain through hostile territory, preventing much death and suffering.

Vietnam

Military trauma systems built during the Korean and Vietnam eras steadily increased the survival rates of wounded soldiers. Helicopter evacuation underwent significant expansion and growth during the Vietnam era, when dedicated MEDEVAC helicopters were deployed en masse. The Bell UH-1, or “Huey,” was large enough to carry several patients as well as a combat medic who could provide care en route to the hospital. Rapid evacuation to surgical care is often cited as one of the principal reasons for the significant reduction in battlefield mortality during the Vietnam conflict compared to other wars of the 20th century. Helicopter MEDEVAC (referred to as “DUST-OFF” after its motto: “Dedicated, Unhesitating Service to Our Fighting Forces”) epitomizes modern battlefield care whereby an injured soldier can be whisked from the battlefield to surgical care within minutes of wounding. Indeed, the icon of modern battlefield medicine is the MEDEVAC helicopter.

Late 20th Century

During the postwar period following Vietnam, US and NATO military planning remained focused on fighting Soviet and Warsaw Pact forces on the plains of Europe. Large-scale, intensive combat with massive numbers of conventional battlefield wounded, as well as casualties from nuclear and chemical warfare, were expected. Combat was expected to be fast paced, highly mobile, and conducted day and night in all weather conditions.

MEDEVAC doctrine continued to focus on rapidly clearing the battlefield. Speed, aircraft performance, and communications were key priorities for MEDEVAC commanders. Little, if any, attention was given to the medical care provided by the flight medic. No substantive medical treatment was expected in a fully loaded aircraft carrying multiple casualties staffed with only a single flight medic. From the Vietnam era until 2012, the flight medic was trained only at the basic combat medic level and had no requirement for any hands-on patient care experience during their training.

During this period, civilian air ambulance services proliferated. The first one was established in 1970. By 1992, more than 220 helicopter ambulance services were established in the United States.[15] Although initially modeled on the military’s rapid transport model, the emerging civilian model evolved with a “care is critical” philosophy whereby highly trained and skilled providers were matched with specific patients’ medical needs, bringing tertiary level care to the patient during transport.[16] As civilian helicopter emergency medical service (HEMS) evolved to bring resuscitation to the patient, the military model continued to focus on bringing the patient as rapidly as possible to resuscitation.

US forces were involved in several small conflicts in the 1980s and 1990s, including operations in Grenada, Iraq, Kuwait, Panama, Somalia, and Kosovo. In all instances, combat operations were short-lived, with relatively few casualties. No trends emerged during these limited conflicts to challenge the Cold War model of evacuation. During the same period, civilian HEMS models became increasingly sophisticated.

On October 3, 1993, the most intense conflict involving US forces since the Vietnam War took place in Mogadishu, Somalia. This conflict revealed some hints about the future of what would be called “asymmetric warfare.” The challenges of fighting in an urban environment, such as the vulnerability of helicopters, difficulty of finding landing zones and resulting prolonged care in the field, and delayed evacuation heralded conditions to come during Operation Iraqi Freedom almost a decade later in Fallujah, Sadr City, and other heavily populated urban areas.[17]

Evacuation Lessons From Iraq and Afghanistan

Iraq

When US and coalition forces invaded Iraq and Afghanistan following the World Trade Center bombing of September 11, 2001, the military medical evacuation model remained focused on time, or rapidly clearing the battlefield of casualties. Further, US evacuation doctrine was directed toward military combat casualties from the POI to surgical care. It did not anticipate the large numbers of pediatric, medical, and critical care transports that would be encountered in the battlescapes of Iraq and Afghanistan.

During the initial maneuver phase of the war, nonstandard CASEVAC vehicles or MEDEVAC ground or air ambulances were often the modes of evacuation to the rear. Casualties entered the evacuation chain at different levels. Sometimes they were transported to an aid station (Role 1) or a brigade support medical company (Role 2), where they were stabilized by non-surgeon medical staff and then transported by MEDEVAC to a forward surgical team (FST). In some instances, casualties were transported directly from the POI to small, mobile FSTs. After surgical stabilization, casualties would be transferred from the FSTs to forward hospitals (Role 3), usually by MEDEVAC helicopters.

In the later phase of the war, a large and robust system of Role 3 facilities was established near most populated areas in Iraq. Compared to Afghanistan, Iraq’s road and highway infrastructure was well developed, with significant urban and suburban populations centered along the Tigris and Euphrates river valleys. Medical assets were robust and located near the areas of most military operations. FSTs were consolidated with Role 3 facilities to provide a more robust surgical and critical care capability. Battalion aid stations (Role 1) or brigade support medical companies (Role 2) were often bypassed by MEDEVAC because surgical care was often close by. Military medical planners had adopted the “golden hour” concept in Iraq and were able to attain an average evacuation time of 55 minutes for seriously injured casualties. Evacuation times from one battalion aid station in Baghdad ranged from 20 minutes to 2 hours during major combat operations, with an average of about 25 minutes.[18]

Challenges during the transfer of postoperative patients aboard MEDEVAC helicopters were noted early in Iraq. A number of cases were described in which patients were stabilized at an FST, transferred to Role 3 by MEDEVAC, and arrived either dead or in extremis.[19] At that time, MEDEVAC helicopters were staffed by a single combat medic credentialed at the Emergency Medical Technician-Basic (EMT-B) level. These medics were not typically qualified to manage patients requiring critical care or advanced resuscitative procedures, such as airway and ventilator management, advanced pharmacology, or blood product administration. It was common for new flight medics to encounter their first seriously injured or ill patient on their first mission in combat.

Treatment protocols, documentation, medical direction, and quality improvement processes were not standardized and varied significantly across US Army helicopter evacuation units, nor were these processes integrated with the overall trauma system. This is in contrast to civilian HEMS systems that operate within the United States, the United Kingdom (UK), and most European countries. Current civilian helicopter evacuation platforms are routinely staffed by critical care trained flight paramedics or comparably trained flight nurses, operating under the medical direction of physicians with emergency medical service (EMS) training, and using formalized protocols, standardized patient care documentation, and rigorous quality improvement processes.[20]

In 2004, the theater trauma director published clinical practice guidelines (CPGs) that directed physicians or nurses trained in critical care to augment postoperative transfers from Role 2 to Role 3.[21] While the CPG provided detailed instructions for critical care transport, no additional personnel were dedicated to this mission by the US military, so the critical care providers would have to come from the transferring Role 2 or the receiving Role 3 facility. At the tactical level, this resulted in the difficult decision of either sending a key provider from a small forward team during combat operations, thus degrading the effectiveness of the team; sending a provider from the receiving Role 3 to the pick-up point; or transporting the patient with a minimally trained flight medic. When providers were sent from an FST or combat support hospital, they often lacked any formal in-flight critical care training or experience. A mix of all three techniques were used, and all presented particular logistical and patient care challenges.[22]

The incidence of poor outcomes during MEDEVAC in Iraq is unknown. No standardized patient care record, chart review, or performance improvement process was in place. Documentation of care during a MEDEVAC flight was not required as part of the medical record, and thus was not subject to review or analysis performed by the Joint Theater Trauma System.

Afghanistan

After major combat operations ended in Iraq in 2009, combat and stability operations in Afghanistan became a primary focus of the US and its coalition partners. Afghanistan presented many different challenges than fighting in Iraq. Afghanistan, in contrast to Iraq, is a vast and sparsely populated country with numerous mountain ranges, poor road networks, and primitive infrastructure. Combat forces were widely dispersed. Unlike in Iraq, most medical evacuations to surgical care in Afghanistan could only be conducted by MEDEVAC helicopter (ground transport was not practical nor safe based on lack of infrastructure, distance to receiving facilities, and semipermissive environments).

Conditions in Iraq had begun challenging the Cold-War-era legacy MEDEVAC model; in Afghanistan, distance and time magnified the challenges of the asymmetric, nonlinear battlefield. The operational environment caused stress to the legacy MEDEVAC model with (a) increased numbers of postoperative critical care patients being transported from Role 2 to Role 3; (b) unprecedented numbers of civilian transports including pediatric, geriatric, and medical cases similar to those seen in civilian EMS; and (c) massively injured polytrauma patients, who would have died in previous conflicts, being kept alive by tactical combat casualty care, improved protective equipment, and access to early surgery.

Gaps in en route critical care capability in Afghanistan were noted as early as 2002.[23] Since then, efforts were made to overcome these institutional gaps by tactical-level providers and commanders on the ground doing the actual day-to-day mission. These ad hoc fixes included mandating licensed medical providers (physicians, physician assistants, nurses) to fly on MEDEVAC platforms; sending flight medics to civilian paramedic training programs between deployments; deploying critical care nurses to augment MEDEVAC crews; using paramedic-trained US Air Force pararescue personnel to perform MEDEVAC; and employing the tiered dispatch of higher capability units such as the British Medical Emergency Response Team (MERT) for the most severely injured patients, particularly in the south and southwest of Afghanistan.

Similar to the Army field surgeons’ experience in Iraq,[19] the deployed theater trauma director in Afghanistan in 2009 noted a number of anecdotal cases where patients had left a Role 2 facility following surgery and had deteriorated significantly or died en route to the Role 3. While Role 2 to Role 3 flights in Iraq were usually much shorter,[22] postoperative transfers in Afghanistan before 2009 often took over an hour to several hours, averaging 1.5 hours.[24] In January 2009, Secretary of Defense Robert Gates prioritized the need to decrease evacuation times to under 1 hour. More FSTs and medical evacuation assets were deployed, and by December that year, the average evacuation time in Afghanistan had been reduced from 100 to 42 minutes.[25]

The 2004 CPG published in Iraq still recommended that a nurse or physician accompany postoperative patients. However, many FSTs, already small in size, were now being split into two 10-person teams in Afghanistan to achieve the 1-hour standard mandated by Secretary Gates. The smaller FSTs were then even less able to give up a provider to accompany a patient during evacuation. In response to the reports of poor patient outcomes following postoperative transfer by MEDEVAC, the theater trauma director initiated a request for forces for the deployment of critical care nurses to augment the MEDEVAC crews during these flights. These en route critical care nurses arrived in Afghanistan in 2010 without predeployment training or recent flight experience, yet they and subsequent groups were able to perform at high standards. Patient documentation and quality assurance measures were put in place, and the outcomes of postoperative patients improved.[26]

Between December 2008 and October 2009, a US Army National Guard MEDEVAC unit was deployed in southern and eastern Afghanistan with a unique crew: nearly 75% of its flight medics were credentialed and experienced EMT-Paramedics who actively practiced in the United States before deployment. These medics had an average of 9 years’ field experience and extensive training in critical care transport prior to deploying. They brought civilian HEMS protocols, documentation, medical direction, staffing, and process improvement standards to their MEDEVAC unit, effectively adapting their civilian expertise to the military environment in Afghanistan. An analysis of this group’s performance demonstrated a 66% reduction in casualties’ risk of death at 48 hours compared to the standard MEDEVAC units deployed before and after them.[20]

The MERT, consisting of a large CH-47 Chinook helicopter staffed with a physician, a nurse, two paramedics, and a ground security force, also appeared to improve the survival of the most seriously injured casualties. The MERT was created for use in Iraq for rapid incident response and deployed in southern Afghanistan in 2006. In Afghanistan, the extensive battle area in the UK’s area of responsibility led to the far-forward employment of critical care assets. UK forces leveraged the experience of many of their deployed clinicians in HEMS. Initially, the MERT’s medical component consisted of a general medical officer delivering advanced trauma care. As the fielding of this team evolved, UK forces scaled their MERT response to add physicians as needed, extending the forward care and life-saving interventions they can provide. It is important to note, though, that MERTs were employed only in areas in which air superiority or air supremacy had been established. It would be premature to extrapolate the MERT’s current success to other phases of battle in which air superiority has not been achieved.[27]

At coalition regional patient evacuation coordination centers, staffed in southwestern Afghanistan around the clock by experienced trauma nurses, the appropriate evacuation platform based on the patients care needs was dispatched. This clinically based dispatch model was aimed at optimizing the patient’s care during transport. The MERT was dispatched for the most severely wounded; US Air Force Pararescue (with two paramedics, call sign PEDRO) were dispatched for advanced life support cases or in nonpermissive environments; and DUSTOFF (with a single EMT-B medic) for all others. Even when the PEDRO or DUSTOFF units have a more rapid response, a MERT was dispatched preferentially for the most severe cases so that advanced resuscitation could be started as soon as possible. If a MERT had a 15-minute response time to the POI, for example, and a DUSTOFF unit had a 10-minute response with a 10-minute subsequent flight to Role 2 or 3, the MERT would be dispatched so that resuscitation began in 15 versus 20 minutes. This tiered response system was unique to one region of Afghanistan.[28]

Specialized Teams

For longer-range transport, beyond the rapid response of a DUSTOFF or MERT unit from the POI, the US Air Force Aeromedical Evacuation system provides fixed-wing movement of regulated casualties with extensively trained aircrew, which can be tasked across the full spectrum of military operations.[29] Traditional aeromedical evacuation teams consist of two flight nurses and three aeromedical evacuation technicians, with specialty training to care for patients on a variety of opportune aircraft, primarily the C-130 Hercules, the C-17 Globemaster, and the KC-135 Stratotanker. In the early 1990s, the US Air Force surgeon general, Lieutenant General P.K. Carlton, had envisioned a critical care air transport team (CCATT) to serve as a mobile intensive care unit, augmenting a traditional aeromedical evacuation mission to provide expert care for critically ill casualties.

CCATTs now consist of a critical care physician, a critical care nurse, and a respiratory therapist, capable of caring for a number of ventilated casualties while simultaneously providing ongoing resuscitative interventions in-flight.[30] Combat casualties surviving extensive, multi-system trauma and stabilized in theater via damage control surgery can now be evacuated safely and rapidly to the United States, often within 48 to 72 hours of the initial injury. Specialized critical care personnel can also augment CCATTs to support patients with additional requirements, including the use of more advanced ventilation protocols and extra-corporeal membrane oxygenation.

Special Operations Teams

The Air Force Special Operations Command (AFSOC) developed its own en route care capabilities to meet special operations forces (SOF) mission sets. The earliest AFSOC en route care specialists were the Special Operations Forces Medical Element (SOFME) teams, comprised of a flight surgeon (typically an internship-trained flight surgeon) and two independent duty medical technicians.[31] These teams had in-garrison base-operating support duties and were on alert at all times for forward taskings. As AFSOC physician assistants (PAs) proved their worth in the SOF medical arena, it became increasingly common for PAs to serve in the SOFME teams in place of the flight surgeon.[32] The SOFME role evolved in the post-9/11 world of increasing operations tempo and expanding SOF application in global engagement. The SOFME operational medical pipeline is robust and has come to involve clinical skills (eg, Advanced Trauma Life Support, Prehospital Trauma Life Support, Tactical Combat Casualty Care, aeromedical disposition) and tactical skills (the AFSOC CASEVAC course, field skills training, and small unit tactics).[33] SOFME teams are located on multiple continents and engage in everything from combat CASEVAC to multilateral training with partner nations and humanitarian assistance/disaster response.

The success of the Air Force CCATT and Mobile Forward Surgical Team (MFST; a five-person surgical team able to carry its own gear and walk into a location) led to the next generation of SOF medical support. The advent of the Special Operations Surgical Team (SOST) and Special Operations Critical Care Evacuation Team (SOCCET) changed the landscape of SOF medical support capability. Now, theater SOF teams had far-forward damage control surgical support with embedded intensive care capability. SOST/SOCCET personnel are highly trained medical and surgical professionals who must keep their medical skills up to date.[34] In addition, their pipeline training requires awareness of small unit tactics, field skills, and essential SOF field support capability.

These teams were initially designed to operate independently as needed, but their field application more often required joint basing in support of ground force SOF operations. SOST/SOCCET teams have worked successfully in many forward settings, ranging from combat support to humanitarian assistance/disaster response.[35] As it became increasingly clear that their predominant use was in support of ground operations, in 2012 the command surgeon of the 24th Special Operations Wing coordinated AFSOC’s plan to place the SOST/SOCCET units under the command of the 720th Special Tactics Group. This strategic move paved the way for major advances in the organization, training, equipping, and application of these mission-critical medical support assets. SOST/SOCCET units based in the continental United States are embedded at civilian trauma centers, a unique feature.[36] As self-contained, geographically separated units, teams live and work at busy civilian trauma centers, honing their critical care and surgical skills. Always on-call, they are able to respond rapidly to the next SOF support mission anywhere in the world.

EVACUATION IN FUTURE CONFLICTS

The Operational Environment

Cold War-era MEDEVAC doctrine emphasized clearing the battlefield and relieving the fighting troops of the burden of casualty care. In today’s conflicts, the challenge for medical evacuation is to provide state-of-the-art care to patients; this will likely be true in future asymmetric conflicts as well. Indeed, the aim of current NATO evacuation doctrine is “to provide a standard of medical care which is as close as possible to prevailing peacetime standards, and follows the principles of best medical practice, while acknowledging the operational posture and environment.”[37]

In the foreseeable future, US military operational environments are likely to be much more complex and challenging than the relatively stable settings of the Cold War, where one large, constant, and discernible threat was the focus. Today, threats are numerous, poorly understood, difficult to identify, and unpredictable. Radical Islam, rogue states possessing weapons of mass destruction, regional instability in the Middle East and northern Africa, international criminal activity, a rising China with a culture and history unknown to most in the West, the threat of pandemic disease, environmental and natural disasters, and global economic instability all create a complex environment for military and military medical planners. No longer is rapid evacuation through echelons of care within a defined battle area or front line axiomatic.

Armed conflict will likely remain asymmetric because most nations and non-state actors cannot match US and NATO forces in conventional air-land battle. Asymmetric war will be fought in urban areas where enemy forces will attempt to negate the superior technology, mobility, and firepower of the United States and its allies. Civilians will be encountered and will be purposefully put into harm’s way as opposing forces seek not only to burden the medical system, but also to create the appearance of atrocities and civilian deaths as a result of US and allied actions. Intensive military operations in urban environments will create difficulties in evacuation similar to those seen in Mogadishu and Fallujah.[38]

Evacuation will often be delayed, necessitating prolonged care in the field. Unarmed MEDEVAC helicopters will be vulnerable to small arms fire and rocket-propelled grenades, and landing zones will be limited. Casualties will be carried by hand on litters and moved by nonstandard CASEVAC vehicles to forward aid stations and forward surgical care, or transported outside the city where landing zones can be secured. A newly evolving capability, the US Air Force tactical critical care evacuation team (with an emergency/critical care physician, certified nurse anesthetist, and emergency/critical care nurse) will provide substantial clinical capability, available on a variety of platforms, with minimal staffing and equipment. Future conflicts will certainly require use of this light, life-saving capability.

Following the withdrawal of combat forces in Afghanistan, political and economic pressures will make another prolonged conflict politically unpopular unless vital interests are directly threatened. Expeditionary operations will likely be the norm. Large, robust, fixed forward medical facilities will not be in place, especially during initial entry operations. Yet state-of-the-art care for US forces will be expected, especially given the low case fatality rates during operations in Iraq and Afghanistan. Combat casualty survival in such an environment will require expert prehospital care and an evacuation chain that emphasizes advanced far-forward damage control resuscitation focused on airway management, resuscitation with blood products, and hemorrhage control.[39]

Military planners have described “an arc of instability,” extending from the Mediterranean Sea to the Sea of Japan, where future conflicts are most likely to arise. This region encompasses vast geographic areas such as Africa, the Indonesian archipelago, the Indian subcontinent, and the South Pacific. Conducting medical evacuation in these areas poses significant problems, and the golden hour requirement will be difficult to attain. US MEDEVAC doctrine will require a fundamental cultural change that focuses on extending the golden hour by bringing skillful advanced resuscitation to the patient in the manner of civilian HEMS systems or the British MERT. Expeditionary medical support will not have a robust holding capability. Patients will be moved mostly by air, and resuscitation will be ongoing throughout transport.

In the event of a large-scale conventional war or a period of intensive conflict in a smaller war, military medical planners may have the option of implementing a “mass casualty” protocol that would return to the Cold War goal of rapidly clearing the battlefield. Evacuation platform staffing, treatment protocols, and patient loads could then be modified according to the tactical situation based on predetermined criteria.

Finally, the military medical evacuation systems must take into account domestic and international disaster support. Military forces offer a tremendous resource to governments following disasters. The military’s logistics and communications capabilities, in conjunction with efficient command and control mechanisms and expeditionary medicine expertise, will continue to be called upon during large-scale humanitarian crises. An evacuation system that operates under the local standard of care will be more adept and more easily integrated into the disaster response.

Principles of Evacuation for Future Conflicts

Overall System Design

The key element in providing quality patient care given the available resources is the design of the prehospital care and evacuation system. Evacuation concepts have carried over from war to war, often based in historical precedent, convenience, and military tradition rather than on a deliberate analysis of patient care needs by experts. Evacuation systems in future conflicts will benefit from a systems analysis approach with patient outcomes as the primary driver. Although resources and military exigencies must be accounted for, keeping the wounded casualty at the center of the system design process allows deliberate policy decisions to be made with the focus on optimizing patient care.

Medical Direction and Oversight

Active supervision of the evacuation system by physicians who practice and have expertise in emergency, critical care, and critical care transport medicine is required to optimize patient outcomes.[40] The medical director should have oversight and accountability of all aspects of the system related to patient care. This includes training and clinical supervision of prehospital providers, development and fielding of patient care protocols, selection of medical equipment, and quality assurance processes including chart/case review, research, and process improvement efforts. The medical director must be competent in providing and supervising patient care in the field and should participate in direct patient care in the field on a regular basis. Regular exposures to conditions in the field are the only way to fully understand how the system functions and where improvements need to be made.[40]

Patients cared for in the evacuation system are the responsibility of the system’s medical director. The non-physician providers in the system are practicing under the license of the medical director; therefore, the medical director should not be subordinate to the commander of the evacuation system but should be free to make decisions and give orders related to the provision of clinical care. He or she must be the final authority over all clinical aspects of the evacuation system. This prehospital specialist, or “prehospitalist,” will change the battlespace not only by applying advanced skills in the administration and oversight of prehospital care systems, but also by bringing to bear specific clinical skills designed for prehospital, austere, and en route care settings. The Department of Defense (DoD) currently trains such “prehospitalists” in a 2-year accredited fellowship based at a Level 1 military trauma center.

Dispatch and Response

Requests for medical evacuation by US forces require transmission of a “9-line” report (Table 39-1). The “9-line” focuses mostly on tactical considerations; only two parts deal with patients. Line 3 lists numbers of patients by precedence (urgent, urgent surgical, priority, routine, and convenience) and line 5 lists the number of patients who are on litters and those who are ambulatory. Because the order of clinical precedence of the patients is subjective, “over-triage” is common using this process; providers on the ground often assign a higher priority than is needed. The recent addition of the MIST (mechanism, injury type, signs, and treatment given) report to the 9-line provides injury mechanism data with physiologic data similar to civilian trauma center transport guidelines.[41] While the current American College of Surgeons (ACS) guidelines, which focus on civilian trauma systems, are too extensive for field use by military medics, the methodology proposed by the ACS guidelines should be applied to military trauma, with the development of military-specific criteria. Expanding on the prehospital MIST report concept, future evacuation systems should take into account physiologic, anatomic, and injury mechanism data to more accurately identify patients requiring aggressive forward resuscitation and rapid transport to forward surgical care.

TABLE 39-1

STANDARD 9-LINE MEDEVAC REQUEST FORMAT

Line 1

Location of pick-up site

Line 2

Radio frequency, call sign, and suffix

Line 3

Number of patients of precedence

(A-Urgent, B-Urgent surgical, C-Priority, D-Routine, E-Convenience)

Line 4

Special equipment required

(A-None, B-Hoist, C-Extraction equipment, D-Ventilator)

Line 5

Number of patients

(A-Litter, B-Ambulatory)

Line 6

Security at pick-up site (in peacetime, number and types of wounds, injuries, illness)

(A- No Enemy in area, B-Possible enemy in area, C-Enemy in area, D-Enemy in area & armed escort required)

Line 7

Method of marking site

(A-Panels, B-Pyrotechnic, C-Smoke, D-None, E-Other)

Line 8

Patient nationality and status

(A-US Military, B-US Civilian, C-Non-US Military, D-Non-US citizen, E-EPW)

Line 9

NBC (in peacetime: terrain description at pick-up site)

(N-Nuclear, B-Biological, C-Chemical)

EPW: enemy prisoner of war

Medical director involvement is required to ensure not only a well-structured dispatch process, but also dispatch of the appropriate evacuation capability based on patient needs. The patient evacuation coordination center or evacuation dispatch element must be staffed with trained and experienced medical personnel and should be collocated in key command and control communications centers to synchronize military operational, security, and medical evacuation operations.

Evacuation Platforms

Many vehicles can be used to move casualties. These may be dedicated ground and air ambulances marked with red crosses, staffed with medically trained personnel, and equipped for patient care, or they may be a nonmedical vehicle or aircraft without medical equipment or personnel. The type of vehicle used will depend on availability, weather, terrain, and the type and intensity of combat operations. A thorough mission analysis by military medical planners using the “PACE” methodology should identify a primary, alternate, contingency, and emergency method for evacuation.

Ground ambulances are the principal method of moving patients from the forward edge of battle during conventional combat operations. A number of variations, each with different capabilities and patient load capacities, exist. Although a detailed discussion of each type is beyond the scope of this chapter, medical directors and planners should be intimately familiar with each ambulance configuration used in their area of operations. Ground ambulances are most appropriate for short transits on established road networks and across relatively flat, open terrain. Some ground ambulances are capable of limited transit across rugged terrain; however, their use in mountainous, jungle, and heavily forested regions will be limited to established road networks. Weather and illumination conditions may degrade the speed of ground ambulance transport, but generally will not inhibit ground evacuation.

In Afghanistan, evacuation by helicopter has emerged as the principal method of transporting patients from the POI to forward surgery and from forward surgery to the combat support hospital. The MEDEVAC helicopter will continue to be the key method of casualty transport during low-intensity and asymmetric conflicts because these types of operations require a wide distribution of forces but a relative centralization of medical assets. In this environment, helicopters will be required to meet current time to surgical care guidelines. MEDEVAC helicopters can be dispatched directly to the POI and are able to retrieve patients from small landing zones or hoist them from the ground while hovering; thus, they are very effective in rugged or heavily forested terrain that may be inaccessible to ground ambulances. Unfortunately, patient care space is limited on helicopters. Noise, cabin lighting, and vibration make patient assessment and treatment difficult. Weather and illumination conditions may inhibit helicopter evacuation. Additionally, operations in urban environments will limit the use of MEDEVAC helicopters because landing zones are difficult to establish and unarmed helicopters are vulnerable to ground fire in dense urban areas.

Fixed-wing aircraft, such as the C-130 Hercules, are excellent forward evacuation platforms under certain circumstances. They have a large cargo area that provides significantly more workspace, and they travel at nearly twice the speed of helicopters, making them ideal for long-distance evacuation. Medical attendants are able to stand erect and move about. Along with substantially less noise and vibration than in a helicopter, this makes patient care and assessment easier to perform. Most fixed-wing cargo aircraft can readily be converted to carry a large number of litters.

However, evacuation by fixed-wing aircraft requires access to a suitable runway. Ground or helicopter evacuation is required to transport the patient from a forward treatment facility to the airfield. Requests for fixed-wing evacuation platforms will become more complex and time-consuming because these aircraft will often not be dedicated to forward medical evacuation. Medical crews and equipment, not typically assigned to the aircraft, will need to be assembled. Weather and illumination conditions may limit fixed-wing evacuation, but to a lesser degree than helicopter transport. Fixed-wing evacuation, when available, is ideal for moving large numbers of casualties or those requiring intensive critical care over longer distances. When MEDEVAC helicopters are limited in urban warfare, moving casualties by ground to an airstrip outside of the urban area for fixed-wing evacuation may be a viable alternative.

Navy en route care has taken a quantum leap forward with the advent of EMS board-certified medical directors; the development of standardized protocols, education, and training; and the evolution of joint en route care CPGs. Sea-basing of casualty collection and treatment, as well as specific en route care training for corpsmen, may revolutionize naval evacuation over vast distances in theaters such as the Pacific Command.

Provider Staffing and Capability

A number of staffing models for both civilian air and ground ambulances exist. For ground ambulance services these include basic life support (BLS), EMT-B level; advanced life support (ALS) providers (paramedics); and in some instances, intermediate-level providers capable of more advanced airway and vascular access techniques than EMT-Bs, yet lacking the advanced capabilities of paramedics. Most civilian air ambulance systems in the United States (93%) are staffed with two providers, most commonly a flight paramedic and flight nurse (67%). Other configurations include two flight nurses (8%), two flight paramedics (5%), and a single nurse or paramedic (3%).[42] There have been no large prospective studies demonstrating an advantage of one staffing model over another. Physicians in North America rarely perform prehospital or field care, although in Europe many ground and air evacuation platforms are routinely staffed by physicians trained to provide prehospital care.

Most military ambulances are staffed with at least two military medics, although Army MEDEVAC helicopters have traditionally been staffed with a single combat medic. Combat medics in the US Army are credentialed at the EMT-B level, but they are trained in more advanced techniques such as surgical airways, needle chest decompression, and intravenous as well as intraosseous access. While studies of military ground ambulance staffing models are lacking, several recent retrospective military studies have shown improved patient outcomes related to helicopter evacuation platform staffed with critical care paramedics[20] and physicians.[43]

In addition to unprecedented numbers of civilian transports, operations in Afghanistan have challenged the conventional evacuation platform staffing model for US forces with (a) severely injured casualties with multiple traumatic injuries kept alive by advanced body armor and tactical combat casualty care, many whom would have died in past conflicts, and (b) increased numbers of postoperative cases. This pattern will likely continue in future scenarios. During a conventional conflict, military-age males with traumatic injuries will be the majority of patients transported, whereas in low-intensity and asymmetric conflicts, civilians of all ages as well as medical cases will frequently be transported.[44] Optimizing casualty outcomes in future conflicts requires MEDEVAC crews capable of meeting the needs of the patients transported across the full spectrum of conflict, from counterinsurgency operations to conventional combined arms battles.

Evacuation times in combat can be incredibly variable, especially during the initial entry phase of operations. Expeditionary, initial entry, and special operations will therefore require forward medical personnel to accompany the wounded during what may be a prolonged evacuation. These medical assets must be trained, experienced, and competent in forward resuscitative care. Staffing models should be flexible and able to care for all types of patients that may be encountered. Using a tiered system (with separate critical care, ALS, and BLS responses) is feasible in a small geographic area such as described above in southeastern Afghanistan. However, such a tiered system would be difficult to implement across a large geographic area or during initial operations in an immature theater of war. Here, a single efficient and flexible staffing model capable of responding across the full spectrum of patient care needs is key.

Although one provider may be adequate for most stable and routine transfers, two providers should be available for any seriously ill or injured patients. Evacuation platform providers should be capable of retrieving a severely injured casualty from the POI and performing stabilizing care (including advanced airway management, hemorrhage control, resuscitation with blood products, chest decompression, and pharmacologic therapy for sedation, pain, blood pressure support, and coagulopathy). Rather than simply transporting the casualty, the goal should be to begin resuscitation on retrieval and continue it until the patient reaches forward surgical care. This same team should be capable of transporting the same patient in the postoperative period to a definitive care hospital, continuing to provide critical care in transit.

Data and Quality Improvement

Military medical providers are dedicated professionals committed to performing quality patient care during medical evacuation in extremely hazardous environments. Such high-quality patient care is expected not only by those in uniform who place themselves in harm’s way, but also by the political leaders, military commanders, and citizens of their respective nations who ask the military to risk life and limb for national defense. Though service members deserve the highest quality of care that can realistically be delivered in a combat setting, functional military systems of data collection, patient care documentation, and quality improvement processes were generally lagging until well into the mid-2010s.

Incomplete patient care data from the prehospital phase of care is the single greatest challenge to improving military medical care. A growing body of evidence suggests the prehospital phase (including evacuation) is the where the largest number of potentially salvageable deaths occur.[45] Yet fewer than 14% of casualties had any documentation of prehospital care on arrival to a surgical facility in Iraq and Afghanistan, according to a 2011 report.[46] Any effort to improve the quality of care during medical evacuation requires data; competency and quality of care cannot be demonstrated nor improved without data collection and documentation.[47] One cannot improve what one cannot measure, and one cannot measure without data.[48]

A detailed discussion of data collection systems, patient documentation, and quality improvement methods is beyond this scope of this chapter. However, the following general principles from “Data A–Z” by Mears[49] should be mentioned:

- For any quality initiative, it is essential that data collection systems be created to measure the fundamental tenets of the EMS system—patient care and service delivery.

- Data elements must be standardized and uniform, with consistent definitions.

- Generating a medical record holds EMS personnel accountable for their critical decision-making and patient care. Medical records also allow identification of educational needs and areas of improvement.

- Information systems should obtain a large portion of data passively from automated systems such as medical devices (monitors) and computers.

- EMS information systems should be strategic and clearly defined. The application of data should enhance patient care, not detract from it. Information systems should drive the EMS system, its service delivery, and its patient care.

- Data entry requirements must be balanced with patient care requirements. Extensive demographic data and other elements not immediately related to patient care should be deferred until the patient reaches a fixed facility.

- If a data system is put into place without adequate training and support, the user experience will be negative. A negative user experience at this critical point can be devastating.

- Technology is critical to the success of an information system, but can be damaging if it is applied inappropriately or before it is mature.[49]

The main argument against prehospital data collection by field providers is that it is precluded by the chaotic nature of combat. While this may be true in some major combat operations at certain periods, the US Army’s 75th Ranger Regiment, one of the most heavily engaged combat units of the US forces, has successfully collected patient data on every casualty sustained during operations in Iraq and Afghanistan. This data has been used to continuously improve the quality of the organization’s casualty response system. The 75th Ranger Regiment is also the only unit in the US military that has demonstrated zero potentially preventable deaths in the prehospital setting after more than a decade of combat.[50]

Prehospital and evacuation patient care data must be captured, integrated, and synchronized with the patient’s medical record and the theater trauma system. With accurate evacuation care data, clinical benchmarks can be established, outcomes can be evaluated, and quality improvement initiatives implemented in a continuous cyclical process.

MODEL FOR FUTURE CASUALTY CARE CONTINUUM SUCCESS

To replicate the successful trauma registries and trauma systems used by US civilian trauma centers, forward deployed trauma surgeons developed the Joint Theater Trauma System, which evolved into the Joint Trauma System (JTS), serving the DoD’s global operations. Housed at the US Army Institute of Surgical Research, the JTS is helping to enable a more structured approach to trauma care from POI to definitive care and rehabilitation. Recognizing that trauma care is a continuous and enduring DoD mission, the system was established to improve standards in trauma care across the continuum of care, built on standardized documentation, registry development, outcome analysis, performance improvement, and evidence-based medical practice across the entire continuum. The JTS continues to evolve, and its trauma registry has served as the model for similar registries in partner nation military medical systems. CPGs are published and routinely updated in an effort to optimize care for combat trauma both on the ground and in the air. This system is built to adapt to the current and future political, strategic, and operational needs of the DoD.

SUMMARY

Evacuation is a core military medical function. Enhanced en route care is the latest innovation in the history of medical evacuation. The interrelationship between military and civilian medicine in this field is clear: each community has made advances in medical evacuation, and each has adopted advances made by the other. While war has driven many of the current advances in prehospital combat casualty care (junctional tourniquets, hemostatic agents and dressings, telemedicine, and TCCC), civilian emphasis on critical care evacuation, quality assurance, protocols, and proactive medical direction is equally improving the landscape of prehospital military medicine.

For combat arms commanders, who place a premium on accomplishing the mission, the best possible care of the combat wounded is an absolute priority. In addition to the first-order effect of reducing mortality and morbidity, exceptional medical care and evacuation provide second- and third-order effects as well: combat troops undertake the mission with peace of mind, knowing the medical team is behind them, ready to take care of them and evacuate them to life-saving care each time they protect national interests by going into harm’s way.

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Chapter 40

PREVENTIVE MEDICINE IN THE DEPLOYED ENVIRONMENT

LUCAS A. JOHNSON, MD, MTM&H,* AND SHAWN M. GARCIA, MD, MPH†

INTRODUCTION

IMMUNIZATION

CHEMOPROPHYLAXIS

SEXUAL HEALTH

ORAL HEALTH

VECTOR CONTROL

WATER STANDARDS

FOOD STANDARDS

WASTE DISPOSAL

ENVIRONMENTAL HAZARDS

UNIT-LEVEL MEDICAL SURVEILLANCE

OUTBREAK INVESTIGATIONS

EMERGENCY PREPAREDNESS

RISK COMMUNICATION

SUMMARY

*Lieutenant Commander, Medical Corps, US Navy; Assistant Professor of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†Lieutenant Commander, Medical Corps, US Navy; Assistant Professor of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland

INTRODUCTION

Military personnel serving in operational environments experience a variety of potentially hazardous exposures. It is well known that conflict erodes existing public health infrastructure, resulting in outbreaks of disease associated with poor hygiene, contamination of food and drinking water, and interruption of vector control measures. Because of the ubiquity of these exposures in operational settings, a variety of effective countermeasures are directed by Department of Defense (DoD) policy, as well as guidance specific to the area of operation, which should be incorporated when planning military operations. It is the responsibility of the locally assigned military leadership, in coordination with the military medical officer (MMO), to assure appropriate preventive medicine resources and risk mitigation procedures are available at the tactical and operational levels to maximize force readiness and preserve the health of deployed forces.

Perhaps more than any other medical discipline, preventive medicine activities influence combat operations at every level of warfighting. Minimizing or mitigating potentially hazardous exposures permits the conduct of operations in environments typically inhospitable to routine tactical maneuvering. Through disease prevention activities, commanders can more easily maintain operational troop strength and lose fewer soldiers, sailors, airmen, and marines to preventable illness. Finally, in preserving and maintaining the health of service members through wellness and readiness initiatives, preventive medicine acts as a strategic force multiplier, helping to ensure a ready and capable force prepared for worldwide deployment.

IMMUNIZATION

Immunization is recognized as one of the great public health achievements of the 20th century.[1] The ability to confer lasting, sterile immunity to previously immune-naïve individuals for the purpose of interrupting and preventing infection has saved countless lives; smallpox vaccination alone is estimated to have prevented 5 million deaths globally each year since its development.[2]

Two critical measures influence how effectively the use of a particular vaccine can prevent disease at the population level. Vaccine efficacy, the reduction in incidence of disease among those who have received vaccination as compared to those who have not, measures how well a vaccine prevents disease in exposed persons. Vaccine uptake, the proportion of individuals who have completed all recommended doses of a vaccine, measures population compliance with immunization recommendations. High vaccine efficacy combined with high vaccine uptake results in the phenomenon of herd immunity, a condition in which an infectious disease is denied a population of susceptible hosts, and can no longer be efficiently transmitted within the largely vaccinated community. In reducing the prevalence of circulating disease, herd immunity also benefits those few individuals unable to be vaccinated due to comorbidities or contraindications. While the exact proportions for specific diseases vary, herd immunity is generally achieved once a population’s vaccine uptake approaches 85%.[3]

Unit medical assets are responsible for ensuring attached personnel have received immunizations required by service-specific instruction as well as geographic command entry requirements. The Defense Health Agency Immunization Healthcare Branch is an excellent source of military vaccine information, including vaccine entry requirements for each geographic area of responsibility.[4] Ensuring appropriate vaccination is critically important when managing populations likely to experience close-quarters living (recruit training centers, barracks residents, ship’s berthing); overcrowding (refugee camps, prisons, detention centers); or foreign travel.[5]

CHEMOPROPHYLAXIS

While sterile immunity remains the gold standard for preventing illness, many military-relevant infectious agents do not yet have an effective vaccine countermeasure. In some instances pharmaceutical interventions (chemoprophylaxis) exist to prevent diseases for which vaccines are not yet available.

Malaria

As early as 1768, James Lind advocated for malaria chemoprophylaxis, recommending that “every man receive a daily ration of cinchona powder” while visiting tropical ports.[6] In virtually every theater of war since then, many reports have been published on the military’s experience with chemoprophylaxis. From the Pacific campaign of World War II to the 2003 peacekeeping operations in Liberia, the primary lesson learned remained unchanged for the greater part of a century: enforcement of appropriate chemoprophylaxis use is a command responsibility (Exhibit 40-1).[7]

EXHIBIT 40-1

COMMAND PRESERVATION OF HEALTH

Burma, 1943. Lieutenant General William Slim’s troop strength was severely compromised. For every soldier evacuated with combat wounds, 120 were evacuated due to illness, a rate of 12 per 1,000 per day. The annual malaria attack rate was 84%, rendering a large percentage of his force combat ineffective for months at a time. Slim recalled, “A simple calculation showed me that in a matter of months at this rate my army would have melted away. Indeed, it was doing so under my eyes.”[1]

An effective prophylaxis for malaria, mepacrine, was available, and evidence of therapeutic compliance easily assessed on physical exam. However, unfounded rumors of the drug causing impotence resulted in poor adherence. Slim’s solution was simple but effective:

I, therefore, had surprise checks of whole units, every man being examined. If the overall result was less than ninety-five percent positive I sacked the commanding officer. I only had to sack three; by then the rest had got my meaning.[1]

Within months, Slim’s malaria forward treatment unit wards were largely empty. By 1945 illness rates plummeted 10-fold, to 1 solder per 1,000 per day. Lieutenant General Slim recognized and leveraged a fundamental relationship in preserving the health of his forces:

Good doctors are of no use without good discipline. More than half the battle against disease is not fought by doctors, but by regimental officers. It is they who see that the daily dose of mepacrine is taken, that shorts are never worn, that shirts are put on and sleeves turned down before sunset, that minor abrasions are treated before, not after, they go septic, that bodily cleanliness is enforced.[1]

___________________

1. Slim W. Defeat into Victory. 2nd ed. London, UK: Cassell & Company Ltd; 1956.

Several highly effective agents are available for use as malaria chemoprophylaxis; each has its own considerations (Table 40-1). Chloroquine was previously used extensively across the globe, but development of resistance has restricted its utility to geographic areas known to have no chloroquine-resistant Plasmodium species. Currently the vast majority of US service members receive doxycycline or atovaquone-proguanil malaria chemoprophylaxis. Providers should always ensure chemoprophylaxis selection is appropriate for local resistance patterns. Mefloquine carries a “black box” warning due to well-described neurologic and psychiatric side effects and should be prescribed within the DoD only as a “drug of last resort.”[8]

Service member compliance with malaria chemoprophylaxis is historically low. Survey data from Operation Enduring Freedom (OEF) veterans indicate compliance with daily dosed regimens approached 60%, and compliance with weekly dosed regimens was less than 40%.[9] Whenever possible, malaria chemoprophylaxis should be administered at the unit level as directly observed therapy (DOT). DOT increases medication compliance and appropriately empowers commanders with a means to preserve the health of their forces.

Travelers who spend prolonged periods of time (generally 6 months or more) in regions with P vivax and P ovale require presumptive anti-relapse therapy (PART) with primaquine for 2 weeks following their return. Primaquine is effective in eradicating the liver hypnozoite phase of P vivax and P ovale. However, primaquine can be used only in G6PD-normal individuals, and no agent is currently approved for PART in service members who are G6PD deficient. Such individuals should be thoroughly counseled regarding bite avoidance and prophylaxis compliance if they require travel to areas where PART would otherwise be recommended.

Leptospirosis

Leptospira is a spirochete bacteria typically transmitted through soil or fresh water contaminated by animal urine. Bacterial invasion occurs through cuts in the skin or mucous membrane exposure. Historically significant leptospirosis outbreaks among service members have only occurred among participants in jungle warfare training who experience substantial amounts of untreated fresh water exposure in tropical environments. Civilian exposures typically result from flooding in the tropics as well as participation in fresh water adventure sports. Doxycycline 200 mg orally once weekly is believed to provide some protection against leptospirosis infection for individuals with limited, discrete exposures to potentially infected water. Prophylaxis should begin 1 to 2 days before potential exposure and continue throughout the period of exposure.[10] The value of chemoprophylaxis for populations with continuous exposures in endemic areas is unclear.[11]

TABLE 40-1

MALARIA CHEMOPROPHYLAXIS AGENTS

DoD: Department of Defense; GI: gastrointestinal; PO: per os (by mouth).

*Data source for pregnancy information: Centers for Disease Control and Prevention. Choosing a drug to prevent malaria. https://www.cdc.gov/malaria/travelers/drugs.html. Published April 25, 2018. Accessed June 6, 2018.

Group A Streptococcus

Group A streptococcal infections are a particular challenge in the recruit setting, where crowding and inadequate hygiene can result in historically aggressive disease manifested by severe pneumonias, empyemas, and tonsillar abscesses. Since the advent of penicillin, military recruit depots have employed chemoprophylaxis to prevent Group A streptococcal infections. Across the services, all recruit training depots engage in year-round prophylaxis, with 1.2 million units of benzathine penicillin G (PCN) administered intramuscularly (IM) during the first week of training. IM PCN protects recruits for approximately 28 days and can be re-dosed if indicated by historical surveillance or an active outbreak. Penicillin-allergic recruits may alternatively be treated with 1 g oral azithromycin weekly for 4 weeks, or 250 mg erythromycin twice daily for 4 weeks.

SEXUAL HEALTH

The force health protection threat posed by sexual activity is an often-neglected reality of operational and deployed military settings. Despite overwhelming evidence to the contrary, some commanders believe prohibition of sexual activity alone is a sufficient intervention to prevent sexually transmitted infections (STIs) and pregnancies in operational settings. History has repeatedly demonstrated this view as fallacious, most recently during OEF and Operation Iraqi Freedom. From 2004 to 2009, over 750 cases of chlamydia and gonorrhea were identified in combat-deployed US military personnel. In some cohorts, rates of chlamydia exceeded stateside civilian age-matched rates.[12]

Continuous promotion of safe sexual behavior, as well as creating an environment where sexual health issues can be confidentially discussed with a medical provider, is critical for preserving force health. Condoms are essential medical supplies that should be available at every echelon of care, discretely and free of charge, regardless of geography or cultural normative behavior of host countries.

Specific expert recommendations for MMOs include (1) promoting condom use as normal protective behavior and characterizing unprotected sexual activity as unnecessarily risky and abnormal; (2) identifying and screening those at risk for STIs (providers should understand demographic factors influencing the epidemiology of specific STIs); (3) ensuring treatment (including treatment of sexual partners whenever possible) occurs in accordance with US Centers for Disease Control and Prevention recommendations; and (4) ensuring confidentiality of reported high-risk behaviors.[13]

Contraceptive availability is a critical component of sexual health. Female service members should be counseled on the availability and efficacy of common contraceptives. In operational or deployed settings where hygiene can become complicated, hormonal contraception that can induce reversible menstrual cycle suppression may be of interest to female service members.[14] Like condoms, contraception, including emergency contraception, is an essential medical supply that should be available to service members at every echelon of care with as few barriers as possible.

ORAL HEALTH

Oral health is an essential component of combat readiness. Service members with oral disease may suffer impaired performance of their duties, poor diet, sleep disturbances, and pain. Despite being a dentally ready force, the Army recorded over 900 unique dental emergencies in service members deployed to Afghanistan each month from July 2009 to June 2011.[15] Research suggests the risk of a service member suffering severe dental disease increases by approximately 4.5% for every month deployed.[16] Proper screening creates a dentally ready force that is one-third as likely to experience a dental emergency requiring care as compared to an unscreened force.[17] Certain cohorts of service members have demonstrated increased risk for a dental emergency in deployed settings; in comparison to the active component of the Army, members of the Army National Guard and Army Reserve demonstrated a 50% increased risk of dental disease during OEF.[16] Assuring appropriate and timely treatment and follow-up after screening prevents impediments to dental readiness prior to and during deployment.

VECTOR CONTROL

Vector-borne disease is a substantial force protection threat in operational and deployed settings. Climate change increases the spread of vector-borne disease to novel areas, making threats more likely in environments previously inhospitable to arthropod vectors.[18] While certain diseases have effective vaccines or chemoprophylaxis measures, minimizing exposure remains the cornerstone of all vector-borne illness prevention.

Minimizing vector exposure begins with avoidance. Both the lifecycle and preferred feeding time of many arthropod vectors follow well-established seasonal, rainfall, and diurnal patterns. Minimizing outdoor exposure during peak biting periods (if tactically permissible) can substantially decrease the likelihood of bites. Similarly, when locations are chosen for habitation in the field, the surrounding vector habitat should be considered. Whenever possible, sites for human habitation should be open, dry, and positioned away from local settlements, animal pens, or rodent burrows.

Reducing the exposed biting surface available to an arthropod is a critically important practice for service members. Proper wear of a long-sleeve military uniform reduces exposure to potential vectors. Sleeves should be worn down and pant leggings should be property bloused or tucked into the boot in the field environment. At night, bed nets are an additional measure of protection against arthropods. Chemical repellants further augment bite avoidance. Permethrin, the DoD standard repellent used to treat clothing, opens voltage-dependent sodium channels in arthropod nervous systems to cause paralysis and death. In high-transmission environments, bed nets should be utilized and treated with permethrin. The exterior of canvas tents can also be treated with permethrin. Many services now issue uniforms factory-treated with permethrin, which protect for 50 wash cycles or more. While each uniform contains specific wash and re-treatment instructions, factory-treated uniforms generally remain effective for 12 months.[19] Uniforms can be treated professionally or using a field expedient method (aerosol spray, individual dynamic absorption, air compressed spray). The Armed Forces Pest Management Board is an excellent resource for information about treatment methods and service-specific uniform considerations.

DEET (N,N-diethyl-m-toluamide or N,N-diethyl-3-methylbenzamide) has been the US military skin repellant of choice for over 60 years. When applied to exposed skin at concentrations over 20%, DEET is effective in repelling a variety of arthropods.[20] Picaridin (1-piperidinecarboxylic acid 2-(2-hydroxyethyl)-1-methylpropylester) is a newer repellant that appears to have a repellant profile at least equivalent to DEET while also being less irritating to skin and less corrosive to plastics.[21] DEET or picaridin should be applied to any exposed skin not covered by a permethrin-treated uniform as part of the DoD insect repellent system. A variety of DEET and picaridin products are approved for military use, assigned a National Stock Number (NSN), and available for unit-level procurement.

The 2012 death of a US soldier from rabies and, in 2014, the largest-ever military rabies contact investigation, illustrate the continued threat animal bites pose to service members.22,23 Rabies virus is transmitted through the blood, saliva, and nervous tissue of infected mammals. While preexposure and postexposure regimens are highly effective at preventing human rabies, avoidance remains the primary mechanism of rabies protection for the vast majority of service members. With the exclusion of US working dogs, all mammals encountered in the operational or deployed setting are potential rabies threats. Adoption of stray animals as unit mascots represents an unacceptable risk and should be prohibited by commanders.

DoD guidance outlines indications for specific individuals (veterinarians, laboratory workers, military working dog handlers, etc) to receive preexposure rabies vaccine due to their elevated risk of coming in contact with rabies virus.[24] Rabies virus preexposure vaccination consists of three doses of immunization delivered on days 0, 7, and 21.[25]

Rabies postexposure prophylaxis becomes necessary when individuals have blood or mucous membrane exposure to the saliva, blood, or central nervous tissue of potentially rabid animals. Bat bites may leave little, if any, evidence of puncture wounds and may not be noticed by a sleeping person. If there is any chance that physical contact with a bat occurred, the bat should be tested for rabies. If the bat is not available for testing, then rabies postexposure prophylaxis should be administered. Clear documentation of an animal having received appropriate rabies vaccination or an examination by a veterinarian familiar with rabies are the only acceptable means of verifying an animal as being free of rabies. In all other mammalian bite cases, MMOs should strongly consider rabies postexposure prophylaxis due to the near 100% fatality rate of human rabies once a person becomes symptomatic. Postexposure prophylaxis consists of cleaning the wound, administering 20 IU/kg body weight of rabies immunoglobulin injected as proximal to the bite site as possible, and four doses of rabies vaccine, on days 0, 3, 7, and 14, administered in the contralateral deltoid.[26] Previously vaccinated individuals should generally not receive immunoglobulin; instead, they should receive a truncated two-dose vaccine schedule on days 0 and 3.

WATER STANDARDS

Ample quantities of safe water are necessary for preservation of health, hygiene, and force readiness. Improperly treated drinking water can transmit a variety of bacterial, viral, protozoan, and parasitic diseases. All potential water sources generated in field conditions (including water from municipal host nation water systems) should be considered unsafe for consumption unless evaluated and approved by trained preventive medicine personnel.[27]

The majority of drinking water produced from field sources is generated by a portable reverse osmosis water purification unit (ROWPU) or procured from commercial sources. After initial purification and treatment to remove dissolved solids and contaminates, all drinking water must be disinfected. Chlorination is the preferred method for water disinfection in the field because it has a measurable residual, which both continues to kill organisms after initial treatment, and also serves as a sentinel for potential contamination when levels fall below acceptable thresholds. Chlorine requires a minimum of 30 minutes of contact time to disinfect water for drinking. Manufacturer information can provide specific dosing recommendations depending on the product used and the volume of water to be treated; however, concentration of dissolved solids, pH, and temperature can affect the volume of chlorine required to safely kill pathogens. The free available chlorine (FAC) indicates the amount of biologically active chlorine available to disinfect water intended for drinking. Table 40-2 outlines minimum FAC concentrations for various water systems and uses.

TABLE 40-2

MINIMUM FREE AVAILABLE CHLORINE (RESIDUAL CHLORINE) LEVELS FOR VARIOUS FIELD APPLICATIONS

Application

Minimum FAC (mg/L or ppm)

Corrective Action

ROWPU production

2

FAC < 2 mg/L: Do not issue water, rechlorinate to FAC of 2 mg/L, ensure FAC of 2 mg/L after 30 minutes prior to issue

Distribution/secondary storage

1

FAC 0.2–1 mg/L: rechlorinate, ensure FAC of 1 mg/L, okay to issue

FAC < 0.2 mg/L: do not issue water, rechlorinate to 1 mg/L, ensure FAC of 1 mg/L after 30 minutes prior to issue

Unit-level storage (eg, water buffaloes, 5-gallon containers)

1

FAC 0.2–1 mg/L: rechlorinate to 1 mg/L, okay to issue

FAC < 0.2 mg/L: do not issue water, rechlorinate to 1 mg/L, ensure FAC of 1 mg/L after 30 minutes prior to issue

Canteens, personal hydration systems

1

FAC < 0.2 mg/L: rechlorinate to 1 mg/L, ensure FAC of 1 mg/L after 30 minutes

Surface water (emergency only, no other treatment available)

5

N/A

Ground water approved by preventive medicine staff

2

N/A

Nonpotable water for hygiene/showers

1

FAC < 1.0: rechlorinate to 1 mg/L

FAC: free available chlorine; N/A: not applicable; ROWPU: reverse osmosis water purification unit

Data source: Departments of the Army, Navy, and Air Force. Sanitary Control and Surveillance of Field Water Supplies. Washington, DC: DA; 2010. TB Med 577.

In operational or deployed settings, water quality measurements including FAC, coliform testing, and a variety of other parameters should be regularly tested and recorded in accordance with tri-service recommendations. Table 40-3 outlines minimum FAC and testing periodicity for a variety of water systems commonly used in field conditions. Any concerns regarding water quality should be immediately reported to engineering personnel for remediation.

Commercial bottled water is increasingly available in modern military operations. All bottled water products require testing and approval by trained US Army Veterinary Services (VS) personnel prior to use. VS maintains an up-to-date list of approved bottled water sources, published in the Worldwide Directory of Sanitarily Approved Food Establishments for Armed Forces procurement.[28] Preventive medicine personnel can extend expiration dates of bottled water in 30-day increments after testing to ensure continued potability.

FOOD STANDARDS

Foodborne illness imposes a substantial burden of morbidity, mortality, and time lost from work in both garrison and deployed settings. The most common factors contributing to foodborne illness include food from unsafe sources, poor personal hygiene, inadequate cooking, and inadequate holding temperatures.[29] Specific interventions and best practices addressing each of these factors can minimize the likelihood of foodborne illness.

Assuring a safe food supply begins with procuring food from safe sources. Installation commanders are ultimately responsible for ensuring food and beverages on installations are served only through establishments inspected and approved by the relevant service-specific regulatory authority. While Meals, Ready-to-Eat (MREs) are specifically engineered to provide safe nutrition in unforgiving environments, service members frequently consume high-risk food from unapproved sources when given the opportunity. Frequent counseling as well as increased availability of additional approved and inspected on-installation food sources (if tactically feasible) are potential countermeasures to discourage high-risk consumption from unapproved food sources.

TABLE 40-3

RECOMMENDED WATER QUALITY TESTING FREQUENCIES

Application

Residual Chlorine

Coliform

pH

Total Dissolved Solids

ROWPU

Every 30 minutes during production operations

Weekly

Weekly

Weekly

Distribution/storage

With every receipt and distribution

Monthly

Monthly

-

Unit-level storage (eg, water buffaloes, 5-gallon containers)

Twice daily

Weekly

Daily

-

Bottled/packaged field water

-

Monthly

-

-

Field showers

Time of delivery and twice daily

-

-

-

Food services

With each meal

-

-

-

ROWPU: reverse osmosis water purification unit; -: not applicable

Data source: Departments of the Army, Navy, and Air Force. Sanitary Control and Surveillance of Field Water Supplies. Washington, DC: DA; 2010. TB Med 577.

Inadequate hygiene, particularly hand hygiene, is frequently identified as a factor contributing to outbreaks of foodborne illness. Food handlers are required to receive specific training in hand hygiene techniques, as well as actions or events throughout the food preparation and serving process that require repeated washing. Hand hygiene is similarly important for food consumers. MMOs are strongly encouraged to ensure handwashing stations or hand sanitizer dispensers are available and promoted for use at installation dining and toileting facilities.

Food handlers must be free of communicable diseases and are required to report symptoms of potential illness (such as vomiting, diarrhea, nausea, jaundice, skin lesions, or sore throat with fever) to their supervisor. A low threshold for exclusion from work should be applied to food handlers to minimize the possibility of foodborne illness resulting from a communicable disease. Food handlers with diagnosed norovirus, hepatitis A, shigellosis, enterohemorrhagic or Shiga toxin-producing Escherichia coli, or Salmonella typhi must be excluded from work and reported to the service-specific regulatory authority. Similarly, food handlers with known or suspected contact with individuals diagnosed with these conditions should also be reported and evaluated by medical personnel.

Proper cooking temperatures destroy pathogenic organisms and minimize potential for foodborne illness. Raw animal foods must be cooked to a temperature and for a time period that comply with the Tri-Service Food Code[29] based on the type of food product as well as method of preparation. Temperatures must be verified with a thermometer; visual inspection is not an adequate means of determining compliance with minimum temperature recommendations.

To facilitate feeding large numbers of service members in a fixed amount of time, large dining facilities rely on stored food products prepared in bulk earlier in the day. Once cooked to a proper temperature, food must be stored hot or cold at an appropriate temperature to prohibit growth of pathogenic organisms. Maximum holding times vary by food product, holding temperature, and preparation style. Improper holding temperature or excessive holding time has been linked to countless foodborne illness outbreaks in cafeteria-style dining settings.

WASTE DISPOSAL

Military field operations generate large amounts of waste products. Waste products may contain infectious agents such as cholera or typhoid, attract vermin capable of spreading zoonotic disease, or serve as breeding grounds for many vectors of human disease. As tactical conditions permit, waste should be collected and disposed of in accordance with local, federal, or host nation law. Increasingly, modern military operations rely on contracted services for collection and disposal of waste; however, such services may not be available for geographically isolated forward operating positions. As a result, MMOs must be familiar with basic principles of human, solid, and liquid waste management in operational settings and ensure waste management is addressed in the planning stages of any operation.

Methods employed for the disposal of human waste are influenced by material availability, soil conditions, source and location of drinking water, and environmental regulations. Positioning of toilet facilities should reduce or minimize the transmission of disease by vermin, vectors, or direct human contact. In general, field toilet facilities should be located at least 100 feet from natural water sources, 100 yards from food service areas, and 50 feet from berthing.[30] All attempts should be made to create handwashing stations at the exit of any human waste facility; hand washing with soap and water is ideal, but hand sanitizer is an acceptable alternative. While contracted chemical toilets are generally preferred whenever possible, logistic and geographic realities of conflict sometimes necessitate field-expedient solutions to managing human waste.

Pit latrines are the simplest form of human waste disposal; however, their practicality is influenced by soil conditions and water table depth. Hard or rocky soil can make digging pit latrines difficult. A shallow water table can result in contamination of natural water sources and restrict the maximum depth to which a latrine can be dug. Pit latrines also require periodic treatment with appropriate insecticides to prevent vector breeding. Once the contents of the latrine reach 1 foot from ground level, pit latrines should be closed and filled in with earth.[30]

Burn-barrel latrines utilize 55-gallon drums cut in half to collect and burn human waste. Prior to use or re-use, a barrel is primed with approximately 3 inches of diesel fuel to ensure more efficient burning of solid waste; the fuel also serves as an insect repellant. Barrels must be burned when more than half full. A mixture of four parts diesel to one part gasoline should completely cover the barrel contents. Occasional stirring of the ignited contents is necessary (although less so with use of priming fuel). Minimizing the urine content of burn barrels greatly improves the efficiency of the burn and reduces fuel requirements.

Solid waste generated in operational environments is disposed of through burial, incineration, or commercial hauling. Burial is suitable only for short-term activities (1 week or less) involving small numbers of persons. While commercial hauling and disposal is greatly preferred, tactical or host nation limitations often necessitate incineration of waste on site. Open burn pits are convenient for use when establishing bases; however, they should be replaced with incinerators as soon as practical due to the inherent health risks associated with unimproved combustion of solid waste.[31]

Waste water generated from field or operational activities must be disposed of in accordance with applicable local, federal, and host nation laws. Use of municipal sanitary sewers is preferred, but sewers are often unavailable in austere settings. When necessary, soakage pits and evaporation beds may be used to dispose of waste water without attracting vermin or serving as breeding pools for vectors. Soakage pits are simply pits filled with a coarse medium such as crushed gravel. Pits may become clogged or saturated over time, requiring the construction of additional pits. Evaporation beds are contained fields of earth groomed into rows of depressions and ridges similar to agricultural beds. The field is flooded to the top of the ridges and waste water is allowed to penetrate the soil and evaporate. A series of evaporation beds are used on a rotating basis to allow approximately 3 days of evaporation prior to next use.

ENVIRONMENTAL HAZARDS

Environmental exposures present a variety of public health challenges, particularly in the field environment. Extremes of temperature, altitude, precipitation, and sun exposure are routinely experienced in operational settings. For deployed forces, the need to maintain a combat-ready posture further exacerbates environmental stressors common to austere environments. Chapter 22, Environmental Extremes: Heat and Cold, discusses environmental hazards specific to military operations, as well as potential countermeasures available to MMOs for ensuring the health of military forces.

UNIT-LEVEL MEDICAL SURVEILLANCE

Medical surveillance, the continuous and systematic collection of health-related data, performs several critical functions. Medical surveillance is descriptive; that is, it provides an objective description of a population’s health at a point in time and thus identifies the basic epidemiology of a particular health problem. Surveillance is also predictive; that is, it helps explain variation in population health based on historical patterns and can serve as an early warning system for impending population health emergencies. Surveillance is informative; that is, the information obtained allows MMOs to provide commanders with specific preventive recommendations based on demonstrable trends in disease. Finally, surveillance is evaluative; when implementing a disease control measure, an ongoing surveillance system affords the opportunity to critically evaluate the impact of an intervention, track progress, and identify population health priorities for policy makers.[32]

Figure 40-1. Sample disease and injury reporting worksheet.
Reproduced from: Office of the Chairman, Joint Chiefs of Staff. Procedures for Deployment Health Surveillance. Washington, DC: JCS; November 2, 2007: C-B-1. https://www.dcms.uscg.mil/Portals/10/CG-1/cg112/cg1121/docs/pdf/MCM-0028-07.pdf. Accessed June 8, 2018.

The simplest form of operational medical surveillance occurs at the individual provider level. All services require mandatory disease reporting for specific conditions via appropriate service-specific channels.33–35 Additionally, state-mandated reportable medical conditions must also be reported to local health departments in accordance with service-specific instruction.[36]

Historically, unit-level surveillance was most frequently accomplished in weekly reporting of disease and injury (D&I) information. Pen and paper D&I reporting has largely been replaced by automatic mining of electronic health records and laboratory data for conditions of significance in the majority of deployed and operational settings. In the most austere environments where electronic health records are unavailable, weekly pen and paper D&I reporting is still employed, using a reporting form such as that shown in Figure 40-1.

OUTBREAK INVESTIGATIONS

An outbreak is the occurrence of disease at a rate that exceeds expected baseline values. Every outbreak represents a systematic breakdown of public health infrastructure that warrants investigation. Outbreak investigations are performed to identify and treat those exposed, expose gaps in public health measures, and identify interventions to interrupt transmission and prevent further cases. Outbreak investigations are often complex and multidisciplinary, and can involve multiple agencies or organizations. In deployed or operational settings, military providers may be tasked to perform outbreak investigations with little specialized training or logistic assistance.

While no two outbreaks are the same, employing a systematic method for investigation substantially increases the likelihood of successfully interrupting transmission of disease. In general, outbreak investigations consist of the following components:

- Identify team and resources.

- Establish existence of an outbreak.

- Construct a case definition.

- Systematically find cases and develop a line listing.

- Perform descriptive epidemiology.

- Evaluate transmission hypothesis.

- Implement control measures.

- Communicate findings.

- Maintain surveillance.

Each component is discussed below. While these components are often presented in a stepwise manner, investigators are not required to rigidly perform an outbreak investigation one step at a time. It is often necessary (and advisable) to perform several tasks simultaneously to ensure expeditious interruption of disease as well as alleviate public fears surrounding an outbreak.

Identify Team and Resources

At first notification of a potential outbreak, an investigator must assess the personnel and material resources at their disposal to provide an adequate response. Personnel with specific outbreak investigation and public health training or prior experience are particularly valuable resources to consider when assembling a team. Local and regional civilian health departments are a wealth of knowledge and experience when conducting outbreak investigations. When the magnitude of the outbreak clearly indicates locally available resources are not sufficient, service-specific public health assistance may be available from the regional Navy environmental preventive medicine unit, the US Army Public Health Command, or the US Air Force School of Aerospace Medicine.

Establish the Existence of an Outbreak

Routine disease surveillance provides the historical context for helping public health officials determine the rates of disease that constitute expected baseline values. Geography, seasonal weather variation, animal migratory patterns, and movement of human populations are some factors that influence expected values of disease incidence. Certain diseases are considered outbreaks based on a single occurrence (inhalational anthrax, human rabies, smallpox), while others may require dozens or hundreds of cases prior to exceeding expected background levels (gastroenteritis, upper respiratory infections).

On occasion investigators may be notified of a spurious increase in the number of reported cases of disease that initially appears to represent an outbreak. “Pseudo outbreaks” typically occur as the result of changing surveillance methodology (such as a new, more sensitive case definition) or other factors unrelated to the disease in question.

Construct a Case Definition

Crafting a meaningful case definition is a critical step in conducting an outbreak investigation. Case definitions that are too restrictive will lack sensitivity in identifying persons with the condition of interest. Conversely, case definitions that are too broadly defined will result in inefficient use of resources as investigators identify and interview more individuals than necessary. A good case definition contains aspects of exposure, symptoms, and temporality to focus investigation efforts on those individuals most likely to represent people truly affected by the disease or illness in question. As the investigation progresses and patterns of exposures and symptoms become more apparent, the team may choose to modify the case definition to be more or less inclusive.

Systematically Find Cases and Develop a Line Listing

Once a case definition is developed, the team is tasked with systematically collecting information from potentially affected persons. Investigators often develop a standardized questionnaire or data collection sheet to survey potential cases for information regarding exposures, symptoms, and temporality pertinent to the case definition. Using standardized questionnaires helps minimize information bias and allows for the same information to be collected from all potential contacts. Individual contact questionnaire or interview data are most often transcribed into a line listing, which is a comprehensive database detailing patient identification, demographic, exposure, symptom, laboratory, and outcome data. In cases of known diseases with historically well-described risk factors and symptoms, the line listing may be truncated to include only the most relevant data needed to perform an investigation. For investigations of an unidentified agent, exposure, or cluster of seemingly unrelated symptoms, line listings will often contain far greater amounts of information.

Figure 40-2. Point source outbreak epidemiologic curve with hypothetical data. Point source outbreaks are characterized by a single common exposure and rapid resolution. Incubation period can be determined by calculating the time elapsed from exposure to the majority of cases developing symptoms. Outliers can be helpful in further establishing causative etiology, particularly in outbreaks of foodborne illness when consumption of leftovers results in individual cases occurring outside the bulk of those affected.

Perform Descriptive Epidemiology

Information contained in a line listing allows investigators to explore how particular demographics and exposures influence disease status. In investigations in which the etiology of illness is unknown, describing basic demographic information about the population or cohort demonstrating an increased risk of becoming ill is a crucial first step in identifying the causative agent of disease. Line listings also afford investigators the opportunity to calculate attack rates (the percentage of individuals who become ill after a discrete exposure). Calculating the attack rate ratio (the attack rate in exposed persons divided by the attack rate in unexposed persons) for each exposure allows investigators to identify exposures most strongly associated with disease. Focusing further laboratory and epidemiologic investigation on exposures with the largest attack rate ratios most efficiently utilizes the limited time and resources available to investigators.

Evaluate Transmission Hypothesis

Line listings are also valuable in compiling data on the symptoms of those affected by the disease in question. In creating a basic epidemiologic (or “epi”) curve (a bar graph depicting the number of cases by the date or time of symptom onset), investigators can develop a hypothesis about how the illness is transmitted. Point source outbreaks result when a single common exposure is responsible for transmitting illness during a restricted period of time, such as food poisoning resulting from Salmonella contained in a dish at potluck luncheon (Figure 40-2). Continuous common source transmission occurs when persons are exposed to the same source over a prolonged period of time. Illness resulting from environmental exposures or from widely distributed manufactured food products are examples of continuous common source outbreaks (Figure 40-3). Propagated spread outbreaks occur as a result of human-to-human transmission and are typically characterized by clusters of patients separated by the incubation time required for a particular illness. Investigations involving vaccine-preventable illnesses are classic examples of propagated spread outbreaks (Figure 40-4).

Figure 40-3. Continuous common source outbreak epidemiologic curve with hypothetical data. Continuous common source outbreaks are characterized by a persistent exposure. Rapid accumulation of cases after initial exposure and large numbers of new cases throughout the outbreak suggest a common community source of exposure (eg, contaminated water or manufactured food product). If an intervention to interrupt transmission of disease is successful, abrupt cessation can be expected approximately one incubation period after last exposure.

Figure 40-4. Propagated spread epidemiologic curve with hypothetical data. Propagated spread outbreaks are characterized by clusters of new cases temporally segregated by approximately one incubation period. This pattern of disease outbreak strongly suggests human-to-human transmission of disease.

Epi curves contain a wealth of additional information. By examining the lag between time of exposure and onset of symptoms, or by investigating the lapse of time between clusters of cases, investigators can estimate incubation periods and therefore narrow the list of potential causative agents. Epi curves graphically display the current trajectory or magnitude of the outbreak. Epi curves also allow for easy identification of outliers—potential sentinel cases standing apart from the remaining population.

Implement Control Measures

Investigators need not wait for definitive identification of a causative agent prior to implementing meaningful control measures. Suspected outbreaks of gastrointestinal or respiratory illness warrant immediate public health messaging to increase hand hygiene and social distancing of ill or coughing persons, respectively. Similarly, if a toxic or harmful exposure is suspected to be the root cause of an outbreak, efforts to mitigate exposure should be implemented as soon as practical instead of waiting for final confirmation of the exact substance responsible.

Implementation of control measures goes beyond simple removal of the offending agent. Because outbreaks represent a systematic breakdown of public health infrastructure, it is necessary to reevaluate existing systems or develop new systematic processes to assure public health. The epi curve can be a helpful tool for visualizing the potential impact of an intervention because the trajectory of cases is anticipated to decline after implementation of a meaningful control measure.

Communicate Findings

Good risk communication is paramount to the successful interruption of disease transmission and should occur at all stages of the outbreak investigation. It is not enough for investigators to swiftly interrupt transmission of disease, they must also strive to keep faith with relevant stakeholders in providing timely and factual information to maintain public trust. Providing early and sustained risk communication alleviates fears and supports partnership between investigators, authorities, and the general public. Such partnerships often result in greater cooperation and more speedy resolution of outbreaks. The value of regularly communicating findings throughout all stages of the contact investigation cannot be over-emphasized. Specific principles and strategies for risk communication are provided later in this chapter.

Maintain Surveillance

After successfully implementing control measures, monitoring for additional cases remains necessary. Outlier populations may continue to experience exposure to the offending agent and serve as additional opportunities to eliminate transmission. Surveillance remains a critical component of outbreak investigations long after the final cases are identified. By its most basic definition, an outbreak is the occurrence of disease at a rate that exceeds expected baseline values. Continued disease surveillance provides baseline values to determine if future occurrences constitute an outbreak.

EMERGENCY PREPAREDNESS

Though emergency preparedness is ultimately the responsibility of the commander, all personnel must take an active ownership role in ensuring their unit remains prepared for an emergency. Medical departments play a critical role in developing, testing, and executing a commander’s emergency preparedness plan. Comprehensive emergency planning is not restricted to active duty military forces; catastrophic events also affect service member families, host nation personnel, and displaced populations. Properly conducted emergency management includes identification of all potentially affected individuals in the area of operations, as well as coordination of planning and response efforts with local, county, state, or national stakeholder organizations. The complexity of such relationships dictates the frequency and scale of planning exercises that should be performed prior to a disaster. The importance of stakeholder rehearsal exercises for preserving life in disasters cannot be overstated. No substitute exists for drilling side-by-side with stakeholder partners to identify strengths and vulnerabilities of a potential unified disaster response.

Preparation and Planning: “All Hazards” Approach

Successful emergency plans are scalable for any size of event and flexible enough to effectively address any variety of disaster. “All-hazards” disaster planning is the most widely used approach because it is sufficiently scalable and flexible. The all-hazards approach identifies four phases of disaster management operations to simplify the planning process: mitigation, preparedness, response, and recovery.[37]

Mitigation actions create lasting risk reductions from hazardous events by reducing known or potential vulnerabilities. Examples of mitigation measures range from maintaining a medically ready and vaccinated force to prevent the spread of communicable disease, to ensuring a medical treatment facility’s generators are housed in a location unlikely to be subjected to water damage from a flood or debris damage from an earthquake. Mitigation measures by their very nature build resilience into populations, communities, and the built environment to lessen potential damage from catastrophic events.

Preparedness involves establishing authorities and responsibilities for emergency actions and adequately maintaining the necessary assets to support such actions. During the preparedness phase of disaster response, support staff roles are clearly defined and assigned, physical supplies are procured and maintained, and contingency operations for day-to-day activities are developed and rehearsed. Critical but often neglected tasks during the preparedness phase include cross-training responders to perform the tasks of missing or injured team members and developing alternative physical work spaces in the event a primary workspace is compromised.

The medical response to a disaster is frequently the most time-sensitive component of an emergency preparedness plan. Communication is critically important during the response phase of disaster management; MMOs should have direct communication to the disaster command and control team or the emergency operations center (EOC). Through the EOC, medical departments receive casualty information, request transportation and supplies, and provide command with information critical for tasking precious resources.

The recovery phase transitions a community back to normal daily functioning. Documentation and surveillance of unique exposures from the disaster, long-term care for the injured, and assessment of successful and unsuccessful actions performed during the disaster occur in the recovery phase. It is absolutely necessary to use the recovery phase to reflect on the actions and results of the emergency response. Recovery should be used to recognize and incorporate future mitigation measures and response improvements based upon the successes and challenges of the disaster response.

Military-Specific Emergency Management Resources

Commanders and MMOs have a variety of assets available to assist with planning, executing, and managing disaster response and public health emergencies. Within the continental United States, every military installation commander has designated a public health emergency officer (PHEO) by name. PHEOs have specialized training and expertise to provide commanders and MMOs with guidance and recommendations on preparing for, declaring, responding to, mitigating, and recovering from public health emergencies. Installations outside the continental US have a PHEO at each geographic combatant command headquarters.

The military treatment facility emergency manager (MEM) is a uniformed or civilian employee with specialized training and expertise essential to medical emergency management. MEMs are responsible for executing all-hazards emergency management activities on behalf of the commander, serving as the facility’s lead for military-civilian emergency management coordination as well as the primary point of contact to the installation emergency manager.[38] The MEM is the primary advocate for ensuring appropriate resource needs are identified to execute the mission of the medical department in an emergency.

VS personnel are a vital and sometimes overlooked asset in public health emergency planning, training, and response. VS provides subject matter expertise for DoD installations and military commands for food safety and security, certain associated laboratory diagnostics, biosecurity, wildlife management, and vector control. Additionally, VS provides field operations support services including prevention and eradication of zoonotic disease, identification of potentially affected animals, animal quarantine implementation, euthanasia, carcass disposal, cleaning and disinfection, and strategic vaccinations and treatments for animals.[38]

Training and Exercise Participation

Training is essential for emergency response personnel to become familiar with their responsibilities, acquire the skills necessary to perform assigned tasks, and identify potential vulnerabilities of a response plan. The MEM, PHEO, and regional health departments are often repositories of excellent planning resources for MMOs tasked with developing a departmental or unit emergency response plan. Regional health departments routinely offer workshops and training courses to promote and develop coordinated regional emergency response planning. At the national level, the Federal Emergency Management Agency supports state training efforts through its Emergency Management Institute, offers a variety of free online courses, and publicly releases major publications relating to planning for specific functions and hazards.

RISK COMMUNICATION

Communicating complex health information to lay persons is an essential skill for all MMOs. While most MMOs are comfortable providing discrete clinical counseling to individual patients, effective risk communication can be challenging due to multiple stakeholder involvement, presence of media, and the high-visibility nature of events requiring intervention. In many operational settings, junior MMOs are routinely relied upon as the subject matter expert for all issues pertaining to unit health. The ability to effectively communicate complex health information factually, reliably, and empathetically has a significant impact on mission success.

Routine health promotion is an ideal opportunity for MMOs to develop risk communication skills. Whether combating tobacco use, low vaccination uptake, or high sexually transmitted infection incidence, the cognitive process employed to reach a vulnerable audience remains the same. To change an unhealthy behavior, an audience must: (1) receive information, (2) understand the information, (3) understand the message applies to them, (4) understand they are at risk if they do not take protective action, (5) decide they need to act on information, (6) understand what actions need to be taken, and (7) be able to take action.[39] Effective risk communication increases the chance an audience will listen and adhere to sound recommendations (Exhibit 40-2).

Principles of Health Risk Communication

The occurrence of an outbreak, disaster, or other event with the capacity to affect significant numbers of people creates an urgent demand for information among the population affected. Effective risk communication builds upon the health belief model, a framework for explaining and predicting health behaviors by directly addressing an audience’s perception of susceptibility, severity, benefits of taking action, barriers to taking action, cues to action, and self-efficacy.[40] Risk messaging should be simple, credible, and consistent. Messages should be repeated often through multiple communication and media avenues and conveyed by a variety of credible sources (subject matter experts, commanders, elected officials, community leaders). The six key principles of risk communication provide a systematic approach to conveying factual information and increasing the likelihood of positively impacting the health of the public.[41]

Be First

Good risk communication occurs early and often. Technology has vastly expanded the availability and speed at which audiences can obtain information. MMOs should be prepared to communicate risk information quickly and often, or they can expect their target audience to receive information elsewhere. Identification and inclusion of all stakeholders when communicating is essential; groups left out of initial risk messaging may feel forgotten or purposefully ignored, resulting in a substantially greater amount of future efforts required in order to regain their trust.

Be Right

The content of a risk communication message must be factual and verifiable. Good risk communication openly acknowledges when data are uncertain or unknown. Speculation is strongly discouraged; messages instead should clearly state what is known and what steps are being taken to investigate current gaps in knowledge.

Be Credible

Honesty and integrity serve as the foundation on which a trusting relationship is built. Audiences accept limitations of knowledge but are wholly unforgiving of deception. Experienced risk communicators defer to subject matter experts to answer questions beyond their area of expertise, and in doing so, bolster their credibility as an honest communicator.

EXHIBIT 40-2

RISK COMMUNICATION EXAMPLES

Even brief risk communication statements conveying factual information have the potential to convey unintended content. Consider the following responses to a hypothetical scenario in which two sailors have been hospitalized and diagnosed with Middle East respiratory syndrome coronavirus (MERS-CoV) while on overnight liberty in a foreign port.

Example A. “Regretfully, arrival of MERS-CoV in your town was probably not preventable. We are evacuating our sailors from your hospital to prevent further exposures. We have cooperated with local health officials and provided them our sailors’ itineraries so exposed local nationals can be identified.”

Example B. “We are very sorry the community has been exposed to this virus; had there been any indication our sailors were sick we would not have granted liberty. We are working closely with local public health officials to identify those in the community who were exposed and limit further spread of this virus in the community.”

Example A somewhat dismisses the importance of the event, conveys a sense the military will leave as quickly as possible, and strikes a somewhat defensive tone. While the factual content conveyed is the same, the message conveyed in example B expresses empathy, stresses the value of working together as partners, and reinforces the idea of community.

Express Empathy

A crisis generates physical as well as psychological harm. Openly acknowledging the suffering of those impacted and those who remain in potential danger builds trust and rapport. Expressing empathy engages an audience so they are more receptive to hear a message and provides an opportunity to communicate those common threads of humanity that bind communities together.

Promote Action

Effective risk communication empowers audiences with actionable knowledge. Providing easily implemented recommendations gives the public something to do, calms anxiety, and restores a sense of personal control. A message as simple as, “Avoid handshakes and use hand sanitizer frequently,” contains evidence-based, factual information that allows the public to be part of the solution.

Show Respect

Individuals within a community will demonstrate substantial variability in how they perceive the same risk. Some individuals will be deeply affected by a crisis and feel vulnerable and wronged. Showing respect through communicating in a way that acknowledges perceptions of vulnerability builds trust and promotes cooperation.

Perception of Risk

Perception of risk is highly subjective and intensely personal; however, certain characteristics of risk substantially influence how a particular threat is perceived by the public at large. Recognizing historical patterns in how individuals and communities assess risk can help planners anticipate the response expected from the public and aid in shaping a risk communication message.[41]

Familiarity

Populations exposed to a recurrent risk often become desensitized despite the continued threat posed from exposure. “Routine” risks are far more readily accepted than the exotic. While seasonal influenza is widely circulated among the public and is responsible for thousands of deaths in the United States on an annual basis, many choose not to be immunized. In contrast, a single case of an exotic virus in a healthcare worker confined to isolation has the ability to evoke an incredible amount of public concern and demand for government intervention.

Natural Versus Manmade

Populations are generally far more tolerant of natural disasters than those resulting from human activities, even though the former are no less traumatic. Communities often accept the risk of living and building in disaster-prone geographic areas; however, mishaps resulting from an industrial process or failed product of engineering are widely viewed as entirely preventable.

Distribution

People generally are more accepting of a risk that is equally distributed among the population at large versus exposures disproportionately concentrated to a defined group or population. Concentrated risks can evoke feelings of inequality and injustice, particularly when such exposures result entirely from an anthropogenic process or involve already disadvantaged or vulnerable communities.

Reputation

Prior performance is the strongest predictor of future performance. Institutions that have built social capital with a populace have reputations affording substantially greater leeway in responding to a crisis in comparison to untrusted or frankly unpopular institutions. Disreputable institutions suffer an additional burden of past transgressions (perceived or genuine) when responding to a crisis.

Adults Versus Children

Communities worldwide are rightly protective of their children. Exposures or illnesses disproportionately concentrated in pediatric populations can evoke a particularly volatile reaction, necessitating a robust and empathetic response to preserve public trust.

Avoiding Pitfalls

Risk communication requires practice. Mistakes are often public, and recovery is difficult. The single greatest mistake an MMO can make in performing risk communication is attempting to accomplish the task alone. Vetting risk communication messages through multiple stakeholders creates a much stronger product, protects against misinterpretation or misrepresentation of information, contributes to unity of effort in ensuring the right message is conveyed, and minimizes opportunities for public disagreement among leadership and subject matter experts. At an absolute minimum, DoD regulations mandate public statements to be cleared for release by the command public affairs officer (PAO). PAOs receive specialized training on communicating with the media and the public. They have a wealth of practical knowledge to assist in crafting and delivering a message that is effective and in accordance with the values represented by the armed forces.

The importance of selecting an appropriate spokesperson to deliver a risk communication message is equally important as the message itself. An expertly crafted message is irrecoverably compromised when delivered by a spokesperson of dubious credentials or questionable character, or who lacks empathy or expresses inappropriate humor. The selection of stakeholder and subject matter expert partners also sways public opinion; many communities will form an initial assessment of the competence of a crisis response based on who they see sitting next to the risk communication spokesperson before a single word of a message is delivered.[41]

While the psychological damage of an event or exposure may not manifest as readily as physical destruction, emotional trauma significantly influences an audience’s receptiveness to information, and outrage should not be dismissed. For this reason specifically, humor has no place in risk communication because its use is nearly always interpreted as callousness and disrespect.[41] Lastly, overtly expressing desired outcomes is acceptable; however, promises should be confined to areas within absolute control.[39] A promise to “ensure no further spread of the disease” is likely impossible; instead, assurances such as “the team will work nonstop to slow further spread of this disease” are reasonably accomplishable.

SUMMARY

Countless examples are found throughout history when communicable disease profoundly influenced the effectiveness of military forces. Maintaining the health and readiness of service members by preventing illnesses common in the deployed environment is critical for preserving force strength and accomplishing the mission. Medical staff must be able to recognize public health threats and be prepared to implement meaningful control measures. Additionally, medical staff must be prepared to respond to public health emergencies by effectively communicating disease risk and mitigation strategies to all stakeholders, from the command staff to individual service members.

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Epilogue

This volume’s three senior editors want to leave you with a few last words intended to distill the accumulated wisdom of all its editors and authors, who together represent over 300 years of practicing and teaching some aspect of military medicine. But it may be the ramblings of fossils; you will need to decide after you have served, practiced, and led for a few years.

Be a professional at military medicine and public health.

Being professional means many things, but it always includes being current in your practice, in terms of both technical knowledge (and its contextual application) and social responsibilities. In becoming a health professional, you have committed to being a lifelong learner, and you are obligated by the licensing authority to maintain some form of continuing education and recertification. Professions are creatures of the society that formed and authorized them, and societies are as dynamic as the professional knowledge base. You need to work at keeping up with your social responsibilities for your entire practice life, just as you keep up with your standards of practice.

For the military medical officer, this really is harder than it is for almost everyone else in the healing professions, because you have two quite different professions in which to maintain good standing. You have quite likely focused on medicine to this point in your career and have learned an enormous amount of required professional material. You have been examined, possibly to exhaustion, on your mastery of this material, and you are now licensed to practice. You may add other credentials along the way, but society and the profession to which you belong have formally declared you a member and capable of doing the job of caring for your patients and communities. With the exception of changes in technology and scientific insights, this job will stay much the same for the next 40 years.

But you are also a military officer, and your orientation for this profession is much more limited. This text, and perhaps your mentors, have cautioned you about the dangers of dual agency—having two duties that may be in tension or even in conflict. The most common tension is between duty to the patient and duty to the command. However, dual agency is not a result of your two professions; rather, it is a challenge for all professionals. Every profession has duties to those it serves and the society that charters it; it is inherent in being a professional (eg, the lawyer whose client confesses to planning a new crime, the priest who hears the confession of an ordained pedophile, the teacher confronted with possible abuse or neglect). As described in relevant sections of this textbook, the real challenge of the military medical officer is dual responsibility; the medical and the military are not so much in conflict as additive.

Unlike those in medicine, law, and divinity, military officers do not receive a complete dose of professional education at the beginning of their career; military and other uniformed officers receive only enough education to prepare for and successfully perform their duties in the next couple of jobs. Formal professional uniformed education is incremental and measured in its exposure to the maturing soldier, sailor, airman, marine, coast-guardsman, and Public Health Service officer. The courses you have had to date are likely called “basic” or “orientation” or a similar title indicating there is more to come. You will encounter intermediate-level education, often called staff college, and then more strategically oriented schools, frequently named senior service colleges or war colleges; such schools provide education in facets of officership not usually needed by the junior officer but that are essential to effective performance in higher-level responsibilities. As a medical officer, you might serve on a squadron or battalion staff before staff college, but it is still helpful and you will find it particularly so in future staff roles. At some point, probably when you least expect it, you will be tasked to serve as a nonjudicial punishment (Uniform Code of Military Justice, article 15.6, or JAGMAN) investigator. Avoid struggling to learn about this role when someone’s career hangs in the balance. Instead, find a mentor, make a plan, take your military courses, in residence when possible or by other means if not, before you need them in order to do your job well.

The second aspect of dual responsibility is that you are expected to respond when called. While society expects you to do something in any emergency, the reality is that, in civil life, prehospital responders are probably better able to manage life’s health emergencies than you are. As a uniformed physician, you will more likely be expected to have command of the knowledge and skills to lead in an emergency. This text has introduced you to military medical resources. Some, like Joint Publication 1, are much more military in nature; others, like Tactical Combat Casualty Care standards, are more medical. Both groups will have successor publications with the same identification but more recent issue dates. These publications are professional tools to help you maintain currency so you can keep up to date in military and uniformed medical practice regardless of your medical specialty.

The Military Health System is changing.

The context in which military medicine is practiced is changing, almost daily. The Military Health System is part of American healthcare, which is struggling with changing expectations, dynamic technology, affordability and access, and aging patients. These system disruptors have created demands for improving population (and individual) health; providing better (more efficient, effective, and emotionally satisfying) clinical encounters; and reducing the costs of providing effective care to enhance accessibility. There are significant professional challenges to leading our society toward an improved healthcare system.

