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Army medical department at war: healthcare in a complex world.

As of February 28, 2014, 1,308,626 US Soldiers had deployed in support of Operations Enduring and Iraqi Freedom. Of them, 808,969 were Active, 336,043 were National Guard, and 163,614 were Army Reserve. Many of them, 383,492 Active, 107,906 Guard and 52,097 Reserve component Soldiers, deployed more than once. Department of Defense casualties from October 2001 through March 2014 include 5,332 killed in action, 1,453 nonhostile deaths, and 51,932 wounded in action (Figure 1). (1) The Army has sustained 3,877 killed in action, 1,044 nonhostile deaths, and 36,421 wounded in action (WIA) (Figure 2). (1) Approximately 33% of Army WIA required evacuation out of theater. Of the Soldiers wounded, 44% remained on active duty or inactive reserve and 17% WIA were medically separated. During a conflict that saw dramatic increases in the severity of injuries, equally dramatic improvements in casualty care from the point of injury through rehabilitation greatly improved survival (Figure 3). Our nation owes a tremendous debt to the service members who sacrificed so much during the current conflict, including the medical personnel who stood shoulder to shoulder with them on the battlefield and the families who supported them back home. While we continue to care for those who currently serve in Iraq and Afghanistan, we must also begin preparations to care for the casualties of future conflicts.

The US Army Operating Concept, Win in a Complex World (2) describes the future environment as unknown, unknowable, and constantly changing. The technological advantage the US military has enjoyed over its adversaries since 1945 is diminishing. War remains a fundamentally human endeavor and the Army is preparing Soldiers to succeed by maintaining its edge in the human dimension of combat power. The US Army Human Dimension Strategy focuses on the cognitive, physical, and social components of professionals and teams. (3) Its lines of effort--agile, adaptive leaders; realistic training; and institutional agility--are incorporated into Army Medicine's ready medical force model (Figures 4 and 5). Army Medicine is applying the human dimension strategy to prepare Army Medical Department (AMEDD) personnel for the increasing complexity and uncertainty ahead. Army Medicine must be prepared for the full spectrum of military operations from major combat through humanitarian missions. It will play a major role in shaping the security environment and developing the capabilities of partners and allies. Combat medics in the future may control truncal hemorrhage while under fire, and laboratory technicians may provide rapid confirmation testing for Ebola in West Africa.

Like armed conflict, healthcare is a complex, risk-filled human endeavor. Military healthcare is even riskier, more emotionally charged, and filled with uncertainty. Army Medicine requires leaders who can thrive and grow in this environment. These leaders build the teams who provide care on the battlefield, in the operating rooms, intensive care units, wards, and clinics. They provide the purpose, direction, and motivation necessary for safe and effective care. The Squad Overmatch Study applies the human dimension concept while training the infantry squad as a team. It builds on existing warrior skills training and incorporates team building, situational awareness, resilience and performance enhancement, and tactical combat casualty care. It also provides a framework for squads to conduct after action reviews and take ownership for improving their team performance (Figures 6 and 7). This model applies equally well to building the AMEDD teams who care for warfighters and their families.

We do not know when or where we will fight in the future. We may be called upon to deploy in days, or a few hours. Our adversaries will continually adapt and present us with new and more difficult challenges. We may operate in remote locations, under austere conditions, with long lines of communication. We may find ourselves in ungoverned megacities or face technologically advanced near-peer competitors. Communications may be degraded, casualty evacuation delayed, and medical personnel may provide prolonged field care. We face many of these challenges around the world today. In Africa, evacuation distances are measured in thousands of miles. In Afghanistan, the Golden-Hour Offset Surgical Treatment-Mission provides casualties with lifesaving damage control resuscitation/surgery near the point of injury. The concept of prolonged field care may begin on the front lines, but it has implications for every subsequent level of evacuation and treatment. It applies not only to trauma but also to disease and nonbattle injuries. Prolonged care of a patient with a pulmonary embolism or cerebral malaria in the field will require skills not traditionally taught in our schools or military treatment facilities. New approaches to education and training, new organizational structures, equipment, and greater reach back capability will required for successful management of complex patients who are awaiting evacuation.




