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A combat support hospital in the Gulf War.

I was privileged to command a hospital that had several missions during Operations Desert Shield and Desert Storm from "peacetime" health care in Saudi Arabia to receiving casualties immediately behind the front lines in Iraq. There are several differences between operating a hospital in the field and one in a fixed facility in the United States, but there are enough similarities that readers can appreciate the issues and problems we faced to carry out our mission: to provide the best possible health care or casualty care that we could. The environment may have been different, but the mandate remains the same.

The 28th Combat Support Hospital (CSH) is a standard U.S. Army field medical unit: an emergency treatment area, 4 operating tables, a recovery area, 200 intensive care and convalescent beds total, and ancillary services. The 28th is stationed at Fort Bragg, N. C., and has the mission to provide medical support to the Rapid Deployment Forces primarily based at Bragg. It had not fielded the entire unit since World War II except for field training exercises. Parts of it had been deployed to Central America, to the Virgin Islands after Hurricane Hugo, and to South America on training deployments.

The hospital normally has a cadre of Medical Service Corps officer administrators; nurses assigned but with duty at a post hospital, a permanent facility; enlisted medical specialists who are often also assigned for duty at the post hospital; and other enlisted personnel who are responsible for communications, personnel administration, field dining facilities, vehicle and physical plant maintenance, and a host of other responsibilities. In garrison the unit maintains equipment, participates in training exercises, ensures that personnel receive individual training, and sees to administrative needs. A Medical Service Corps officer commands the hospital when it does not have a patient care mission. When the hospital receives a patient care mission, command passes to a designated Medical Corps officer, a physician who sees to it that the staff provides good patient care.

Physicians are not normally assigned to field medical units in their specialty; they are instead pulled from duty at fixed hospitals to be sent to fill positions in field units as necessary. This is worked out ahead of time in a Professional Filler System, or PROFIS. Most physicians are given this assignment when they report to a new duty station. In reality, few physicians are able to spend any time with their field unit because of the press of peacetime patient care. The same system is used for nurses and medical specialists.

All this results in a hospital staff that has to work together for a time before the unit comes together. The 28th CSH was no exception. Most of the clinical staff had spend less than six weeks with the unit before deployment to Saudi Arabia. They had no opportunity to check out the hospital equipment or to adjust to a new work environment. The 28th was among the first units to be sent to Saudi Arabia, so it had to mature as an organization as it cared for soldiers in a strange environment.

The 28th was not scheduled to receive the new Deployable Medical System (DEPMEDS) until 1992. It had been maintaining its ancient equipment but had limited ability to field the entire system. The press of providing peacetime health care had left little time for clinicians to point out where equipment needed replacement or upgrading. Upon alert to deploy to Saudi Arabia, the hospital had no time to inventory and requisition supplies and equipment before loading up and moving to port and onto ships for the voyage to Saudi Arabia. The hospital had a total changeover of key personnel in the few months preceding Desert Shield, so they were busy defining their responsibilities.

I took command of the unit after it had been in country less than a month. My first task was to define problems and issues so that we could address them. The first asset I counted was the confidence of the Medical Brigade commander, my immediate superior. He had asked me to take command because the previous PROFIS commander appeared to be overwhelmed by the challenges. I had worked with the brigade commander in previous assignments, and I knew he believed I could command well. The hospital was blessed with several capable people. The Executive Officer was bright, hard-working, and able to coordinate the staff as we outlined problems and issues that needed attention.

I selected a brash, outspoken surgeon to be the Deputy Commander and Chief of Professional Services. He had an unusual combination of clinical and military experience, having previously served for several years as an infantry officer with significant command and staff experience. This would serve the hospital well very soon.

The hospital Sergeant Major, the senior enlisted man, was brimming over with energy and ready to get people working. I gave him responsibility for area security. He coordinated with nearby units for reaction forces, communications, material for erecting barriers, and many other tasks as part of security.