Since many, if not most, of the determinants of health, affordability, and the management of societal financial risks and behaviors that enhance or detract from health are not wholly resident in the medical profession, improving the nation’s health and its healthcare system will require a multidisciplinary effort on the part of politicians, the business sector, faith and civic communities, and others. But the medical profession must be prominent in its involvement; healthcare providers have the knowledge and must find a way to assert their leadership. As a medical professional, you will work in this arena, at least to the degree you are counted as being represented by your professional organizations. How do you know a new test, technology, or drug is better for the patient than what it is proposed to replace? Do you honestly evaluate the data; do you accept, based on careful evaluation of past success and present activities, the opinion of others; or do you just go with the flow of the last thing you heard that did not seem outrageous?

Professionals have a fiduciary obligation to those they serve. Because this obligation or trust is both individual and corporate, you must engage with your professional organizations and practice settings. Since these are part of the Military Health System, you must engage there as well: what drugs should be in the formulary, what instruments sets should be in the deployed packs, how should tactical home and field care be organized, what interventions should be required, what can you do to combat stigma in the patient population? These and many other questions must be addressed. However, if you examine the goals of the Military Health System, you will find a variable that civilian health service administration does not share: the impact on the military force’s readiness to fight and win the nation’s wars, as well as a broader professional readiness to maintain social order, contribute meaningfully to national well-being and security, and remain economically viable and socially sustainable. Costs, encounters, technology, and population health questions must all be examined in the light of operational readiness. Again, being a professional military medical officer is more demanding than being a general health professional, but if you reflect on the people you serve and the mission you share, the work is well worth it. Remember the people and the mission as the system struggles with costs and communication; do what you can to reduce costs and improve communication. At the end of the day, both issues are best managed by ensuring the highest quality care that focuses on the needs of all your patients, individuals and units.

The Military Health System is part policy and part preparedness. Sometimes the leadership will focus on one or the other, and may need to be reminded of the mission’s complexity. Those who work with and for you will at times forget the twin challenge of peace and wartime practice that faces the system. We live in a society where medical care for workers and their dependents is usually a benefit of employment. Government policy has seen fit to provide this benefit in the all-volunteer military through a combination of access to uniformed healthcare and paying for civilian healthcare. These choices have associated access and system costs. They may also have patient satisfaction components, and some are beyond your immediate control, but none are beyond your professional understanding.

Part of your role as a uniformed professional is to help those who do not have insider knowledge understand the underlying strategic framework for the provision of peacetime and deployed healthcare, and the operational challenges of balancing competing demands. Among these challenges is the recognition of actual preparedness issues implicit in providing care. Some of these issues are simple (eg, a civilian does not know how to certify a service member or dependent for living outside the United States). Others are more complex. For example, providers in military treatment facilities must maintain familiarity with the tools available in deployed environments. Remember that your patients—most uniformed like you—have been in atypical locations doing atypical things, and optimal management of their health needs requires that you be more contextually literate and more culturally aware than providers at the civilian clinic down the street. Helping patients who have been deployed and separated from family and community successfully reintegrate with family, attend to late-emerging physical and emotional consequences, or reintegrate into the unit may present issues that are broader than ICD and CPT codes in the chart. The twin reasons of policy and preparedness require you to be a uniformed medical officer even in garrison.

The world can be a dangerous place.

The final component of the military medical officer’s dual responsibility is best summarized as personal readiness. Being ready is more than having your shots and gear; it is more than being up to date on your professional competencies. Being ready requires awareness and thought about your probable and possible missions. A common exercise in middle school social studies provides an outline of a continent, and students are asked to draw in the countries so that the right countries touch each other. This exercise is about awareness rather than artistic ability. The map you drew 15 or 20 years ago is no longer accurate—can you do it today? And what of the non-nation-state actors that threaten the nation’s security, such as transnational criminal and terrorist enterprises? What are the big issues facing each combatant command, and what are the principal policies of the US government in addressing various security issues around the globe? As an informed citizen you try to keep up, at least every couple of years to elect our leaders, but as a military officer you need to keep up in real time. Do you have a reliable source of general information and a plan to get smart on specifics “just in time”? You and your teammates in military and uniformed medicine stand a better than average chance of serving as a “strategic corporal,” being in a situation where your medical “tactical” actions have strategic policy and communication implications.

But going to war, the traditional duty of the military medical officer, will not be your only, or necessarily your most likely, duty. Since the end of the Cold War, the Department of Defense has been employed in a variety of other tasks, usually as a support activity under the lead of the State Department or other agencies. These activities go by many labels, from operations other than war (OOTWs) to stability and support operations (SASOs). The very names suggest that those engaged in these important roles are at the edge of their competencies and comfort, working on something other than what they were organized and trained to do. But over the last decade this has changed; the 2010 National Defense Strategy placed support of State Department activities as a role of the military equal to the defense of the nation. Called nation-building, stability operations, counter-insurgency operations, and a variety of other terms, these activities use the diplomatic virtues of health and other infrastructure benefits to win friends and influence people.

Are you prepared to think about medicine and health in other than a US cultural context? Our healthcare depends on significant capitalization of infrastructure. How will you adapt to an environment where electricity, clean available water, sewers, and other utilities are not always available? How do you manage expectations while building infrastructure? The government and the Internet have courses of instruction about other cultures and their economic and cultural expectations and resources, and as a military medical officer, readiness requires you to maintain a broad awareness of world affairs.

Are you ready to go where the US military and government send you, and to do the job according to the strategic and operational goals of the nation? In the classic 18th century phrase that formed the basis of our military traditions, you have “taken the King’s shilling” and so are honor-bound to do your duty. Part of that duty is to actually be ready to do it. It is our hope that Fundamentals of Military Medicine is a useful tool to start you on the path of your dual responsibilities as a medical and military or uniformed professional. We also hope it and successor editions will remain a useful tool as you advance in your career because the fundamentals will remain important to your credibility and success. We commend you for your sense of national and community duty and are grateful that those with whom we trained, worked, and deployed, and from whom we learned, have been followed by successive generations of accomplished uniformed officers of your caliber. We wish you the best of luck and success in one of the most challenging and rewarding roles in all the world as you spend your life learning to care for those in harm’s way.

ABBREVIATIONS AND ACRONYMS

A

AAR: after action review

ABCA: American, British, Canadian, and Australian armies

ACA: Affordable Care Act

AE: aeromedical evacuation

AFI: Air Force instruction

AFMS: Air Force Medical Service

AFRICOM: Africa Command

AHLTA: Armed Forces Health Longitudinal Technology Application

AMEDD: Army Medical Department

AO: area of operations

AR: Army regulation

ASD(HA): Assistant Secretary of Defense for Health Affairs

ASIMS: Aeromedical Services Information Management System

ATO: air tasking order

B

BUMED: US Navy Bureau of Medicine and Surgery

C

CBRNE: chemical, biological, radiological, nuclear, or explosive

CENTCOM: Central Command

CFR: Code of Federal Regulations

CHAMPUS: Civilian Health and Medical Program of the Uniformed Services

CJCS: chairman of the Joint Chiefs of Staff

CJIM: combined, joint, interagency, or multinational

COCOM: combatant command

CONUS: continental United States

CRI: CHAMPUS Reform Initiative

CSM: command sergeant major

D

DHA: Defense Health Agency

DHP: Defense Health Program

DMO: dive medical officer

DNBI: disease and nonbattle injury

DoD: Department of Defense

DOTMLPF: doctrine, organization, training, materiel, leadership, personnel, and facilities

DPG: secretary of defense’s planning guidance

E

EHR: electronic health record

EQ: emotional intelligence

EUCOM: European Command

EXSUM: executive summary

F

FHP: force health protection

FRAGO: fragmentary order

FS: flight surgeon

FTCA: Federal Tort Claims Act

G

GC: Geneva Convention

GPS: global positioning system

H

HIPAA: Health Insurance Portability and Accountability Act

HIV: human immunodeficiency virus

HIS: health information system

HMO: health maintenance organization

HPO: human performance optimization

HSS: health service support

I

ICC: International Criminal Court

IDES: Integrated Disability Evaluation System

IDMT: independent duty medical technician

IED: improvised explosive device

IFAK: Individual First Aid Kit

IHL: international humanitarian law

IQ: intelligence quotient

ISAF: International Stabilisation Afghanistan Force

ISOPREP: isolated personnel report

J

JCS: Joint Chiefs of Staff

JER: Joint Ethics Regulation

JOA: joint operations area

JP: joint publication

JTF: joint task force

L

LIMDU: limited duty

LOAC: law of armed conflict

M

MASCAL: mass casualty

MCA: Military Claims Act

MEB: Medical Evaluation Board

MEDEVAC: medical evacuation

MEDLOG: medical logistics

MEDPROS: Medical Protection System

MERS-CoV: Middle East respiratory syndrome-coronavirus

MESL: Military Exposure Surveillance Library

METC: Medical Education and Training Campus

MHS: military health system

MIMU: multinational integrated medical unit

MMO: military medical officer

MMRB: MOS/Medical Retention Board

MOS: military occupational specialty

MRRS: Medical Readiness Reporting System

MTF: medical treatment facility

MVA: motor vehicle accident

N

NATO: North Atlantic Treaty Organization

NCMI: National Center for Medical Intelligence

NCO: noncommissioned officer

NDS: National Defense Strategy

NGO: nongovernmental organization

NIMH: National Institutes for Mental Health

NMS: National Military Strategy

NOD: night optic device

NORTHCOM: Northern Command

NSS: National Security Strategy

O

OCONUS: outside the continental United States

OEH: occupational/environmental health

OIC: officer in charge

O&M: operation and maintenance

OPLAN: operation plan

OPORD: operation order

P

PACE: primary, alternate, contingency, emergency

PACOM: Pacific Command

PDR: predeployment readiness

PDRL: permanent disabled retired list

PEB: Physical Evaluation Board

PHS: Public Health Service

PITO: personal, interpersonal, team, organizational

PME: professional military education

PO: petty officer

POIC: petty officer in charge

PPBE: planning, programing, budgeting, and execution

PPO: preferred provider organization

S

SCPO: senior chief petty officer

SERE: survival, evasion, resistance, and escape

SGM: sergeant major

SIOP: single integrated operational plan

SOCOM: US Special Operations Command

SOUTHCOM: Southern Command

SRP: Soldier Readiness Program

STI: sexually transmitted illness

STRATCOM: US Strategic Command

T

TCCC: Tactical Combat Casualty Care

TDRL: temporary disabled retired list

U

UCMJ: Uniform Code of Military Justice

UHF: ultra-high frequency

UK: United Kingdom

UMO: undersea medical officer

UN: United Nations

USD(P&R): Under Secretary of Defense for Personnel and Readiness

USSOCOM: US Special Operations Command

USTRANSCOM: US Transportation Command

USUHS: Uniformed Services University of the Health Sciences

V

VA: Department of Veterans Affairs

VHF: very high frequency

VUCA: volatile, uncertain, complex, and ambiguous

W

WAPS: Weighted Airman Promotion System

WARNO: warning order

INDEX

A

A-LOC. See Almost loss of consciousness

AARs. See After action reviews

ABCA Armies program, 194, 195, 197

ABCDE care, 482

Abdominal breathing, 579

Abdominal pain

emergency treatment, 462–463

Absolute pressure, 326

ACA. See Affordable Care Act

Academies, service, 4

Academy of Nutrition and Dietetics, 308

Acceleration forces, 334–335

Acceptable macronutrient distribution range, 301

Acclimation, 315

Acclimatization, 315, 340

Accreditation Council for Graduate Medical Education, 166

ACLS. See Advanced cardiac life support

Actigraphs, 386–387

Active listening, 169

Actiwatch Spectrum, 386

Acupuncture, 564

Acute care, 447

Acute decompression, 339

Acute mountain sickness, 328, 338–340

Acute pain service, 559–561

Acute radiation syndrome, 544, 545

Acute stress reactions, 576

Adequate intake, 301

Advanced cardiac life support, 155, 471–472

Advanced resistive exercise device, 353, 358

Advanced Trauma Life Support, 155

AE. See Aeromedical evacuation

Aeromedical evacuation

Afghanistan War, 610–611, 615

evolution of, 608–612

health services support, 211–213, 218

Iraq War, 609–610

Korean War, 608

Vietnam War, 608–609

Aeromedical Services Information Management System, 133, 438

Affordable Care Act, 53, 118

Afghanistan War

aeromedical evacuation, 610–611, 615

health services support, 212

MEDEVAC, 265

multinational medical collaboration, 196, 198, 200

Operational Detachment Alpha, 329

operational planning, 262–263

AFMLOC. See Air Force Medical Logistics Operations Center

AFMS. See Air Force Medical Service

After action reviews, 173

After-drop, 315

AGE. See Arterial gas embolism

Agent Orange Act, 234

AHLTA, 227

AICS. See Arm immersion cooling system

Air and Space Interoperability Council, 194

Air Force, US

culture of, 44–45

leadership communication requirements, 168

medical logistics flight, 252

operation planning, 259

patient movement flow, 220

physical readiness tests, 292

predeployment profiling basics, 435

values of, 184

Air Force Medical Logistics Operations Center, 252

Air Force Medical Operations Agency, 252

Air Force Medical Service, 116, 180

Air Force Working Capital Fund, 251

Air tasking order, 45

Airborne medicine, 161

Airline diving, 327

AJBPO. See Area joint blood program office

Aldrin, Buzz, Jr., 352

All-volunteer military force, 42

Allen, John, 43

Almost loss of consciousness, 335

Alternobaric extremes

altitude extremes, 329–330, 332–334, 338–340

applied physiology terminology, 326–327

aviation extremes, 330, 334–335, 340–341

definitions, 326–328

human performance optimization strategies, 338–343

injury terminology, 328

military applied physiology, 332–338

resources, 343

undersea operations, 330–332, 335–338, 341–343

Alternobaric vertigo, 328

Altitude diving, 326

Altitude environment

human performance optimization strategies, 338–340

military applied physiology, 332–334

military history and epidemiology, 329–330

Ambient pressure, 326

Ambulance exchange point, 216

Ambulances

Mine-resistant, Ambush-Protected ambulances, 212

shuttle system, 216–217

AMEDD. See Army Medical Department

American British and Canadian Australian Armies, 192, 195, 197

American College of Sports Medicine, 288

American College of Surgeons, 614

American Laws of War, 69

American Psychological Association, 366

Amphibious operations, 218

AMPLE survey, 467

AMS. See Acute mountain sickness

Analgesics, 565

Anthrax, 539–540

Anti-Doping Agency, 307

Antibiotics, 492–493

Anticholinergic poisoning, 470

Antidote Treatment Nerve Agent Auto-injector, 535

Antietam National Battlefield, 151

AOR. See Area of responsibility

Apache helicopters, 331, 334

APFT. See Army physical fitness test

Apollo 11, 352

Appellate reviews, 80

APS. See Acute pain service

Area joint blood program office, 253

Area of responsibility, 439–440

ARED. See Advanced resistive exercise device

Arm immersion cooling system, 320, 322

Armed conflict law. See Law of armed conflict

Armed Forces Blood Program Office, 253

Armed Forces Health Longitudinal Technology Application, 227

Armed Forces Health Surveillance Branch, 239

The Armed Forces Officer, 36, 38, 47

Armstrong’s line, 349–351

Army, US

culture of, 44

leadership communication requirements, 168

medical logistics companies, 252

operation planning, 259

patient movement flow, 219

physical readiness tests, 292

predeployment profiling basics, 435

training principles during the 1950s, 289

values of, 184

Army Medical Department, 9, 10, 16, 116

Army Medical Research and Materiel Command, 251, 252

Army Medical School, 17

Army of the Potomac, 13–14

Army physical fitness test, 397

Army Regulation 15-6, 76

Army Regulation 350-41, 288

Arnold, Hap, 45

ARS. See Acute radiation syndrome

Arterial gas embolism, 328, 339

“Article 15,” 77

Article 92, UCMJ, 72, 73

Article 32 investigations, 79

Artificial colloids, 489

Ascent rate, 326

ASD(HA). See Assistant Secretary of Defense for Health Affairs

Asia-Pacific Military Health Exchange, 195

ASIMA. See Aeromedical Services Information Management System

ASIMS. See Aeromedical Services Information Management System

Assistant Secretary of Defense for Health Affairs, 112

Astronauts. See also Space environment

human performance optimization, 273

ATLS principle, 481, 482

Atmospheres absolute, 326

ATNAA. See Antidote Treatment Nerve Agent Auto-injector

ATO. See Air tasking order

Atrial natriuretic peptide, 338

AUSCANNZUKUS, 194

Australia

multinational medical collaboration, 194

Automated Neuropsychological Assessment Metrics, 433

Aviation environment

fluid maintenance schedule for rotary-wing aviation crews in hot environments, 342

human performance optimization strategies, 340–341

military applied physiology, 334–335

military history and epidemiology, 330

AVPU scale, 467

AXP. See Ambulance exchange point

B

Bacterial agents, 539–541

BAGs. See Budget activity groups

Balkans operations

multinational medical collaboration, 195–196

Bancroft, George, 11

Barotrauma, 328, 336, 339

Barton, Clara, 12

BAS. See Battalion aid stations

Base Realignment and Closure Commission, 117

BASs. See Battalion aid stations

Battalion aid stations, 210

Beecher, Henry K., 557

Behavior health

effect of space environment, 355

high-energy trauma and, 450

Behavioral modification, 434

Bends, 328

Bernard, Claude, 330

Bert, Paul, 330

BICEPS principle, 578

Billig, Donal, 80

Biologic warfare agents

anthrax, 539–540

bacterial agents, 539–541

biological toxins, 543

botulinum, 543

plague, 540–541

ricin, 543

smallpox, 541–542

tularemia, 541

US biological warfare program, 538–539

viral agents, 541–543

viral hemorrhagic fever, 542–543

Biological toxins, 543

Bissonette, Mark, 47

Blackhawk helicopters, 265, 331, 334

Blair, Dennis, 42

Blast injuries

evaluation of, 548

management of, 548

mechanisms of, 547–548

Blister agents, 533–534

Blood management

artificial colloids, 489

crystalloids, 489–490

fresh whole blood, 488–489

medical logistics, 253

stored constituents of blood, 489

Blood Program Office, 253

Blood support detachment, 253

Blood transfusion, 488–489

BLUF concept, 170

BMD. See Bone mineral density

BMSO. See Brigade medical supply office

Bond, George F., 332

Bone mineral density

impact of space environment, 353

Bonica, John, 557

Boone, Joel, 18

“Bottom line up front” concept, 170

Bottom time, 326

Botulinum, 543

Boyle’s law, 326, 334, 336

Breast cancer screening, 434

Brigade medical supply office, 252–253

British Army Medical School, 14

Brocklesby, Richard, 132

Brodie, Bernard, 42

Brown, Jacob, 9, 185

Brown, Monica Lin, 190

Budget activity groups, 120

Budget Control Act of 2011, 121

Builder, Carl, 44

BUMED. See Bureau of Medicine and Surgery

Bureau of Medicine and Surgery, 11, 116

Burnside, Ambrose, 14

Byng, John, 4

BZ, 537

C

Cadet Prayer, 41

Caffeine dosing, 306–307

Calhoun, John C., 9

CANA. See Convulsant Antidote, Nerve Agent

Canada

multinational medical collaboration, 194

Captains Career Course, 19

“Captain’s mast,” 77

Cardiac arrest

emergency treatment, 471–473

Cardiogenic shock, 469

Cardiopulmonary resuscitation, 472, 483

Cardiorespiratory fitness, 286

Cardiovascular system

effects of space environment, 352–353

Care under fire, 482

Carlton, P.K., 146

Case fatality rate, 479–480

CASEVAC. See Casualty evacuation

Casualty collection points, 215, 217, 218, 520–523

Casualty evacuation

aeromedical evacuation evolution, 608–612

data collection, 616

definition, 604

dispatch and response, 614

evacuation platforms, 614–615

evolution of military doctrine, 605–608

in future conflicts, 612–617

health services support, 211–212, 215–217

medical direction and oversight, 613–614

model for future casualty care continuum, 617

operational environment, 612–613

provider staffing and capability, 615–616

quality improvement, 616–617

system design, 613

terminology, 604–605

Casualty Rate Estimation Tool, 264

CBRNE. See Chemical, biological, radiological, nuclear, or explosive weapons

CCATTs. See Critical care air transport teams

CCPs. See Casualty collection points

Centers for Disease Control and Prevention, 241–242, 434, 549, 588

Central Intelligence Agency, 242

Certification as a specialist in sports dietetics, 304

CEVIS, 357–358

CFR. See Case fatality rate

Chairman of the Joint Chiefs of Staff, 108, 114

CHAMP. See Consortium for Health and Military Performance

CHAMPUS, 117–118

CHAMPUS Reform Initiative, 118

Change of station moves, 418–419

Chaplains, 407

Character traits, 52, 55–56

Charles’s law, 326, 336

Chemical, biological, radiological, nuclear, or explosive weapons, 162. See also Biologic warfare agents; Chemical warfare agents; Explosive injuries; Radiological and nuclear exposures

Chemical warfare agents

categories of, 532–533

cyanide, 536–537

decontamination, 537–538

incapacitating agents, 537

lung-damaging toxic industrial chemicals, 535–536

nerve agents, 534–535

patient decontamination site, 538

personal protective equipment, 533

principles of chemical casualty care, 533

riot-control agents, 537

vesicants, 533–534

Chemoprophylaxis, 434, 622–624

Chernobyl incident, 543–544

CHEs. See Complex humanitarian emergencies

Chest pain

emergency treatment, 463–465

Chest trauma, 486–487

Children

impact of military life, 421–422

psychological well-being and, 370

resources, 425

with special needs, 421–422

Chokes, 328

Cholinergic crisis, 470, 534

Chronic pain cycle, 559

Church, Benjamin, 7

Circadian dysynchrony, 339

Circadian rhythm

impact of space environment, 356

sleep and, 382

Civil-military relations, 41–44

Civil Reserve Air Fleet, 218

Civil War

evolution of international law, 92

military medical officers during, 13–14

wounding patterns, 481

Civilian Health and Medical Program of the Uniformed Services, 117–118

Civilian offenses, 71–72

CJCS. See Chairman of the Joint Chiefs of Staff

CJIM. See Combined, joint, interagency, or multinational environment

Class VIII materiel, 255

Clinical Guidelines for Operations, 198

Clinical practice guidelines, 548, 586, 593, 595

Clinton, Bill, 43

Clinton, Hillary, 43

Coalition Health Interoperability Handbook, 197

Coalition partners, 98–99

COAs. See Courses of action

COCOM. See Combatant command

Code of conduct, 26

Cohen, Eliot, 41

COLBERT, 358

Cold extremes

definitions, 314, 315–316

guidance to the commanding officer, 323

human performance optimization strategies, 321–322

military applied physiology, 318–319

military history and epidemiology, 314, 316–317

resources, 323

role of the military medical officer, 322–323

thermal injuries in active component service members, 2010-2104, 316

Cold stress/strain, 315

Collaboration. See Multinational medical collaboration Collins, Jim, 56

Collins, John, 277

Colloids, 489

Colon cancer screening, 434

Colony stimulating factors, 546

Color guard, 186

Combat casualty rehabilitation, 446

Combat Feeding Program, 308

Combat load, 158

Combat Rations Database, 307

Combat stress, 368

Combat stress control

causes of, 574–575

evaluation elements, 578

examples of, 576

individual resiliency and vulnerability, 575

management and disposition of severe reactions, 581

management of stress reactions, 579–581

medication management in theater, 580

mental stressors, 576

physical stressors, 576

physiology of human stress response, 574

principles of, 578–579

principles of assessment, 577–578

psychology of human stress response, 574

psychotherapy in theater, 579–580

reactions to, 576–577

restoration centers, 580–581

traumatic event management, 581–582

unit resiliency and vulnerability, 575–576

Combat support hospitals, 564–566

Combatant command, 113–114, 237–238

Combatives training, 156

Combined, joint, interagency, or multinational environment, 194, 197

Combined health services. See Multinational medical collaboration

Combined Operational Load Bearing External Resistance Treadmill, 358

Command authority, 127

Command discretion, 75

Command sergeant major, 181

Command surgeons

clinical capabilities, 132

communicating risk to the commander, 135

health surveillance duties, 132–133

medical logistics support, 132

medical planning, 134–135

preventive medicine duties, 132–133

responsibilities of, 131–132

stress casualties prevention, 133–134

Commanders

characteristics of effective staff officers, 128–131

command authority, 127

command responsibility, 127

command surgeon duties, 131–135

coordinating staff, 124–125

duality of medical officers, 135–138

expectations of medical officers, 138

general military authority, 127

personal staff, 126

special staff, 125–126

staff officers, 124–128, 141–142

technical authority, 127–128

Commanding officers

extreme environments role, 323, 359–360

human performance optimization role, 281

medical readiness role, 440

musculoskeletal injuries prevention role, 400

performance nutrition role, 307

physical fitness role, 293–294

rehabilitation role, 451, 453

sleep management role, 387–388

spirituality role, 410–411

Commission, officer’s, 36–37

Committee for Military Nutrition Research, 302

Committee on Tactical Combat Casualty Care, 481–485

Committee the Chiefs of Military Medical Services, 195

Common Article 3, 95–96

Communication

addressing difficult topics, 173

communication training, 158–160

components of military communication, 177–178

counseling, 172–173

definition, 166

feedback, 172–173

formal oral, 171–172

forms of, 170–171

importance to the military family, 173

informed consent, 167

as it relates to leadership, 168–169

military-specific requirements, 171–173

9-line MEDEVAC request, 159, 160, 215, 614

principles of effective communication, 169–170

radio frequency types, 159

relevance of military and medical communication, 166–168

resources, 173–174

staff officer requirements, 130–131, 142

types of, 52–53, 59–60

written, 171

Competence skills, 52, 56–57

Complex humanitarian emergencies, 505, 507

Comprehensive health surveillance, 235

Computed tomography, 465–466, 468, 597, 598

Concussions. See also Postconcussive symptoms

garrison concussion management, 592

management in deployed settings, 589–591

management in nondeployed settings, 592–593

patient-contered care, 594

progressive return to activity, 593

return to play guidelines, 592–593

Conduction, 315

Conflict continuum, 24

Congressional Budget Office, 53

Congressional security reforms, 109

Consortium for Health and Military Performance, 277, 307

Constitution of the World Health Organization, 100

Context characteristics, 52, 57–59

Continental Congress, 69

Contingency capacity, 506

Continuous peripheral nerve block, 558, 561

Convection, 315

Convening authority, 68

Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 100

Convention on the Prevention and Punishment of the Crime of Genocide, 94–95, 100

Conventional capacity, 506

Convoy operations, 157–158

Convulsant Antidote, Nerve Agent, 535

Coordinating staff, 124–125

Coping behaviors, 369–370

Core values, 371

COs. See Commanding officers

Counseling, 172–173

Courses of action, 258, 260, 267–269

Courts-martial

appellate reviews, 80

Article 32 investigations, 79

definition, 68

historical evolution of the UCMJ, 69–70

levels of, 78–79

Manual for Courts-Martial, 68

post-trial, 80–81

referral of charges, 78

referral to, 79

referred cases, 80

role of military medical officers, 80

Cousteau, Jacques-Yves, 332

CPG. See Clinical practice guidelines

CPR. See Cardiopulmonary resuscitation

CRASH-2 trial, 491

Credibility concept, 170

CREstT. See Casualty Rate Estimation Tool

CRI. See CHAMPUS Reform Initiative

Crisis capacity, 506

Critical care air transport teams, 212, 218, 611

Critical event debriefing, 582

Critical incident stress debriefing, 582

Crowe, William, 43

Crystalloids, 489–490

CSFs. See Colony stimulating factors

CSM. See Command sergeant major

CSSD. See Certification as a specialist in sports dietetics

CUF. See Care under fire

Cultural characteristics, 58

Cutbush, Edward, 180, 181

Cyanide, 536–537

Cyber Command, 114

Cyber security, 229

Cycle ergometer with vibration isolation system, 357–358

D

D-I-M-E efforts, 147–148

Daily value, 301

Dalton’s law, 327, 337

Damage control resuscitation

adjuncts to, 490–491

artificial colloids, 489

crystalloids, 489–490

fluid resuscitation strategies, 490

fresh whole blood, 488–489

objectives in prehospital setting, 488

overview, 487–488

stored constituents of blood, 489

Data management, 438–439

Dayton Peace Accord, 195–196

DCS. See Decompression illness/sickness

Decatur, Stephen, 10

Decompression illness/sickness, 328, 331–332, 337–339, 342

Decompression tables, 327

Decontamination

chemical warfare agents, 537–538

radiological and nuclear exposures, 546

DEET, 626

Defense and Veterans Brain Injury Center, 586, 593

Defense and Veterans Pain Rating Scale, 566

Defense bureaucracy, 42–43

Defense Center of Excellence, 596

Defense counsel

definition, 68

Defense Health Agency, 113, 117–119

Defense Health Program, 112–113, 120–121

Defense Logistics Agency, 250–251

Defense Manpower Data Center, 239

Defense Medical Logistics Center, 251

Defense’ planning guidance, 119–120

Defense Satellite Systems, 350

Defense Working Capital Fund, 251

Definitive care capability, 211

Delafield, Richard, 13

Delirium, 450

Dempsey, Martin, 43, 47

Dental treatments, 434

Department of Defense

budgeting process, 119–120

combatant commands, 113–114

Congressional oversight, 108–109

force health protection policy and instructions, 235–236

Goldwater-Nichols Department of Defense Reorganization Act, 47, 107, 114

Joint Chiefs of Staff, 114

joint doctrine, 114–116

Joint Ethics Regulation, 83–85

Joint Staff, 114

Law of War Manual, 92, 93

Office of the Secretary of Defense organization, 109, 111–113

organization of, 109–110

Standards of Conduct Office, 85

traumatic brain injury definition, 586

Department of Health and Human Services, 81

Deployments

developing a health surveillance program, 239–246

health activities, 235–236, 238–239

medical readiness, 439–440

military medical officer roles, 23–24

Dereliction of duty, 72–73

DHA. See Defense Health Agency

DHP. See Defense Health Program

D&I reporting. See Disease and injury reporting

Died of wounds, 479–480

Dietary reference intakes, 301, 303

Dietary Supplement Health and Education Act, 305

Dietary supplements, 305–306

DIME program. See Dynamic Integrated Movement Enhancement

Diplomatic efforts, 147

Directive 1308, 288

Disease and injury reporting, 630–631

Disease and nonbattle injuries, 28, 30, 243, 245

Disease outbreaks, 631–635

Distributive shock, 469

Dive medicine, 161

Dive profile, 327

Divers Alert Network, 327

DLA. See Defense Logistics Agency

DNBIs. See Disease and nonbattle injuries

Doctrine, organization, training, materiel, leadership, personnel, facilities domains, 199

DoD. See Department of Defense

Dodge, Granville, 16

Dodge Commission, 16

DOTMLPF domains, 199

Douhet, Giulio, 45

DOW. See Died of wounds

DPG. See Defense’ planning guidance

DRIs. See Dietary reference intakes

Driving training, 157

Drucker, Peter, 56

Drug use

psychological well-being and, 365–366

Dual sovereignty doctrine, 71

Dunant, Henri, 12, 13

DUST-OFF, 608, 611

DVBIC. See Defense and Veterans Brain Injury Center

DVPRS. See Defense and Veterans Pain Rating Scale

Dynamic Integrated Movement Enhancement, 398, 400

E

Eating behavior. See Performance nutrition

EBV. See Epstein-Barr virus

ECGs. See Electrocardiograms

Economic efforts, 148

Ectopic pregnancies, 463

Education programs. See also Training programs for military medical officers, 27

EHRs. See Electronic health records

18th Medical Group, 252

Eisenhower, Dwight D., 277

Electrocardiograms, 464–465, 473–474

Electronic health records, 227–228

Emancipation Proclamation, 152

Emergency management cycle, 508–510

Emergency Medical Treatment and Labor Act, 460

Emergency medicine

abdominal pain, 462–463

cardiac arrest, 471–473

challenges specific to the emergency department, 461

chest pain, 463–465

deployed emergency medicine challenges, 461

determining sick patients, 459

dispositions, 473–474

emergency department concepts, 459–461

emergency department workup, 460–461

emergency physicians, 458

headache, 465–466

initial assessments, 459

patient issues, 461

poisoning, 470–471

prehospital arrivals, 459

red flags, 462–473

safety nets, 460

shock, 468–470

specific chief complaints, 462–473

trauma, 466–468

Emergency physicians, 458

Emergency preparedness, 635–636

Emotional Intelligence, 56–57, 169

Employment

psychological well-being and, 370

EMRE. See Expeditionary Medicine Requirements Estimator

EMTALA. See Emergency Medical Treatment and Labor Act

EMU. See Extravehicular mobility unit

En route care system, 210, 211–213, 212, 604

Encyclopedia of Ethical Failure, 85

Endurance training, 290

Engineering and Medicine Health and Medicine Division, 308

Enlisted service members

assignment of enlisted personnel, 189–190

enlisted training, 187–189

garrison healthcare unit assignment, 189

history of, 180–181

operational unit assignment, 189–190

rank structure, 181–183

role of noncommissioned/petty officers, 183–187

special category enlisted medical personnel, 190–191

Environmental extremes

alternobaric, 326–343

cold, 314–324

heat, 314–324

space, 348–360

Environmental hazards, 629

Epidemiology curves, 633–634

EPs. See Emergency physicians

Epstein-Barr virus, 354

EQ. See Emotional Intelligence

ERCS. See En route care system

ESP. See Estimating Supplies Program

Estimated average requirement, 301

Estimating Supplies Program, 264

Ethics. See also Military law

ethics counsel, 68

Joint Ethics Regulation, 72, 83–85

Ethics counsel

definition, 68

EVA. See Extravehicular activity

Evaporation, 315

The Exceptional Family Member Program, 422

Executive summaries, 171

Exercise. See also Physical fitness

psychological well-being and, 365

Exercise prescription, 286

Exertional heat stroke, 316

Expeditionary Medicine Requirements Estimator, 264

Explosive injuries

evaluation of, 548

management of primary blast injury, 548

mechanisms of blast injury, 547–548

EXSUMs. See Executive summaries

Extravehicular activity, 349, 352, 353, 356

Extravehicular mobility unit, 349, 352

Extreme conditions. See Environmental extremes

Eye protection, 253

F

F. Edward Hebert School of Medicine

establishment of, 117

“White Coat Ceremony,” 1

Family

definition, 416

Family members

psychological well-being and, 368–369

Family readiness

career obstacles, 420

common stressors, 418–421

coordinating care, 426

definitions, 416–417

direct support for military families, 426

dual or single military parents, 420–421

educating military unit leadership, 426

enhancement strategies, 422–425

expectation management, 423

facilitating dialogue, 422

geographic separation, 418

managing uncertainty, 422–423

military children, 421–422

permanent change of station moves, 418–419

preventive strategies, 422–424

psychological first aid, 424

reactive strategies, 424–425

resources, 424–426

role conflict, 419–420

role of the military medical officer, 426

Family resilience

definition, 417

FAST. See Focused abdominal sonography

Fatigue

definition, 382–383

management tools, 386–387

FDA. See Food and Drug Administration

Federal Assimilative Crimes Act, 73

Federal Emergency Management Agency, 507–508

Federal Tort Claims Act, 82

Feedback, 172–173

Feet of sea water, 327

FEMA. See Federal Emergency Management Agency

Feres Doctrine, 82–83

FHP. See Force health protection

Field skills. See Tactical field skills

Final Multiple Score, 183

First responder care capability, 210

First Strike Ration, 302

Fitness tests, 292

Five Eyes, 194

Fleet Marine Corps Reserve

UCMJ jurisdiction, 70

Fleet Reserve

UCMJ jurisdiction, 70

Flight medicine, 161

Fluid resuscitation, 490

Flynn, Mike, 42, 43

FM. See Frequency modulation

FM 21-20, 288

FMS. See Functional Movement Screen

FOB. See Forward operating base

Focused abdominal sonography, 463

Food and Drug Administration, 306, 549

Food and Nutrition Board, 303

Food standards, 627–628

Force health protection, 29–31

deployment health activities, 235–236, 237–239

developing a deployment health surveillance program, 239–246

DoD policy and instructions, 235–236

ratio of non-hostile deaths to hostile deaths in US military conflicts, 234

Formal oral communication, 171–172

Forward operating base, 211

Forward resuscitative surgery system, 210

Forward surgical care, 563–564

FourCe-PITO leadership model

character element, 52, 55–56

communication element, 52–53, 59–60

competence element, 52, 56–57

context element, 52, 57–59

elements of, 27, 54–61

framework, 52–53, 61

interpersonal element, 53, 60–61

organizational element, 53, 60–61

personal element, 53, 60–61

psychosocial levels of, 53, 60–61

team element, 53, 60–61

use of framework, 62

Fragmentary order, 172

FRAGO. See Fragmentary order

Free available chlorine, 627

French Revolution, 8–9

Frequency modulation, 159

Fresh whole blood, 488–489

Frostbite, 316

FRSS. See Forward resuscitative surgery system

FSR. See First Strike Ration

FTCA. See Federal Tort Claims Act

Functional fitness, 286

Functional Movement Screen, 398

G

G forces, 334–335

G-induced loss of consciousness, 335, 339

G-LOC. See G-induced loss of consciousness

Gagnan, Emile, 332

Gauge pressure, 327

Gay-Lussac’s law, 336

Gender characteristics, 58

General military authority, 127

Generational characteristics, 58

Geneva Conventions

application of international law in peacetime medical deployments, 99–100

evolution of international law, 92

grave breaches definition, 94

law of war code, 12–13, 73

multinational medical collaboration, 199

treaties of, 95–98

Genocide, 94

Geographic separations, 418

Gifts

regulation of, 84

Gillibrand, Kirsten, 38–39

Glasgow Coma Scale, 592

Global positioning system, 156, 349, 351

Goldwater-Nichols Department of Defense Reorganization Act, 47, 107, 114

Good order and discipline

definition, 68

Gorgas, William, 17

Government Performance and Results Act, 107

GPS. See Global positioning system

Graft versus host disease, 488

Grave breaches, 94

Green, Bruce, 146

Green, Steven, 74

Greene, Ralph, 330

Grenada invasion

health services support, 209

Grimes, Billie, 150

Grotius, Hugo, 12

Group A streptococcus, 624

Group processes, 54

Gynecologic system

effects of space environment, 355

H

Habituation, 315

HACE. See High altitude cerebral edema

Hague Convention, 12, 73

Halley, Edmund, 331

Hamner, Michael, 73

HAPE. See High altitude pulmonary edema

Harris, Thomas, 10

Hay-McBer group, 57

Hazardous materials, 504, 507

HAZMAT. See Hazardous materials

Headaches

emergency treatment, 465–466

indications for referral, 596

Headquarters and Headquarters Company, 128

Health Affairs, Assistant Secretary of Defense for, 112

Health information systems

affordability, 229

as component of a comprehensive health delivery system, 228–229

considerations for military medical officers, 230–231

cyber security, 229

definition, 226

dependents in a joint military environment, 231

electronic health records, 227–228

end-user efficiency, 229

force health protection, 236

handwritten information, 227

interoperability, 229–230

military-specific requirements, 229–230

operating room suite system, 228

operational viability, 230

principles of effective system employment, 228–229

procurement of, 230–231

provider efficiency, 229

relevance to military healthcare providers, 227

requirements identification, 228

requirements of, 230–231

sustainability, 229, 230

types of, 227–228

virtual health information systems, 231

Health information technology

definition, 226

Health Insurance Portability and Accountability Act, 75, 136

Health maintenance organizations, 118

Health protection. See Force health protection

Health risk assessment

factors to consider, 240

health threat categories, 242

joint task force staff sources, 241

resources, 241

sources of information, 241

template for disease and nonbattle injuries by category, 243

Health risk communication, 636–639

Health services support

command surgeons’ duties, 132

conformity principle, 208–209

continuity principle, 209–213

control principle, 212, 213

definitive care capability, 211

en route care capability, 211–213

first responder care capability, 210

flexibility principle, 213

forward resuscitative care capability, 210

joint health services support, 258–270

the Military Health System and, 206–208

mission of, 207

mobility principle, 212, 213

operational planning, 258–270

principles of, 208–213

proximity principle, 213

representative medical laydown in a joint operations area, 213–220

resources, 221–222

role of the medical officer on the command staff, 207–208

theater hospitalization care capability, 210–211

Health surveillance programs

command support, 245–246

command surgeons’ duties, 132–133

conducting health risk assessment, 240–244

developing countermeasures, 244

health risk communication, 245

identifying population at risk, 239–240

monitoring disease and injury, 244–245

preventive countermeasures, 244

reporting disease and injury, 244–245

Health threat

categories of, 242

definition, 240

Healthcare systems

impact of mass casualty incidents, 505–507

military, 28–29

Hearing profiles, 436–437

Heat exhaustion, 316

Heat extremes

actions of heat acclimatization, 320

definitions, 314, 315–316

factors underlying heat intolerance, 320

guidance to the commanding officer, 323

human performance optimization strategies, 319–321

military applied physiology, 317–318

military history and epidemiology, 314, 316–317

resources, 323

role of the military medical officer, 322–323

thermal injuries in active component service members, 2010-2104, 316

work/rest and water consumption table, 321

Heat injury, 316

Heat stress/strain, 315

Heermann, Lewis, 10

Heliox, 327

Hematologic system

effects of space environment, 355

Hemorrhage control

hemostatic dressings, 484–485

junctional hemorrhage, 485

tourniquets, 483–484

Hemostatic dressings, 484–485

Henry’s law, 327, 337

Herniated nucleus pulposus, 354

Herpes simplex, 354

Heterotopic ossification, 450

HF radio, 159

HHC. See Headquarters and Headquarters Company

High altitude, 327

High altitude cerebral edema, 328, 333–334, 339–340

High altitude headache, 334

High altitude pulmonary edema, 328, 333–334, 339–341

High-energy trauma, 450

High frequency radio, 159

High-pressure nervous syndrome, 328

HIPAA. See Health Insurance Portability and Accountability Act

Hippocratic Oath, 136, 143

HISs. See Health information systems

HMO. See Health maintenance organizations

HNP. See Herniated nucleus pulposus

Home care, 447–449

Homer, 55

Hooker, Joseph, 14

Hospital Corps, 17

House Armed Services Committee, 108

HPO. See Human performance optimization

HSS. See Health services support

Human immunodeficiency virus, 433

Human papillomavirus, 433

Human performance optimization

alternobaric extremes, 338–343

astronauts, 273

cold extremes, 321–322

definitions, 276

demands/resources model, 279

factors serving as demands and/or resources, 280

guidance to the commanding officer, 281

heat extremes, 319–321

historical context, 276–279

proposed model, 278–279

resources, 281

role of the military medical officer, 24, 280–281

soldier-centered care, 279

space environments, 355–360

Total Force Fitness, 277–279

Human Performance Resource Center, 291, 307

Humanitarian assistance

complex humanitarian emergencies, 505, 507

foreign humanitarian assistance, 514

Humphrey, Frederic E., 330

Huntington, Samuel, 38, 41

Hyperbaric oxygen, 327

Hypobaric hypoxia, 328, 333

Hypochlorite solution, 538

Hypothermia, 315, 316, 490

Hypovolemic shock, 468–469

I

ICC. See International Criminal Court

ICP. See Intracranial pressure

ICS. See Incident command system

IDC. See Independent duty corpsman

IDES. See Integrated Disability Evaluation System

IDMT. See Independent duty medical technicians

IEDs. See Improvised explosive devices

IFAK. See Individual First Aid Kit

Immobility, 448

Immune system

effect of space environment, 354

Immunizations, 434, 622

Improvised explosive devices, 157, 262, 466

Improvised nuclear device, 544

In-extremis leadership, 58

Incapacitating agents, 537

Incident command system, 509, 510–511

Inclusive leadership, 57

Independent duty corpsman, 191

Independent duty medical technicians, 190–191

Individual First Aid Kit, 158

Information systems. See also Health information systems definition, 226

Informational efforts, 147–148

Informed consent, 167

Injury patterns, 480–481, 514–515

Injury reporting, 630

Integrated Disability Evaluation System, 112

Intelligence briefings, 162

Intelligence preparation of the battlefield, 262

Intelligence quotient, 56–57

Interallied Confederation of Medical Reserve Officers, 195

Intermediate Level Education, 20

Intermittent hypoxic exposure, 339–340

International Classification of Headache Disorders, 595–596

International Committee of Military Medicine, 195

International Committee of the Red Cross

creation of, 12, 13

International Covenant on Civil and Political Rights, 100

International Criminal Court, 74, 94

International humanitarian law, 92

International law

application in peacetime medical deployments, 99–100

evolution of, 92–93

International medical collaboration. See Multinational medical collaboration

International Space Station, 352, 353, 356

International Stabilisation Afghanistan Force, 196

Interpersonal leadership element, 53, 60–61

Intracranial pressure, 354–355

Investigational New Drugs, 539

Ionizing radiation, 544

IPB. See Intelligence preparation of the battlefield

IQ. See Intelligence quotient

Iraq War

aeromedical evacuation, 609–610

health services support, 212

joint health services support, 266

multinational medical collaboration, 196

wounding patterns, 481

Ireland, Merritt, 18

IS. See Information systems

ISAF. See International Stabilisation Afghanistan Force

Isolated personnel report, 154–155

ISOPREP, 154–155

ISS. See International Space Station

Ivy, John, 304

J

Jackson, Stonewall, 556

JAGMAN, 76

Janowitz, Morris, 41, 44

JCS. See Joint Chiefs of Staff

JER. See Joint Ethics Regulation

JMPT. See Joint Medical Planning Tool

JOA. See Joint operations area

Joint Base Elmendorf-Richardson, 186

Joint Chiefs of Staff, 114–115

Joint Concept for Health Services, 115–116

Joint doctrine, 114–116

Joint Ethics Regulation

definition, 68

function of, 72, 83

gifts, 84

outside employment regulation, 84–85

principles of, 83–84

relations with non-federal entities, 84

teaching, writing, and speaking regulation, 84

Joint health services support. See also Health services support

course of action development, analysis, comparison and approval, 267–269

defining operational environment, 261–263

determining specified, implied, and essential tasks, 263–264

essential tasks, 263–264

identifying available resources and shortfalls, 265–267

implied tasks, 263–264

joint operation planning process, 258–259

key points for medical staff officer, 269

medical resources, 266

mission analysis, 260–267

operation order format, 264

operation planning process, 260, 268

planning considerations, 265

planning initiation, 260, 261

resources, 269–270

risk management, 266–267

service-specific operational planning, 259

specified tasks, 263–264

time factors, 266

Joint Medical Planning Tool, 264

Joint operation planning process, 258

Joint operation planning process for air, 259

Joint operational planning, 134, 135

Joint operations area, 206, 213–221

Joint Staff, 114

Joint task force, 237–238, 241–242

Joint Theater Trauma Registry, 466

Joint Theater Trauma System Clinical Practice Guidelines, 198

Joint Trauma System, 591

Jones, Jim, 42

JOPP. See Joint operation planning process

JOPPA. See Joint operation planning process for air

JTF. See Joint task force

JTS. See Joint Trauma System

JTTR. See Joint Theater Trauma Registry

Judge advocate

definition, 68

Jumper, Johnnie, 60

JumpSTART algorithm, 519

Junctional hemorrhage, 485

Junior enlisted promotions, 181

Jurgersen, Brent, 150

K

Karman line, 349, 351

Kelly, John, 42, 330

Kennedy, John F., 46, 349

Ketamine, 492, 562–563

KIA. See Killed in action

Killed in action, 479–480

Knights Hospitaller, 12

Korean War, 19, 481, 608

Krulak, Charles C., 150

Kunsch, Joe, 151

Kuwaiti operations

multinational medical collaboration, 195

L

Lahm, Frank P., 330

Lakin, Terrence, 73

Landing craft, air cushion, 218

Landing Error Scoring System, 398

Larrey, Dominic Jean, 9, 604–605

Law. See Military law

Law of armed conflict

application by medical officers, 93

application of international law in peacetime medical deployments, 99–100

evolution of international law, 92–93

intent in relation to military medicine, 95–96

medical operations conducted in cooperation with coalition partners, 98–99

protection of civilian medical staff and hospitals, 99

responsibilities and protections of military medical personnel and units, 97–98

status of military medical units and personnel, 96–97

war crimes, 93–95

Law of war, 73, 92

Law of War Manual, 92, 93

LCAC. See Landing craft, air cushion

Leader-member exchange, 57

Leadership

character leadership, 40–41

communication skills, 168–169

comparison to management, 56–57

cultural characteristics, 58

definition of, 25

development of military medical leaders, 53

dimensions of complexity in engagement and organization, 149–150

FourCe-PITO, 52–62

gender characteristics, 58

generational characteristics, 58

history of, 54

importance of military medical leadership, 53–54

in-extremis leadership, 58

inclusive leadership, 57

leader-member exchange, 57

medical officer role, 27–28

operational, 149

organizational culture and, 58

psychological well-being and, 368

strategic, 149

styles of, 54

tactical, 149

training, 188–189

transactional style, 56

transformational style, 56

warrior-leadership in the profession of arms, 37–38

Leadership training, 188–189

Legal accountability, 26–27

LeMay, Curtis, 45

LEO. See Low earth orbit

Leptospirosis, 623–624

LESS. See Landing Error Scoring System

Letterman, Jonathan, 13–14, 124–125, 132, 135, 146, 151–152, 234, 276, 605–606

Letterman plan, 152

Letters of reprimand, 77

Levy, Howard, 19, 74

Lewin, Kurt, 54, 55

LIMDU. See Limited duty profiles

Limited duty profiles, 30

Lincoln, Abraham, 12, 13, 92, 124, 151

Lind, James, 6–7, 300

LOAC. See Law of armed conflict

Logistics. See Medical logistics

Lovell, Joseph, 9, 10

Low earth orbit, 349, 352

Lung-damaging toxic industrial chemicals, 535–536

M

MacArthur, Douglas, 40, 43

MACE. See Military Acute Concussion Evaluation

MacFarland, Sean, 37

Mahan, Alfred Thayer, 45

Malaria, 622–624

Management

comparison to leadership, 56–57

Manned Orbital Laboratory, 348, 350

Manned spaceflight engineers, 350

Manual for Courts-Martial, 26

cover of, 69

definition, 68

Manual of the Judge Advocate General, 76

MARCH care, 483

Marice Corps planning process, 259

Marine Corps, US

culture of, 45–46

leadership communication requirements, 168

medical logistics companies, 252

operation planning, 259

patient movement flow, 220

physical readiness tests, 292

values of, 184

Marshall, George C., 40, 47

Marshall, S.L.A., 36–37, 47

MASCAL. See Mass casualty incidents

Mass casualty incidents

casualty collection points, 520–523

combat operation injury patterns, 514–515

defense support to civil authorities, 513–514

deployed roles for joint health services, 511–513

emergency management cycle, 508–510

foreign humanitarian assistance, 514

garrison preparedness and response, 507–511

impact on healthcare systems, 505–507

incident command system, 510–511

job action sheet example, 512

planning checklist, 516

preparedness and training, 162

rapid needs assessment, 517

scene management, 515–517

scope of the problem, 504–505

transportation management, 523

triage, 517–520

universal mass casualty principles, 515–523

MATTERS trial, 491

Mattis, Jim, 40, 42

Maximal aerobic power, 286

Mayo, Charles, 17–18

Mayo, William J., 17–18

MCA. See Military Claims Act

McChrystal, Stanley, 40, 482

McClain, Anne, 273

McClellan, George, 13–14, 124, 125

MCI. See Mass casualty incidents

McMaster, H.R., 42

MCPP. See Marice Corps planning process

MDMP. See Military decision-making process

MDRIs. See Military dietary reference intakes

Meal, Ready-to-Eat, 302, 628

Mean arterial pressure, 490

MEB. See Medical evaluation boards

MEDEVAC. See Medical evacuation

Medical care, 28–29

Medical collaboration. See Multinational medical collaboration

Medical Education and Training Campus, 187

Medical Emergency Response Team, 610–611

Medical evacuation

Afghanistan, 265, 610–611

definition, 604

health services support, 211–212, 215–217

Iraq War, 609–610

Korean War, 608

9-line MEDEVAC request, 159, 160, 215, 614

training, 157, 162

Vietnam War, 608

Medical evaluation boards, 136, 438–439

Medical Field Service School, 18

Medical fitness checklist, 432

Medical intelligence preparation of the operational environment, 240, 262

Medical logistics

blood management, 253

checklists, 255

integrated medical logistics management, 250–251

medical maintenance, 253

operational roles, 252

optical fabrication, 253

organizational roles and missions, 251–254

patient movement items, 253–254

planning considerations, 255

resources, 255

service agencies, 251–252

strategic role, 251

tactical roles, 252–253

tips for providers, 254–255

Medical logistics company, 252

Medical logistics support program, 132

Medical maintenance, 253

Medical officers. See Military medical officers

Medical Planners’ Toolkit, 264

Medical Protection System, 133, 438–439

Medical readiness

force health protection and, 29–31

guidance to the commanding officer, 440

role of the military medical officer, 432–440

Medical Readiness Reporting System, 133, 439

Medical Retention Board, 136

Medical Service Corps, 18

Medical Service in Campaign: A Handbook for Medical Officers in the Field, 16, 17