Within the lectures and papers presented in this edition of the AMEDD Journal are key lessons learned for each of the components of the DOTMLPF-P* domain. The discussion at the end of the symposium raised further issues to consider as we look to the future of Army Medicine. The questions presented below range from the tactical to the strategic level and apply across all AMEDD Corps:

1. How do we effectively capture the lessons of a conflict, apply them in real time to provide advances in care, and document them for those who follow us?

2. How do we identify and apply the enduring lessons of the current conflict while preparing for the new challenges of the next?

3. What is the best format to distribute lessons learned more broadly, rapidly, and effectively? What is the appropriate use of handbooks, clinical practice guidelines, doctrine, and policy changes?

4. How do we ensure the National Guard and Reserves are incorporated into readiness and lessons learned programs?

5. How do we best transition from a counterinsurgency campaign and prepare for the full range of military operations where ground and air evacuation may be more difficult, communications degraded, and operations may be conducted in megacities or a CBRN * environment?

6. How do we develop the critical thinking skills required for healthcare in a complex world?

7. How do we retain the expertise gained across all AOC/MOS and Roles of Care in the current conflict?

8. How do we provide the education, training, and experience necessary for casualty care within our schools, MTFs, and in the civilian community?

9. How can we best use our senior NCOs to provide education, training, and experience in garrison?

10. How do we best develop and implement the concept of multidisciplinary teams providing casualty care from the front lines through rehabilitation, without an artificial distinction between care in theater and care at home?

11. How do we transition from an AMEDD focused on AOCs/MOSs * to one focused on required capabilities? How do we capture the transition in our monitoring and reporting systems?

12. How do we ensure modularity and scalability across the full spectrum of operations?

13. Given the lack of SIPR * access for most in Army Medicine, especially in the Army Reserve and Guard, how do we improve communication within NIPR * and/or SIPR channels?

14. Does the current PROFIS* model adequately address requirements of the sustainable readiness model?

15. How can the Army Medical Command collaborate more closely with operational and special operational forces?

16. How do we modify our business processing and monitoring systems to measure the education, training, and experience components of readiness?

17. How do we use Role 1, 2, and 3 outcome data to validate the effectiveness of predeployment training programs including Tactical Combat Management Course, Army Trauma Training Course, and Joint Forces Trauma Management Course?

18. How should we select, train, and evaluate personnel for operational assignments? How do we best develop their knowledge, skills, and behaviors prior to their assignment?

19. How should we optimize the electronic health record to facilitate treatment and support quality improvement programs?

20. How do we use CCQAS, * credentialing, and privileging to document and manage training, education, and experience readiness requirements across both the Army Medical Command and operational units?



The Strategic Landscape that Influences the Future of
Army Medicine Including Concept of Operations and

Joint Medical           Army Warfighting         ATP 4-02-55 Army
Concept Required           Challenges             Health System
Capabilities                                     Support Planning
                                                Medical Functions

Joint medical        Develop situational      Medical mission
  planning             understanding.           command
Joint theater        Shape the security       Medical treatment
  directed             environment.
  and medical
Monitor patient      Provide security         Medical evacuation
  outcomes, assess     force assistance.
  effects, and
Joint force          Adapt the                Hospitalization
  development         institutional Army.
  framework for
  health services
Medical mitigation   Counter weapons of       Dental services
  of the               mass destruction.
Joint                Conduct homeland         Preventive medicine
  credentialing        operations.              services
  and privileging
Medical treatment    Conduct space and        Combat and
  facilities           cyber                    operational stress
                       electromagnetic          control
                       operations and
Patient evacuation   Enhance training.        Veterinary services
Patient management   Improve solider,         Medical logistics
                       leader and team
Joint medical        Develop agile and        Medical laboratory
  leader               adaptive leaders.        services
Medical              Conduct airground
  intelligence         reconnaissance.
Joint and service    Conduct entry
  medical              operations.
  education and
Joint medical        Conduct wide area
  research and         security.
Medical logistics    Ensure
                       and operate
                       in a joint,
                       and multinational
Health services      Conduct combined arms
  contracts and        maneuver
Global health        Set the theater,
  services network     sustain operations
                       and maintain
                       freedom of
                     Integrate fires.
                     Deliver fires.
                     Exercise mission
                     Develop capable

Joint Medical        Medical Warfighting
Concept Required          Functions

Joint medical        Medical mission
  planning             command
Joint theater        Prehospital care
  and medical
Monitor patient      Primary care
  outcomes, assess
  effects, and
Joint force          Evacuation and
  development          enroute care
  framework for
  health services
Medical mitigation   Hospital care
  of the
Joint                Rehabilitation and
  credentialing        definitive care
  and privileging
Medical treatment    Force health
  facilities           protection

Patient evacuation   Medical sustainment
Patient management   Medical engagement

Joint medical        Medical information
Medical              Research and
  intelligence         innovation
Joint and service
  education and
Joint medical
  research and
Medical logistics

Health services
  contracts and
Global health
  services network


As we emerge from the mountains and deserts of Afghanistan and Iraq, we must prepare for a future that is unknown, unknowable, and constantly changing. We can study the lessons of the hybrid war being conducted in eastern Ukraine, the conflicts in Syria and Africa, and terrorism in Europe. At the same time, we must maintain situational understanding of the entire world since any region be our next battlefield. Army Medicine will face these challenges and, as in the past, it will adapt and overcome them. It will face them as a team that includes all Components and Army Civilians. It will draw guidance from the Army Operating Concept and Joint Concept for Health Support. As shown in the Table, the Army Warfighting Challenges, Joint Essential Medical Capabilities and Medical Warfighting Functions will serve as the framework for analysis of new concepts. (4-6) It will address the entire continuum of casualty care from the point of injury through evacuation, definitive care, rehabilitation, and reintegration (Figure 8).


(1.) Carino MJ. Army Casualty: Summary Statistics Overview-Update [presentation]. Falls Church, VA: Office of the Army Surgeon General; March 27, 2014.

(2.) The U.S. Army Operating Concept, Win in a Complex World 2020-2040: TRADOCPamphlet 525-3-1. Fort Monroe, VA: US Army Training and Doctrine Command; October 31, 20l4. Available at: http:// Accessed December 15, 2015.

(3.) The Army Human Dimension Strategy 2015. Wash ington, DC: US Department of the Army; 2015. Available at: fault/files/publications/20150524_Human_Di mension_Strategy_vr_Signature_WM_1.pdf. Accessed December 15, 2015.

(4.) Joint Concept for Health Services. Washington, DC: Joint Staff, US Dept of Defense; August 31, 2015:2. Available at: cepts/joint_concepts/joint_concept_health_servic es.pdf. Accessed December 15, 2015. *

(5.) Force 2025 and Beyond. Unified Land Operations. Win in a Complex World. Fort Monroe, VA: US Army Training and Doctrine Command; October 2014. Available at: http://www.ardc. force2025andbeyond-unifiedlandoperationswininacomplexworld_07oct2014.pdf. Accessed December 15, 2015.

(6.) Army Techniques Publication 4-02.55: Army Health System Support Planning. Washington, DC: US Department of the Army; September 2015. Available at: DR_pubs/dr_a/pdf/atp4_02x55.pdf. Accessed December 15, 2015.

* DOTMLPF_P indicates Doctrine, Organization, Training, Material, Leadership, Personnel, and Facilities. CBRN indicates chemical, biological, radiological, nuclear.

AOC/MOS indicates area of concentration/military occupational specialty.

SIPR indicates secure internet protocol router.

NIPR indicates nonsecure internet protocol router.

PROFIS indicates the Professional Filler System which predesignates qualified Active Army AMEDD personnel to fill positions in early deploying and forward deployed Army medical units upon mobilization for execution of an operations plan or a contingency operation, or for the conduct of mission-essential training.

CCQAS indicates Centralized Credentials Quality Assurance System, an internet-based, worldwide credentialing, privileging, risk management, and adverse actions database for the Defense Health Agency.


COL Murray is Deputy Chief of the US Army Medical Corps and Medical Corps Specific Branch Proponent Officer, AMEDD Center & School, Joint Base San Antonio-Fort Sam Houston, Texas.

MG Jones is the Commanding General, AMEDD Center & School, US Army Health Readiness Center of Excellence, Joint Base San Antonio-Fort Sam Houston, Texas.
Figure 1. Reported deaths and wounded in action by
military service, and mechanism of nonhostile
deaths (source: Carino (1)).


                                 ARMY     NAVY   MARINES

OEF   TOTAL HOSTILE DEATHS        1,303    83      373
      TOTAL NON-HOSTILE DEATHS      325    46       80
      WOUNDED IN ACTION (WIA)    13,900   390    4,915
OIF   TOTAL HOSTILE DEATHS        2,536    64      852
      TOTAL NON-HOSTILE DEATHS      697    39      171
      WOUNDED IN ACTION (WIA)    22,228   638    8,626
OND   TOTAL HOSTILE DEATHS           38    --       --
      TOTAL NON-HOSTILE DEATHS       22     2       --
      WOUNDED IN ACTION (WIA)       293     2       --

                                 AIRFORCE   DOD TOTAL

OEF   TOTAL HOSTILE DEATHS        54         1,813
      TOTAL NON-HOSTILE DEATHS    45           496
      WOUNDED IN ACTION (WIA)    488        19,693
OIF   TOTAL HOSTILE DEATHS        29         3,481
      TOTAL NON-HOSTILE DEATHS    22           929
      WOUNDED IN ACTION (WIA)    450        31,942
OND   TOTAL HOSTILE DEATHS        --            38
      TOTAL NON-HOSTILE DEATHS    4             28
      WOUNDED IN ACTION (WIA)     2            297


KIA, DWRIA             3,877     147    1,225         83     5,332
NON-HOSTILE DEATH S    1,044      87      251         71     1,453
WIA                   36,421   1,030   13,541        940    51,932

7 October 2001-26 March 2014

DEATHS                                                      TOTAL

Accident                607      44       173         49      873
Illness/Injury          114      22        11         11      158
Homicide                 34       4        10          2       50
Self-inflicted          270      11        56          8      345
Undetermined             17       5         1          1       24
Pending                   2       1        --         --        3
                      1,044      87       251         71    1,453

Figure 2. Casualty types for Department of Defense
overall and US Army specifically.

U.S. Military Casualties--OCD(GWOT) Casualty Summary
by Casualty Type

(As of March 26, 2014)

Operation/Casualty Type   Weaponry    Other    Transport   Pending

OEF Hostile Death             508      1,079       28        20
OEF Non-Hostile Death         132        175       89        16
OEF Pending                    --          2       --        --
  Non-Hostile Death
OEF Wounded in Action       3,659     10,484       16        21
OIF Hostile Death           2,079      1,062       92        54
OIF Non-Hostile Death         273        256      255        24
OIF Wounded in Action      19,324      8,953      131        25
OND Hostile Death              12         26       --        --
OND Non-Hostile Death          16          4       --        --
OND Wounded in Action          77        207       --        --

Operation/Casualty Type   Unknown   Medical   Total

OEF Hostile Death            176       2       1,813
OEF Non-Hostile Death         26      56         494
OEF Pending                   --      --           2
  Non-Hostile Death
OEF Wounded in Action      5,474      39      19,693
OIF Hostile Death            170      14       3,481
OIF Non-Hostile Death         27      94         929
OIF Wounded in Action      3,492      17      31,942
OND Hostile Death             --      --          38
OND Non-Hostile Death          2       #          28
OND Wounded in Action         13      --         297

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Title Annotation:Conclusion
Author:Murray, Clinton K.; Jones, Stephen L.
Publication:U.S. Army Medical Department Journal
Article Type:Report
Geographic Code:1USA
Date:Apr 1, 2016
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