One of my first steps was to insist on regular meetings of the combined clinical and administrative staff leaders. I wanted a forum where everyone had an opportunity to hear others' problems and their views of the issues we confronted. I encouraged every leader to keep their sections constantly informed about all we were doing. To motivate them to keep ahead of me, I held open sessions with all unit sections to try to answer questions, dispel rumors or confirm them, and find out the things they wanted to do their jobs better. These sessions were held every week at first, then every other week after people became more confident that we were telling them all that we could.

The 28th CSH was equipped with a 1960s vintage physical plant. The MUST (Medical Unit, Self-Inflating, Transportable) design was the successor to the Korean War vintage MASH. Instead of canvas tents, MUST consisted of inflatable structures and expandable towed boxes for operating rooms, laboratory, and x-ray. The suddenness of decisions to deploy to Saudi Arabia left no time for changeover to more modern systems. The hospital was struggling with equipment that wasn't standing up to the temperature extremes--130 degrees by mid-afternoon. Air-conditioning, compressed air to inflate the facility, and hot and cold water all depended upon gas turbine utility packs (UPACs) that shut down in temperature extremes.

The Sergeant Major had ordered a local fix before I had arrived. The UPACs weren't working in hot weather because the prevailing winds were carrying the turbine exhaust over the air inlet. The air conditioner couldn't cool the superheated air enough, and the air compressor shut down when overheated. The UPACs then automatically shut down. The turbine exhaust was vented away from the air intake by a six-foot stack, so the UPACs continued to work through the heat of the day. The MUST sections remained inflated, and more wards could be opened. This happened shortly after I arrived. I had to consider it more a good omen than a good decision, though the latter it undoubtedly was. I was fortunate in the timing of the fix. It bought me time to make corrections and make resources available so that people could see that progress was being made.

A decision to convert over to DEPMEDS was made during the 28th's movement to Southwest Asia. Because of timing, the transition would be made in Saudi Arabia for most units. This proved to be a blessing, as it allowed all sections of the hospital to participate in the reception, inventory, design, and erection of the new hospital. DEPMEDS consists of components; the type of medical unit determines the amount of tentage and expandable shelters made available. The components can be assembled in ways limited only by the imagination of the design team and the limitations of the terrain. We assigned the clinical staff to assist the design team, directing only that casualty flow should be one-way as much as possible. Physicians, nurses, and other officer professionals provided detailed input to a design team of senior sergeants who sketched out the plan linking emergency medical service, pharmacy, laboratory, x-ray, surgery, and wards. This effort allowed the staff to pull together in a practical bonding exercise and did more for unit cohesion than any amount of talking on my part. They came up with innovative solutions to water and electrical problems, as well as an excellent floor plan. The DEPMEDS fielding team took the plan back to its headquarters to study as an efficient way to lay out the facility. Enough new equipment was brought in with the new hospital that most of the concerns of the clinical staff were put to rest. At last, everyone felt that the 28th was their hospital.

Once we had treated a few casualties from accidents and the clinical staff saw that the facility, the supporting staff, and the equipment could work, they began to settle down and get on ith the business of preparing for combat casualty care.

Medical supply would always be a sore point with the doctors. The supply pipeline is 8,000 miles long, the equipment representative is not as near as the telephone, and the unit supply staff was converting over to a new computerized ordering system. We listened to numerous complaints about lack of supplies and the unresponsiveness of the hospital supply section before we discovered that the doctors were treating the system the same way they did back home. They asked for an item and assumed it should appear soon. Our solution was to educate the end users. Every ward and clinical section was assigned a physician who was given the task of learning the supply system. We took them to the supply depot, where they found assistance in matching the catalog numbers to the supplies they needed.

Shortly after I took coomand, I assessed our hospital mission as care of a "peacetime" force on a deployment, with possible missions into Kuwait if Iraq suddenly were to leave or in a war of movement with combat forces should Iraq invade Saudi Arabia. When we heard of the decision to increase troop strength in November, most of us realized that we faced the real possibility of caring for casualties. We were going to evict Iraqi forces from Kuwait by force. This put a new and greater sense of urgency upon our preparations. As other medical units arrived, I could only guess which might get the nod to go north. With an offensive capability developing, the need to anticipate how we would be deployed became part of our planning.

Early on, I had given the staff the task of determining how we would support a military force that would be highly mobile, be able to advance 50 to 100 miles a day, and find itself suddenly in combat with little time to prepare to receive casulaties. Based on my experience in Panama, I advised the surgeons to be prepared to care for casualties in tents for up to several hours while the rest of the hospital set up.

The Deputy Commander, the Executive Officer, an I put together a plan that called for a mobile team that would operate under canvas. We called it our Forward Surgical Element. One tent would house a casualty receiving and resuscitation area. A second tent contained two operating tables, with six intensive care beds for postoperative patients. This element would set up and function while the rest of the hospital was put up. It could begin to receive and treat casualties 30 minutes after starting to set up and could begin major surgery within an hour. We planned for an extreme scenario in which we would have very little notice to move from convoy to casualty care.

We briefed the concept to the Brigade, which was quite interested. The arguments were divided between "going light," and therefore fast, to get some--any--forward surgical capability where casualties could begin to receive care as quickly as possible, and "going heavy" to get as much capability forward as possible to care for large numbers of casualties. Our work with our Forward Surgical Element had caught the interest of higher headquarters and proved to be the impetus for the fast, mobile school of thought. Other light mobile surgical teams already existed, but the 28th had taken the concept of operation and made it heavier. It would not be able to function withotu resupply or help with evacuating casualties for any extended period, but it was the solution the staff had developed within the limits and assumptions for how we thought the hospital could best move and be close to combat forces. We planned to function for up to five days without resupply, anticipating it would take that long before any medical supply would follow ammunition and fuel resupply efforts.

It was the overall realities of the situation that gave the go ahead to the "light" approach. Amateur strategies argue tactics, but professionals always think logistics, trying to do what supplies will allow. The fact was that there was only so much transportation available to move fuel, ammunition, food, people, medical supplies, casualties, and anything else. No means existed within the allowed time to move a fully equipped hospital without using transportation assets of othe rmedical units. All commercial transportation in Saudi Arabia had been contracted by this time, so we couldn't expect to find any trucks.

The medical brigade opted to configure hospitals light and to lay down medical units sequentially, positioning each medical task force with support units about every 40 to 50 miles. This represented a day's planned advance and gave each unit time to set up while the previous unit was still within evacuation range by helicopter. Brigade provided more trucks for us and the other mobile units by stripping them from hospitals positioned in Saudi Arabia just south of Irag. We still lacked transport to move all but a portion of the entire hospital.

We began an effort to educate the clinical staff on what they might face in providing combat casualty care. Military physicians and other health care providers are not much different from their civilian counterparts. How similar they are became obvious as we recognized that few on active duty had any actual combat casualty care experience. Advanced trauma life support and combat casualty care courses were a help and proved to be a good starting point. Protocols were developed and drilled. Much of what was being done served to change mindsets as well as to refresh memories. The Army brought over its chemical casualty care experts to give courses. They did much to dispel rumors and provided a rational care plan for chemically injured soldiers. Staff members were now shifting to a mindset in which they had much more confidence in their abilities.

We talked with a Forward Surgical Team located nearby to get some of its ideas. It had been in Panama in December 1989 and had first-hand experience treating combat casualties in deployable facilities. It proved to be a great source of information on the differences we would encounter in tents and transportable shelters as opposed to a permanent hospital facility. They shared their experience and let my surgeons know that surgical care was possible insuch primitive surroundings. We were asking our doctors to tolerate conditions they would scream at back home, conditions most of them had never experienced and would consider malpractice. They had to learn that they weren't being asked to provide defintive care but just-good-enough or just-in-time care to stabilize casualties to be moved farther to the rear. They needed to hear from someone other than me that it was possible. I had credibility as a clinician and first-had experience as a combat surgeon, but because I was now management, I had to assume my motives were always questioned. I brought in as many people as I could find to deliver the message.

We were ordered to move to an assembly area on the Saudi-Iragi border about the time that air operations began against Iraq. There we would make final preparations for movement north.

One of the points that is difficult to communicate is the scale of the conflict. We started in Dhahran, a principal port on the Persian Gulf, 180 miles south of Kuwait. From there, we moved more than 350 miles to our assembly area just south of the Saudi-Iraqi border. We then advanced more than 130 miles northeast into Iraq. Other medical units moved even farther. We were part of the medical force that supported XVIII Corps, with four divisions, an armored cavalry regiment, and many supporting brigades and battalions. The Corps advanced over a distance equivalent to that from Norfolk, Va., to Cincinnati, Ohio, in moving to the preattack assembly areas. It then attacked over the distance from Cincinnati to Pittsburgh, Pa., by the time ground hostilities stopped.

We remained in our assembly area for the almost six weeks of the air offensive while we trained, received last-minute supplies and equipment, made final coordination with other supporting units, and made contingency plans for resupply, and patient evacuation, and further movement north or east as the battle might develop.

By this time, I was given command of a two-hospital medical task force, supplemented by an ambulance platoon and a medical platoon to handle the bulk of chemical casualty decontamination that was expected. We were to be the treatment point at the first large logistical base in XVIII Corps area. If the battle advanced closer to Basra, we were alerted to move our Forward Surgical Element forward if it became necessary, as the other units were expected to be fully committed and unable to move forward.

During this phase, the war planners were predicting a short, violent war; the medical planners with whom we dealt at our immediate higher headquarters developed our concept of support of the battle plan with this idea in mind. We at the 28th approached this estimate with some skepticism, for standard military teaching is that no plan survives initial contact with the enemy. We were told to pare down our equipment to less than 50 beds, and six O.R. tables; our limiting factor was the availability of trucks as well as the requirement to move overland rather than on hard road. We were assured that evacuation assets were enough to move casualties rapidly to the rear, so that they would not overwhelm us.

We crossed into Iraq just behind the combat elements of a Mechanized Infantry Division. Our greatest obstacle was time. We were able to arrive at our objective and set up the Forward Surgical Element (despite a 50-knot shamal, a desert wind) in time to care for early casualties, while the rest of the hospital was setting up. After hostilities ceased, we remained in position for almost a month to support U.S. forces in southern Iraq. We ended up caring for quite a few Iraq civilians, as unrest plagued southern Iraq, before moving back south.

The actual conduct of combat casualty care seemed anticlimatic after the months of preparation. People moved quickly to care for wounded, worked as a team, and kept each other informed. The short duration of the ground war certainly helped, but the time spent reviewing how we might be working to care for casualties was time well spent.

The challenges we faced weren't unique to the 28th Combat Support Hospital. In a six-month span we built a team, achieved goals, and overcame some significant challenges. Admiral Ernest King, Chief of U.S. Naval Operations in World War II, said that difficulties are the name we give to those obstacles it is our duty to overcome. I was reminded of that axiom almost every day in Saudi Arabia and Iraq.

I have tried to described our story from the viewpoint of the medical executive, to show that management and leadership techniques civilian physician executives use in their work every day are the same tools we needed and used to perform our mission. It was the privilege of a lifetime to command a medical unit supporting combat forces. I found myself relying on knowledge and skills I had spent a career accumulating. Most of our solutions to problems were blazing flashes of the obvious in light of our collective experience. The challenge, and the fun, was participating in the process to draw out those answers we needed for the difficulties we faced.

COL Hugh J. Donohue Jr., MD, FACS, USAMC, is Chief, Department of Surgery, Womack Army Medical Center, Ft. Bragg, N.C. The opinions expressed in this article are those of the author andare not necessarily those of the Department of Defense, the U.S. Army, or the Army Medical Department.
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Author:Donohue, Hugh J., Jr.
Publication:Physician Executive
Date:Jan 1, 1992
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