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--> 5 Force Medical Support A New Concept of Casualty Care Historically, military forces have been supported by a large complex of in-theater, health service support facilities. As with other logistics functions, there was a system of progressively more capable facilities, stretching from combat units rearward to CONUS. The focus was on returning patients to duty from the lowest possible echelon of care. Patients who could not be returned to duty within prescribed times were evacuated to the next higher echelon. Patients could spend from 30 to 120 days in the theater health care system before being evacuated to hospitals outside the theater; by then, patients were stable and required little care en route. The concept of casualty care supporting OMFTS is dramatically different from the traditional approach (see Figure 5.1).1 The concept places emphasis on early trauma care on the battlefield; rapid tactical aeromedical evacuation to a casualty-receiving and casualty-care facility (in most cases an amphibious assault ship); minimum, essential care and hospitalization in-theater; and rapid evacuation of casualties from the theater. In short, save life and limb, stabilize, and evacuate. Implementing the concept requires a carefully structured balance among 1 Marine Corps Combat Development Command. 1997. "A Concept of Casualty Care for Operational Maneuver from the Sea (Working Draft)," Marine Corps Combat Development Command, Quantico, Va., and Naval Doctrine Command, Norfolk, Va., November. Available online at <http://ndcweb.navy.mil/concepts/ccc/ccc1.htm>.
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--> FIGURE 5.1 OMFTS casualty-care concept. shore-based care, ship-based care, and evacuation capabilities. If shore-based medical capabilities are minimal, evacuation, en route care, and sea based capabilities must compensate. If evacuation times are long, shore-based capabilities must be sufficient to stabilize the patient before movement.2 The long distances implicit in the OMFTS vision of combat operations mean that tactical aeromedical evacuation from the battlefield to ship-based care could take 1 to 2 hours. Thus, the keys to casualty survival will be effective first aid and lifesaving emergency surgery on the battlefield. First-Responder Care Hemorrhage and inability to breathe require immediate attention at the site of injury. Other Marines (buddy care) and corpsmen offer the first opportunity to apply lifesaving procedures. Better training and medical equipment are needed to provide those first responders with the skills and tools they need to be effective. Injuries to the extremities are the most common wartime wounds. A study of Vietnam War casualties found that management of such wounds and associated bleeding was inadequate. Corpsmen were not trained to handle life-threatening injuries, and they lacked such simple field equipment as effective tourniquets. 2 Experience from the Vietnam War underscores the value of early trauma care. In that war, 78 percent of those killed in action died within 5 minutes, 16 percent in 5 to 30 minutes, and 6 percent in 1/2 to 2 hours. Eight to 10 percent of combat casualties required lifesaving surgery.
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--> Most thoracic injuries do not require immediate surgery, but do require temporary closure of wounds and the ability to expand the lung and control hemorrhaging in the chest cavity. Current field dressings do not provide adequate sealing of the chest cavity, and no device exists for field use in reexpansion of the lung and drainage of hemorrhaged blood. Pain management is important if evacuation is delayed or circumstances make it necessary to keep the casualty functional, for example, to perform self-care or unit duties. Current painkillers cannot be administered by untrained personnel and often leave the patient with impaired cognitive functions. Forward Surgical Unit Some minimal surgical capability will be needed to support the ground-combat units. The mission will be to stabilize casualties, including selected emergency surgery, prior to evacuation to ship-based care. The medical facility should be small, easily deployable, reconfigurable for transport by air or ground vehicle, and sustainable with water, oxygen, blood products, and recyclable non-consumables. Staffing would be tailored to the circumstances, but the minimum would be about ten medical personnel, among them at least two general surgeons, one orthopedic specialist, and two nurse anesthesiologists or anesthetists. Most importantly, the type of medicine practiced in an austere, forward surgical unit will be dramatically different from that taught in medical schools and practiced in hospitals or in previous conflicts. The staff should be trained to practice combat casualty care in that type of deployable facility, with the limited equipment, personnel, supplies, and time available. Aeromedical Evacuation Timely evacuation from the battlefield to ship-based medical care and from the ship to a hospital or hospital ship is a critical element in the OMFTS casualty-care concept. For these evacuations, the Marine Corps probably will not use dedicated medical evacuation aircraft but will assign aircraft to medical evacuation missions as needed, i.e., aircraft of opportunity. To increase casualty survivability during prolonged evacuation flights, an "en route care kit" should be designed. Such a kit should include equipment for monitoring a patient's vital signs and easy-to-use, life-sustaining emergency equipment. For example, the following minimum needs for transport of trauma patients should be met: monitoring of oxygen and carbon dioxide; respirator support for patients who can and cannot breathe on their own; multiple port suction equipment; electrical power to connect the equipment; and drugs specific for the type of patients. To increase the number of aircraft that could perform medical evacuation missions, the Navy should explore the feasibility of fixing man-rated evacuation pods to a