Medical Specialist Corps, 116

Medical specialization, 18–19

Medical support gaps, 266

Medical surveillance, 629–631

Medical Surveillance Monthly Report, 588

Medical treatment facilities, 117, 213–221

Medically retired personnel

UCMJ jurisdiction, 71

Medicare Eligible Retiree Health Care Fund, 120

MEDLOG. See Medical logistics

MEDPROS. See Medical Protection System

MEDPRS. See Medical Protection System

Mellinger, Jeffrey J., 184–185

Mental health. See also Psychological well-being

evaluations, 76–77

high-energy trauma and, 450

history and testing, 433

resources, 425

spirituality and, 409

Mental stressors, 576

MERT. See Medical Emergency Response Team

MESL. See Military Exposure Surveillance Library

Metabolic equivalents, 342

METC. See Medical Education and Training Campus

METs. See Metabolic equivalents

Mexican War, 11

MHS. See Military Health System

Military Acute Concussion Evaluation, 433, 586, 589–591

Military bearing, 161–162

Military “catchall” offenses, 73, 74

Military Claims Act, 82

Military decision-making process, 259

Military dietary reference intakes, 301, 308

Military education, 27

Military efforts, 148

Military emergency managers, 636

Military Exposure Surveillance Library, 239

Military Extraterritorial Jurisdiction Act, 70, 74

Military Health System

budget, 53

health services support, 206–208

healthcare, 28–29

Office of Transformation, 53

website, 133

Military justice system

administrative actions, 77

command discretion, 75

historical evolution of the UCMJ, 69–70

investigations, 76

jurisdictions covered by the UCMJ, 70–71

mental health evaluations, 76–77

nonjudicial punishment, 77–78

offenses under the UCMJ, 71–75

reports of UCMJ violations, 75–76

sanity boards, 76–77

Military law. See also Ethics

courts-martial, 78–81

definitions, 68

disciplinary rules unique to Public Health Service officers, 81–82

Federal Tort Claims Act, 82

Feres Doctrine, 82–83

how the military justice system works, 75–78

military justice system, 69–71

offenses under the UCMJ, 71–75

Military medical officers

American Revolution era, 7–8

civil-military relations, 41–44

Civil War era, 13–14

code of conduct for members of US Armed Forces, 26

commission, 36–37

conflicts between loyalty to the patient and to the commander, 136, 143–144

courts-martial role, 80

courts-martial roles, 80

deployment roles, 23–24

duality challenge of maintaining two professions, 135–136

in the early 19th Century, 8–13

emergence of medical specialization, 18–19

extreme environments role, 322–323, 355–359

family readiness role, 426

field roles, 23

force health protection, 29–31

garrison roles, 22–23

health services support role, 207–208

human performance optimization role, 24, 280–281

as leader of character, 40–41

leadership role, 25, 27–28, 37–41, 52–62

legal context of accountability, 26–27

line versus staff functions, 137

medical readiness, 29–31

medical readiness role, 432–440

medical research and, 24

as member of a profession, 38–39

military healthcare, 28–29

as military professionals, 42–44

military service academies, 4

modern military medical officers, 14–19

musculoskeletal injury prevention role, 400

national security structure and, 107–109

oath of, 36–37

officership, 25

operational medicine, 25

performance nutrition role, 307

physical fitness role, 293

physicians before becoming officers, 5–7

physicianship, 25

professional military education, 27

professional relationship with the commander, 138

professionalism, 26

psychological well-being role, 371–372

rehabilitation role, 449

retirement role, 43–44

roles and responsibilities of, 4–5, 22–32, 37–41, 43–44

as servant of the nation, 39–40

sleep and rest role, 384–386

specialized expertise, 44–47

spectrum of assignments, 31

spirituality role, 410

technical chain of command, 137–138

training of, 27

“vector” model, 25–26

during War with Spain, 15–17

as warrior-leader in profession of arms, 37–38

during World War I, 17–18

during World War II, 18–19

Military medicine

complexity in leader engagement and organization, 149–150

instruments of national power, 147–148

organization of medical services, 116–117

role in national defense, 148–149

“the strategic corporal,” 150–151

Military occupational specialty, 136

Military service academies, 4

Military service secretaries, 112

Military values, 106–107

Miller, Matthew, 263

MIMUs. See Multinational integrated medical units

Mindfulness, 370

Mine-resistant, Ambush-Protected ambulances, 212

MIPOE. See Medical intelligence preparation of the operational environment

MIST report, 614

Mitchell, Billy, 44, 45, 330

MLC. See Medical logistics company

MMB. See Multifunctional medical battalion

MMMSG. See Multinational medical management steering group

MMOs. See Military medical officers

MMRB. See Medical Retention Board

MOL. See Manned Orbital Laboratory

Moral injury, 577

Morgan, Andrew, 273

Morgan, John, 132

MOS. See Military occupational specialty

Motion sickness, 339

MPTk. See Medical Planners’ Toolkit

MRAP. See Mine-resistant, Ambush-Protected ambulances

MRE. See Meal, Ready-to-Eat

MRI scans, 597

MRRS. See Medical Readiness Reporting System

MSEs. see Manned spaceflight engineers

MSK-I. See Musculoskeletal injuries

MSMR. See Medical Surveillance Monthly Report

MTFs. See Medical treatment facilities

Multifunctional medical battalion, 252

Multinational integrated medical units, 194, 196, 198

Multinational medical collaboration

current alliances and organizations, 195

historical examples of, 195–197

indigenous security forces as part of a coalition, 199

keys to success, 199–200

multinational integrated medical units, 198–199

principles of, 197

purpose of, 194

Multinational medical management steering group, 198

Multiservice markets, 118–119

Munson, Edward L., 15, 16

Muscular endurance, 287

Muscular strength, 286

Musculoskeletal injuries

definitions, 395

developing prevention approaches, 395

epidemiology, 394

equipment modifications, 398

functional assessments, 398

guidance to the commanding officer, 400

mitigation programs, 394–395

movement training, 398, 400

prevention strategies, 397–400

risk factors, 396–397

role of the military medical officer, 400

running shoe selection guidance, 398

SMART centers, 394–395

Sports Medicine Injury Prevention program, 395

steps for effective preventive training program, 399–400

stress fracture incidence by mileage and run time, 397

training modifications, 397

Musculoskeletal system

effects of space environment, 353–354

Mustard, 533–534

MV-22 Osprey, 262

Myer, Albert, 166

Myers, Richard, 150

Myocardial infarction, 464

N

National Academy of Sciences

Engineering and Medicine Health and Medicine Division, 308

nutrition terms, 301

National Center for Medical Intelligence, 241

National Command Authority, 108, 127

National Committee on Physical Fitness, 287

National Defense Authorization Act of 2017, 112, 117

National Defense Strategy, 107

National Guard

UCMJ jurisdiction, 70

National Institutes of Health, 566

National Intelligence Agency, 108

National Military Strategy, 107

National Oceanographic and Atmospheric Administration, 327

National power instruments, 147–148

National Reconnaissance Office, 350

National Red Cross Societies, 97

National Research Action Plan, 598

National Security Act of 1947, 108, 109, 113

National Security Council, 108, 114

National Security Strategy, 107

National security structure

Congress and DoD oversight, 108–109

Defense Health Agency, 117–119

defense health program, 120–121

DoD budgeting process, 119–120

DoD organization, 109–116

military medical officers and, 107–109

military medical services organization, 116–117

national command authority, 108

National Security Council, 108

professionalism and military values, 106–107

readiness for the future, 121

unified medical program, 120–121

NATO. See North Atlantic Treaty Organization

NATO Interoperability Handbook, 195, 196

Naval Health Research Center, 264

Naval Ophthalmic Support and Training Activity, 253

Navigation training, 156–157

Navy, US

culture of, 45

leadership communication requirements, 168

operation planning, 259

patient movement flow, 219

physical readiness tests, 292

predeployment profiling basics, 435

values of, 184

Navy Experimental Diving Unit, 327

Navy Medical Logistics Command, 251

Navy planning process, 259

NCMI. See National Center for Medical Intelligence

NCOs. See Noncommissioned officers

NDS. See National Defense Strategy

Nerve agents, 534–535

Neurobehavioral Symptoms Inventory, 593

Neuroimaging, 597

Neuroophthalmological system

effects of space environment, 354–355

Neurovestibular system

effects of space environment, 351–352

Neutral Buoyancy Laboratory, 273

New Zealand

multinational medical collaboration, 194

NHRC. See Naval Health Research Center

Night optic devices, 158

Nightingale, Florence, 11, 13, 14

9-line MEDEVAC request, 159, 160, 215, 614

Nitrogen narcosis, 328

Nitrox, 327

Nixon, Richard, 350, 538

NMLC. See Navy Medical Logistics Command

NMS. See National Military Strategy

NODs. See Night optic devices

Non-federal entities

regulation of DoD personnel relations, 84

Noncommissioned officers

as backbone of units, 186

chain of command, 184, 185–186

as command staff, 124, 127, 131–132

officer-noncommissioned officer support relationships, 183

promotions, 181, 183

relationship with officers, 184–185

role of, 183–187

standard bearer role, 183–184

supervising and training junior enlisted members, 186–187

support channel, 184

unit history and traditions, 186

Nonjudicial punishment, 68, 77–78

Nonprofit organizations

rehabilitation role, 448, 449

Nonsteroidal antiinflammatory drugs

for pain control, 491–492, 562–563

use in space environment, 358–359

North Atlantic Treaty Organization, 194, 195, 196, 197

NPP. See Navy planning process

NRO. See National Reconnaissance Office

NSAIDs. See Nonsteroidal antiinflammatory drugs

NSS. See National Security Strategy

Nuclear exposure. See Radiological and nuclear exposures

Nurse Corps, 17

Nutrient timing, 304–305

Nutrition. See Performance nutrition

Nutritional fitness, 301

O

Oath of Commissioned Officers, 136, 144

Obama, Barack, 40, 42

Obamacare. See Patient Protection and Accountable Care Act

Obstructive shock, 469

Occupational and environmental health site assessments, 237–238

Occupational Physical Assessment Test, 292

OEH. See Occupational and environmental health site assessments

Off-gassing, 327

“Office hours,” 77

Office of the Secretary of Defense, 109, 111–113

Office of Transformation, 53

Officer Advanced Course, 19

Officers, medical. See Military medical officers

Officer’s oath, 36–37

OPAT. See Occupational Physical Assessment Test

Operation Iraqi Freedom

multinational medical collaboration, 196

wounding patterns, 481

Operation orders, 132, 172

Operation plans, 132

Operation Supplement Safety, 306

Operation URGENT FURY, 209

Operational briefings, 162

Operational Detachment Alpha, 329

Operational fatigue, 577

Operational medical training, 161

Operational stress control

causes of, 574–575

examples of, 576

individual resiliency and vulnerability, 575

management and disposition of severe reactions, 581

management of stress reactions, 579–581

medication management in theater, 580

mental stressors, 576

physical stressors, 576

physiology of human stress response, 574

principles of, 578–579

principles of assessment, 577–578

psychology of human stress response, 574

psychotherapy in theater, 579–580

reactions to, 576–577

restoration centers, 580–581

traumatic event management, 581–582

unit resiliency and vulnerability, 575–576

OPIAD. See Opioid-induced androgen deficiency

Opioid-induced androgen deficiency, 560

Opioid poisoning, 470

OPLANS. See Operation plans

OPORDs. See Operation orders

OPSS. See Operation Supplement Safety

Optical fabrication, 253

Oral communication, 171–172

Oral health, 625

Oral transmucosal fentanyl citrate, 491–492, 562

Organizational culture, 58

Organizational leadership element, 53, 60–61

Osprey, 262

OTFC. See Oral transmucosal fentanyl citrate

Outbreak investigations, 631–635

Outside employment regulations, 84–85

Overuse injuries, 395

Oxygen fraction, 327

Oxygen toxicity, 328, 339

P

P-U-L-H-E-S, 436–538

PACE communication, 158, 614

Pain Assessment Screening Tool and Outcomes Registry, 566

Pain management

acute pain service, 559–561

chronic pain cycle, 559

combat support hospitals, 564–566

forward surgical care, 563–564

high-energy trauma and, 450

history of military pain management, 556–559

immediate first aid, 562–563

medical centers outside the theater, 566

on the modern battlefield, 561–566

pain measurement, 566–567

polytrauma triad, 559

tactical medicine, 491–492

Pain Management Task Force, 561

PAM 21-9, 287–288

PAR. See Population at risk

Paré, Ambroise, 5

Partial pressure, 327

PASTOR. See Pain Assessment Screening Tool and Outcomes Registry

Patient-centeredness, 167

Patient Condition Occurrence Frequency tool, 264

Patient decontamination site, 538

Patient Health Questionnaire-2, 433

Patient movement flow, 215–221

Patient movement items, 253–254

Patient movement request, 604

Patient Protection and Accountable Care Act, 118

Patton, George S., 276–277

Payton, Gary, 350

PCE. See Potentially concussive event

PCOF. See Patient Condition Occurrence Frequency tool

PDHRA. See Post-Deployment Health Re-Assessment Program

PDR. See Pre-deployment readiness

PDRL. See Permanent Disabled Retired List

PEA. See Pulseless electrical activity

Peake, James, 558

PEB. See Physical Evaluation Board

Perceived self-interest, 170

Percy, Pierre-François, 8–9

Performance nutrition

caffeine dosing, 306–307

definitions, 300, 301

dietary supplements, 305–306

establishing nutrient requirements, 303

evolution of performance nutrition, 303

guidance to the commanding officer, 307

history of military nutrition, 300–302

importance of nutrition to mission success, 300–302

nutrient timing, 304–305

protein requirements, 305, 306

psychological well-being and, 365

resources, 307–308

role of the military medical officer, 307

scope of practice, 304

Performance optimization. See Human performance optimization

Permanent Disabled Retired List

UCMJ jurisdiction, 70, 71

Persian Gulf War, 238

Personal equipment layers, 158

Personal leadership element, 53, 60–61

Personal protective equipment, 533

Personal staff, 126

Personnel and Readiness, Under Secretary of Defense for, 112

Personnel Reliability Program, 434

Petty officers

as backbone of units, 186

chain of command, 184, 185–186

officer-petty officer support relationships, 183–187

promotions, 181, 183

relationship with officers, 184–185

role of, 183–187

standard bearer role, 183–184

supervising and training junior enlisted members, 186–187

support channel, 184

unit history and traditions, 186

Phillips, Patricia, 70

PHS. See Public Health Service

Physical Conditioning, 287–288

Physical Evaluation Board, 136

Physical fitness. See also Total Force Fitness

aging and, 293

Army training principles during the 1950s, 289

balance, 286

benefits of, 288–290

cardiorespiratory fitness, 286

components of, 291

concepts of, 291–292

coordination, 286

definitions, 286–287

endurance training benefits, 290

exercise prescription, 286

fitness tests, 292

flexibility, 286

functional fitness, 286

guidance to the commanding officer, 293–294

history of military physical fitness, 287–288

intensity level, 286

maximal aerobic power, 286

mobility and, 291

overload, 286

overtraining, 292

periodization, 286

physical readiness tests, 292

plyometrics, 291

postpartum physical fitness, 292

power and, 291

pregnancy physical fitness, 292

progression, 286

recovery, 286

resistance training benefits, 290

resources, 294

role of the military medical officer, 293

for special populations, 292–293

specificity, 286

strength training, 286–287

volume, 287

for wounded, injured and ill service members, 293

Physical profiles, 436–439

Physical readiness tests, 292

Physical Readiness Training, 397

Physical stressors, 576

Physicians’ Committee on Preparedness, 17

PIES principle, 578

PITO. See FourCe-PITO leadership model

Plague, 540–541

Planning, programing, budgeting, and execution system, 119, 121

Plyometrics, 291

PME. See Professional military education

PMIs. See Patient movement items

PMR. See Patient movement request

PMTF. See Pain Management Task Force

Pneumothorax, 467–468, 486–487

POI. See Point of injury

Point of injury, 213–215, 217–218, 511

POIS. See Pulmonary over-inflation syndrome

Poisoning

emergency treatment, 470–471

Polytrauma

pain management, 559

traumatic brain injuries and, 591–592

Population at risk, 265

Portman, Robert, 304

POs. See Petty officers

Positive affect, 370

Post-Deployment Health Assessment, 239

Post-Deployment Health Re-Assessment Program, 440

Postconcussive symptoms

assessments for common symptoms, 595–597

clinical practice guideline for management, 593

headache red flags, 596

neuroimaging, 597

patient-contered care, 594

Postdeployment period

health activities, 239

medical readiness, 440

military medical officer roles, 24

Posttraumatic stress disorder, 368, 594

Potentially concussive event, 586–587, 589

PPBE. See Planning, programing, budgeting, and execution system

PPO. See Preferred provider organization

Pre-Deployment Health Assessment, 237

Pre-deployment readiness, 133

Preble, Edward, 10

Predeployment period

behavioral modification, 434

chemoprophylaxis, 434

concerns for individual deployers, 438

data management, 438–439

evaluation, 434

health activities, 235–236, 237–238

hearing profiles, 436–437

immunizations, 434

medical evaluation boards, 438–439

medical fitness checklist, 432

medical readiness, 133, 432–439

mental health history, 433

military medical officer roles, 23–24

physical profile serial chart, 436–437

physical profiles, 438–439

prevention activities, 432–434

screening, 432–434

service-specific profiling basics, 435

treatment, 438

Preferred provider organization, 118

Prehospital Trauma Life Support manual, 208

Presidential Support Program, 434

Preventive countermeasures, 244

Preventive medicine

chemoprophylaxis, 622–624

command preservation of health, 623

command surgeons duties, 132–133

deployment health activities, 238

emergency preparedness, 635–636

environmental hazards, 629

food standards, 627–628

Group A streptococcus, 624

immunization, 622

leptospirosis, 623–624

malaria, 622–624

oral health, 625

outbreak investigations, 631–635

risk communication, 636–639

sexual health, 625

training, 162

unit-level medical surveillance, 629–631

vector control, 625–626

waste disposal, 628–629

water standards, 626–628

Primacy concept, 170

Primary, Alternate, Contingency, Emergency communication, 158

The Principles of Sanitary Tactics, 15

Pringle, John, 6, 132

Professional military education, 27, 188

Professionalism, 106–107

Progressive muscle relaxation, 579

Protection of Victims of International Armed Conflicts, 95

Protection of Victims of Non-International Armed Conflicts, 95

Protein requirements, 305, 306

Protocols Additional to the Geneva Conventions, 95

PRT. See Physical Readiness Training

Psychological well-being

awareness and, 366

behaviors relevant to, 365

beliefs and appraisals, 366

children, 370

cognitive processes, 366

combat stress, 368

coping, 369–370

definition, 364

definitions, 364

drug use and, 365–366

eating behavior, 365

emotional factors, 367

employment and, 370

exercise and, 365

foundations of, 365–367

guidance to the commander, 372

indicators of, 370–371

injury and, 368

leadership and, 368

meaning and purpose, 370

military families, 368–369

military life and, 367–370

mindfulness, 370

positive affect and, 370

psychological first aid, 424

psychological fitness, 364

relationship quality, 369

resilience, 366

resources, 372

role of the military medical officer, 371–372

service core values, 371

sexual behavior, 366

sleep and, 365

social support, 370–371

transitions, 368

unit cohesion, 371

well-being, 364

wounded warrior care, 369

Psychotherapy, 579–580

Ptah-hotep, 57

PTSD. See Posttraumatic stress disorder

Public affairs officers, 639

Public health emergency officers, 636

Public Health Service

disciplinary rules, 81–82

UCMJ jurisdiction, 70

values of, 184

Public Health Service Act, 70

Puller, Lewis “Chesty,” 46

Pulmonary over-inflation syndrome, 336, 342

Pulseless electrical activity, 468, 472

Q

QDR. See Quadrennial Defense Review

Quadrennial Defense Review, 107

Quadripartite Working Group on Health Service Support, 195

R

RADIAC. See Radiation detection, indication and computation counters

Radiation, 315

Radiation detection, indication and computation counters, 546

Radiation effects, 544

Radiation exposure device, 544

Radio discipline, 159

Radio frequency types, 159

Radioisotopes, 547

Radiological and nuclear exposures

acute radiation syndrome, 545

Chernobyl incident, 543–544

decontamination, 546

external exposure, 544–545

internal exposure, 547

ionizing radiation, 544

radiation effects, 544

treatment of radiation-injured patients, 545–547

triage, 545–546

Radiological dispersion device, 544

Ramazzini, Bernardino, 6

RAND Corporation, 53

Rank insignia, 182

Rank structure, 181–183

Rapid eye movement sleep behavior disorder, 384

Rapid needs assessment, 517

RD. See Registered dietitians

RDAs. See Recommended dietary allowances

REBOA. See Resuscitative endovascular balloon occlusion

Rebreather, 327

Recency concept, 170

Recommended dietary allowances, 301, 303

Recompression chamber, 327

Recovery. See Sleep management

Recreation

rehabilitation and, 449

Red Crescent emblem, 98

Red Cross, 12, 13, 97, 98

Red Crystal emblem, 98

Red Shield of David, 98

Regional anesthesia, 558–559

Registered dietitians, 304

Rehabilitation

acute care, 447

combat casualty rehabilitation, 446

definitions, 445

elements of, 446–449

guidance to the commanding officer, 451, 453

home care, 447–449

immobility complications, 448

military history, 446

military roles of care, 444

nonprofit organizations, 448, 449

role of the military medical officer, 449

secondary complications from high-energy trauma, 450

sports and recreation, 449

team members and roles, 449, 451, 452–453

Rehearsal of concept, 172

Reintegration phase

military medical officer roles, 24

rehabilitation and, 444–453

Religion

military history of, 406

relationship to disease, 408

Repetition concept, 170

Reserve personnel

UCMJ jurisdiction, 70

Resilience, 366, 427, 575–576

Resistance training, 290

Resources

alternobaric extremes, 343

cold extremes, 323

communication, 173–174

family readiness, 426

health services support, 221–222

heat extremes, 323

human performance optimization, 281

joint health services support, 269–270

medical logistics, 255

performance nutrition, 307–308

physical fitness, 294

psychological well-being, 372

sleep management, 388

spirituality, 411

total Force Fitness, 281

Rest. See Sleep management

Restoration centers, 580–581

Resuscitative endovascular balloon occlusion, 490–491

Retired personnel

UCMJ jurisdiction, 70, 71

Reverse osmosis water purification units, 626–627

Revolutionary War

evolution of international law, 92

military medical officers’ responsibilities, 7–8, 39–40

Rewarming, 315

Rewarming shock, 315

Reynolds, Charles, 71

Ricin, 543

Riot-control agents, 537

Risk communication, 636–639

ROC. See Rehearsal of concept

Role conflict, 419–420

Rome Statute, 74, 94

Rowntree, Leonard G., 288

RSDL, 538

Rumsfeld, Donald, 43

Running shoe selection, 398

Rush, Benjamin, 7–8, 132, 300

Russell, William, 13

S

SABP. See Space-adaptation back pain

SALT algorithm, 519

Sanity boards, 76–77

Sarin, 534–535

Satellite phones, 160

SCAT 5. See Sport Concussion Assessment Tool

Schenk, Paul, 303

School of Application for Infantry and Cavalry, 15

Schoomaker, Eric, 561

SCUBA, 331–332

Second Italian War for Independence, 12

Secretary of Defense, Office of, 109, 111–113

Security structure. See National security structure

Selective serotonin reuptake inhibitors, 580

Self-contained underwater breathing apparatus, 331–332

Self-hypnosis, 579

Selfridge, Thomas, 330

Senate Armed Services Subcommittee on Personnel, 109

Senate Committee on the Armed Services, 108

SERE. See Survival, evasion, resistance, escape

Sergeant major, 181

Service academies, 4

Service core values, 371

Service values, 184

Sexual behavior

psychological well-being and, 366

Sexual health, 625

SGM. See Sergeant major

Shallow water black-out, 328

Shinseki, Eric, 42

Shock

emergency treatment, 468–470

Shooting training, 155–156

Shortwave radio, 159

Sick call, 29

Signal Corps, 166

SIMLM. See Single integrated medical logistics manager

Single integrated medical logistics manager, 250

Single integrated operational plan, 45

SIOP. See Single integrated operational plan

6th Medical Logistics Management Center, 252

Skylab, 350

Sleep hygiene, 386–387

Sleep management

definitions, 382–383

fatigue management tools, 386–387

guidance to the commanding officer, 387–388

psychological well-being and, 365

psychomotor vigilance task, 385

rapid eye movement sleep behavior disorder, 384

resources, 388

role of the military medical officer, 384–386

sleep deficits and military service, 383–384

sleep deprivation outcomes, 383

sleep hygiene, 386–387

sleep inducers, 387

space environment effects, 355, 356–357

trauma-associated sleep disorder, 384

two-process theory of sleep, 382

Sleepiness

definition, 382–383

Slim, William, 623

Smallpox, 541–542

SMART centers, 394–395

SMEs. See Subject matter experts

SMIP. See Sports Medicine Injury Prevention program

Smith, Dale, 151

SOAP notes, 171–172, 260, 261

Social skills, 169

Social support, 370–371

SOCOM. See Special Operations Command

SOF. See Special operations forces

SOFME. See Special Operations Forces Medical Element

Soldier readiness program, 133

Soman, 534–535

Sonny Carter Training Facility, 273

Soviet Sputnik, 348

Space-adaptation back pain, 350, 353–354, 359

Space environment

applied physiology terminology, 349

behavioral effects, 355

cardiovascular effects, 352–353

conditioning and, 357–358

critical mission tasks, 359–360

definitions, 348–350

evidence-based strategies to optimize performance, 357

guidance to the commanding officer, 359–360

gynecologic effects, 355

hematologic effects, 355

human performance optimization, 273, 355–360

immune system effects, 354

impact on sleep and rest, 356–357

medication and, 358–359

military applied physiology, 351–355

military history, 348–351

musculoskeletal effects, 353–354

neuroophthalmological effects, 354–355

neurovestibular effects, 351–352

on-orbit conditions, 359

operational mission tasks, 360

physiologic effects, 351–355

pressure effects, 357

risk factors and challenges of, 357

role of the military medical officer, 355–359

Space flight anemia, 355

Space Transportation System, 350

Spatial disorientation, 339

Special Forces medical sergeant, 191

Special needs children, 421–422

Special Operations Command, 47

Special Operations Critical Care Evacuation Team, 612

Special operations forces

aeromedical evacuation, 611–612

culture of, 46–47

physician training, 154

Special Operations Forces Medical Element, 612

Special Operations Surgical Team, 612

Special staff, 125–126

Specialized teams

aeromedical evacuation, 611

Specialty training, 188–189

Spirituality

chaplains role, 407

concepts of, 408–410

considerations in provider-service member/patient relationships, 410

definitions, 406, 407

guidance to commanding officers, 410–411

health and, 408–409

military history of, 406

performance and, 408–409

relationship to disease, 408

resources, 411

role of the military medical officer, 410

spiritual care for service members and patients, 409–410

Sport Concussion Assessment Tool, 590

Sports

concussions and, 592–593

rehabilitation and, 449

Sports Medicine Injury Prevention program, 395

Spouses

psychological well-being, 369

resources, 425

SRP. See Soldier readiness program

ST-elevation myocardial infarction, 464

Staff College, 20

Staff judge advocate

definition, 68

Staff officers

characteristics of effective officers, 128–131

communication skills, 130–131, 142

competence of, 128

confidence of, 130

coordinating staff, 124–125

creative thinking of, 129

creativity of, 129

decision briefing format, 130, 142

flexibility of, 129–130

helping commanders “see” the battlefield, 129

initiative of, 129

management skills, 130

mission briefing format, 130, 142

personal staff, 126

special staff, 125–126

team loyalty, 130, 141

Standards of Conduct Office, 85

START algorithm, 519

STEMI. See ST-elevation myocardial infarction

Sternberg, George, 15–16, 146

Stevenson, Walter, 71

Stewart, Clarence, 146

STRATCOM, 114

Stratton, Nate, 128

Straub, Paul F., 16, 17

Strength training, 286–287

Stress casualties prevention, 133–134

Stress fractures, 397

STS. See Space Transportation System

Subject matter experts, 293

Subjective, Objective, Assessment, Plan notes, 171–172, 260, 261

Summers, Harry, Jr., 146

Sunderland, Pearson “Trey,” 81

SuperTracker, 308

Supplemental Standards of Ethical Conduct for Employees of the Department of Defense, 84

Supreme Headquarters Allied Expeditionary Force for the European Theater, 113

Survival, evasion, resistance, escape, 161

Sustainment load, 158

Swanson, Steve, 358

Sympathomimetic poisoning, 470

Syrian Conflict, 93–94

T

Tabun, 534–535

TACEVAC. See Tactical evacuation

Tactical Combat Casualty Care, 155, 210, 466, 481–485, 589, 591

Tactical Emergency Medicine Support, 482

Tactical evacuation, 212, 482, 604

Tactical field care, 482

Tactical field skills

airborne medicine, 161

communication training, 158–160

convoy operations, 157–158

dive medicine, 161

flight medicine, 161

mass casualty planning and training, 162

medical evacuation, 162

military bearing, 161–162

military vehicles driving, 157

need for training, 154–155

operational and intelligence briefings, 162

operational medical training, 161

personal equipment layers, 158

preventive medicine, 162

principles of navigation, 156–157

shooting, 155–156

survival, evasion, resistance, escape, 161

time management, 162

Tactical medicine

airway management, 485–486

antibiotics, 492–493

case review, 493–494

chest trauma, 486–487

contrast to civilian prehospital care, 482–483

damage control resuscitation, 487–491

definitive proof of effectiveness, 482

hemorrhage control, 483–485

history of combat death statistics, 479–480

medications, 491–493

mission profiles for a marine expeditionary unit, 479

origins of, 481–482

pain control, 491–492

phases of care, 482

tactical environment, 478–479

tranexamic acid, 491

wounding patterns, 480–481

Tactics, techniques, and procedures, 210, 211

Task Force Marauder, 265

TBIs. See Traumatic brain injuries

TCCC. See Tactical Combat Casualty Care

TDRL. See Temporary Disabled Retired List

Team leadership element, 53, 60–61

Technical authority, 127–128

Technical chain of command, 137–138

Technical Co-operation Council Programme, 197

Technical training, 187–188

Technology. See Health information technology

Telehealth

definition, 226

TEM. See Traumatic event management

Temporary Disabled Retired List, 70, 71

TEMS. See Tactical Emergency Medicine Support

TFC. See Tactical field care

TFF. See Total Force Fitness

“The strategic corporal,” 150–151

Theater hospitalization care capability, 210–211

Theater lead agent for medical materiel, 250–251

Thermal balance equation, 315

Thermotolerance, 315

Time management, 162

Time-out procedure, 171–172

TLAMM. See Theater lead agent for medical materiel

TOCs. See Toxic industrial chemicals

Tolerable upper intake levels, 301

Toner, James, 37

Total Force Fitness. See also Physical fitness

model, 277

resources, 281

role in force health protection and readiness, 278

soldier-centered care, 279

spiritual fitness, 406–411

tenets of, 277

Tourniquets, 483–484

Toxic industrial chemicals, 535–536

Training programs

emergency preparedness, 636

enlisted service members, 189–190

leadership training, 188–189

for military medical officers, 27

operational medical training, 161

specialty training, 188–189

technical training, 187–188

unit training, 189

Tranexamic acid, 487, 491, 493

Transactional leadership style, 56

Transformational leadership style, 56

Transportation management, 523. See also Casualty evacuation

Trauma-associated sleep disorder, 384

Trauma treatment, 466–468

Traumatic brain injuries

background of, 586

clinical management algorithms, 589

concussion management in deployed settings, 589–591

concussion management in nondeployed settings, 592–593

defining postinjury periods, 587

definition, 586

demographics, 586

epidemiology, 586

Glasgow Coma Scale, 592

incidence among civilians, 588

management in deployed settings, 589–592

military incidence of, 587–588

with polytrauma, 591–592

postconcussive symptom management, 593–597

potentially concussive events, 586–587

predeployment screening, 433

primary blast injuries, 548

research considerations, 598

severity range, 587

Traumatic event management, 581–582

Traumatic grief, 577

TRAVAX.com, 591

Travelers’ Health, 242

Treadmill 2 with vibration isolation system, 357–358

Trench foot, 316

Tri-Service Food Code, 628

Tri-Service Pain Management Task Force, 561

Triage

mass casualty incidents, 517–520

radiation-injured patients, 545–546

Trial counsel

definition, 68

Triarchic intelligence, 59

Tricare, 117–118

Tricare For Life, 120

Trimix, 327

Tripler, Charles, 13

Truman, Harry, 40, 109

Trump, Donald, 43

TTP. See Tactics, techniques, and procedures

Tularemia, 541

2B-Alert Web application, 387

U

UCMJ. See Uniform Code of Military Justice

UHF radio, 159–160

Ultra high frequency radio, 159

Ultrasonography, 463

Under Secretary of Defense for Personnel and Readiness, 112

Undersea and Hyperbaric Medical Society, 327

Undersea operations

effects of depth on volume, pressure and gas partial pressure, 337

human performance optimization strategies, 341–343

military applied physiology, 335–338

military history and epidemiology, 330–332

Unified Command Plan, 113

Unified medical program, 120–121

Uniform Code of Military Justice. See also Military law

civilian offenses, 71–72

conduct prejudicial to good order and discipline, 74

conduct unbecoming an officer, 74

definition, 68

dereliction of duty, 72–73

failure to obey a lawful order, 72–73

historical evolution of, 69–70

jurisdictions covered by, 70–71

military “catchall” offenses, 73, 74

military medical officers’ accountability, 26

reports of violations, 75–76

reserve jurisdiction, 70

uniquely military offenses, 72–73

war crimes, 73–75

Uniformed Services University of the Health Sciences

function of, 117

operational planning, 268

“White Coat Ceremony,” 1

Uniquely military offenses, 72–73

Unit cohesion, 371

Unit training, 189

United Kingdom

multinational medical collaboration, 194

United Nations

Convention on the Prevention and Punishment of the Crime of Genocide, 94–95, 100

International Covenant on Civil and Political Rights, 100

multinational medical collaboration, 194

United States

multinational medical collaboration, 194

Universal Declaration of Human Rights, 99–100

US Air Force Academy, 53

US Anti-Doping Agency, 307

US Army Medical Materiel Agency, 251

US Army Medical Materiel Center-Europe, 252

US Army Medical Materiel Center-Korea, 252

US Army Medical Materiel Center-Southwest Asia, 252

US Department of Agriculture, 308

US Food and Nutrition Board, 300

US Military Academy, 41

US Preventive Services Task Force, 433

US Sanitary Commission, 13, 92

US Special Operations Command, 47

US Transportation Command, 254

USAMMA. See US Army Medical Materiel Agency

USAMMC-E. See US Army Medical Materiel Center-Europe

USAMMC-K. See US Army Medical Materiel Center-Korea

USDA. See US Department of Agriculture

USUHS. See Uniformed Services University of the Health Sciences

V

Valsalva maneuver, 327, 334–335

Variola, 541–542

Vector control, 625–626

“Vector” model, 25–26

Vehicle driving training, 157

Venous thromboembolic events, 450

Very high frequency radio, 159

Vesicants, 533–534

Vestibular and Oculomotor Screening, 594

VHF radio, 159

Victory Corps, 287

Vietnam War

aeromedical evacuation, 608–609

Agent Orange, 234

Levy case, 19, 74

multinational medical collaboration, 195

wounding patterns, 481

Viral agents, 541–543

Viral hemorrhagic fever, 542–543

Virtual health information systems, 231

Voluntary Aid Societies, 97

Volunteer military force, 42

Von Braun, Wernher, 348

Von Clausewitz, Carl Philipp Gottfried, 44, 146

Von Steuben, Friedrich Wilhelm Augustus, 7–8, 234

W

WAPS. See Weighted Airman Promotion System

War crimes

grave breaches, 94

prosecutions, 73–75

responsibilities of military medical personnel, 93–94

War Crimes Act, 74

War-gaming, 267

War of 1812, 9

War of Austrian Succession, 12

War Powers Act of 1973, 148

War with Spain, 15–17

Warden, John, 45

Warning order, 172

WARNO. See Warning order

Warrior Strong Study, 594

Warrior Transition Units, 561

Washington, George, 39–40, 47, 92, 180, 234

Waste disposal, 628–629

Water standards, 626–628

Weapons training, 155–156

Weighted Airman Promotion System, 183

Well-being. See Psychological well-being

Wet bulb globe temperature, 315

What3words, 157

“White Coat Ceremony,” 1

Whiteside, Elizabeth, 79

Williams, Jeffrey N., 358

Williams, Sunita, 358

Wind chill temperature, 315

World Fact Book, 241

World Health Organization, 242

World War I

casualty evacuation, 606–607

military medical officers, 17–18

multinational medical collaboration, 195, 196

wounding patterns, 481

World War II

casualty evacuation, 607–608

military medical officers, 18–19

multinational medical collaboration, 195, 196

wounding patterns, 481

Wounded warriors

psychological well-being, 369

Wounding patterns, 480–481, 514–515

Wright, Orville, 330

Wright, Wilbur, 330

Wrist actigraphs, 386–387

Written communication, 171

X

XABCDE care, 466–467

Y

Yerkes-Dodson Law of Optimal Arousal, 367