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--> proportion of the light helicopter fleet; such pods could be useful in evacuating casualties contaminated with chemical, biological, or radiological agents. Although the large amphibious assault ships have excellent casualty-care capabilities, they have little critical-patient holding space.3 To ensure that the ship does not become a bottleneck in the care system, the flow of casualties to more appropriate facilities must be maintained. Once emergency care has been provided, patients must be moved from the ships to hospitals that can continue the care. Current ship-capable aircraft, including the V-22, lack suitable en route care capabilities for long, medical evacuation flights; in-theater hospital care, a hospital ship, or transfer to strategic medical evacuation must be readily available. A ship-capable STOL transport would relieve this potential bottleneck in the casualty care system. Chemical and Biological Decontamination Medical planning must assume that some casualties will be contaminated with chemical or biological agents. Current planning and the capability to manage such an eventuality are inadequate. Standard procedures are needed for the following tasks: Care, handling, and decontamination of contaminated casualties, both in the field and on-board casualty receiving and care ships; Decontamination of medical staff and equipment; and Medical evacuation of contaminated casualties and medical support personnel without risk to aircrew. Medical Management and Integration The concept of minimum essential care and rapid evacuation, and the wide dispersion of medical capabilities, call for a centrally planned and well-integrated medical management system. Short-term allocation and reallocation of medical assets, management of patient flows, and management of medical workload will be essential to keeping the system balanced and responsive to combat developments. Moreover, as with other functions of logistical support, it will be essential to fully integrate medical considerations into the planning and execution of all aspects of the tactical operation, including especially aviation support. Medical personnel and the medical command structure must be trained to make decisions in the military medical care environment and must be provided the real-time data and information systems necessary to making those decisions. 3 Amphibious assault ships have ample capacity for patients suffering from short-term illness or minor injuries.
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--> The "SMART card," a programmable, personal data file card worn by each Marine, is currently the best approach to capturing, quickly and accurately, essential casualty data from a forward surgical unit or ship-based medical treatment facility. Medical Research and Development The Navy needs to mimic high-technology industry and put medical research and development on a requirements basis, i.e., targeted to specific needs of the combat casualty-care user for product functionality, reliability, cost-effectiveness, training, and support. The following are a few examples of the type of equipment that is long overdue in the field: Pneumatic tourniquets for each corpsman's kit; Portable device to take vital signs in a noisy, unlighted evacuation vehicle; Easy-to-use, life-sustaining emergency equipment for use on an "evacuation vehicle of opportunity"; Pain management compounds that can be administered by untrained personnel; Wound-dressing material impregnated with clotting substances; Blood substitutes that are ready for field use without laboratory verification, refrigeration, or preparation; Infection control management; Shore-facility oxygen generator; Miniaturized, reusable monitor of physiological signs; Means for shipboard manufacturing of intravenous liquids and solutions; Imaging equipment for casualty care in an austere environment; Better tents or shelters for forward surgical units; and Gear for medical personnel treating contaminated patients. Creating a balanced, effective casualty care system that will support OMFTS requires redirecting medical training, research and development, acquisition, and management to the critical features of the system: Marines who are trained to stop bleeding and aid breathing of a wounded "buddy," corpsmen who are trained and equipped to provide simple but lifesaving trauma care on the battlefield; forward surgical teams trained to practice combat trauma care in small, austere, deployable medical facilities; and aeromedical evacuation that provides essential en route patient monitoring and care. Throughout the system design, special attention needs to be given to procedures for handling and treating patients who have been contaminated with chemical or biological agents and to the management information systems needed to integrate all patient care activities in the task forces area of operations.
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--> RECOMMENDATION:The Navy and Marine Corps should reengineer the casualty-care system to match the warfighting concepts of OMFTS, giving highest priority to improving first-responder care, developing a forward surgical unit, handling and caring for patients contaminated by biological, chemical, or radiological agents and evacuating patients to at-sea care facilities and onward to points of strategic aeromedical evacuation.
Representative terms from entire chapter: