Army medical department at war: healthcare in a complex world.
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.
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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?
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The Strategic Landscape that Influences the Future of Army Medicine Including Concept of Operations and Readiness. 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. coordination, synchronization, and medical situational awareness Monitor patient Provide security Medical evacuation outcomes, assess force assistance. clinical effects, and adapt operations. Joint force Adapt the Hospitalization development institutional Army. framework for health services Medical mitigation Counter weapons of Dental services of the mass destruction. environment 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 maintain communication. Patient evacuation Enhance training. Veterinary services Patient management Improve solider, Medical logistics leader and team performance. Joint medical Develop agile and Medical laboratory leader adaptive leaders. services development Medical Conduct airground intelligence reconnaissance. Joint and service Conduct entry medical operations. education and training Joint medical Conduct wide area research and security. development Medical logistics Ensure interoperability and operate in a joint, interorganizational, and multinational environment. Health services Conduct combined arms contracts and maneuver resource programming Global health Set the theater, services network sustain operations and maintain freedom of movement. Integrate fires. Deliver fires. Exercise mission command. Develop capable formations. Joint Medical Medical Warfighting Concept Required Functions Capabilities Joint medical Medical mission planning command Joint theater Prehospital care directed coordination, synchronization, and medical situational awareness Monitor patient Primary care outcomes, assess clinical effects, and adapt operations. Joint force Evacuation and development enroute care framework for health services Medical mitigation Hospital care of the environment 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 leader development Medical Research and intelligence innovation Joint and service medical education and training Joint medical research and development Medical logistics Health services contracts and resource programming 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:// www.tradoc.army.mil/tpubs/pams/TP525-3-1.pdf. Accessed December 15, 2015.
(3.) The Army Human Dimension Strategy 2015. Wash ington, DC: US Department of the Army; 2015. Available at: http://usacac.army.mil/sites/de 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: http://dtic.mil/doctrine/con 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. army.mil/app_Documents/tradoc_ausa_ 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: http://armypubs.army.mil/doctrine/ 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)). CONCLUSION 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 OCO (OEF, OIF, OND) ARMY NAVY MARINES AIRFORCE DOD TOTAL 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 OCO (OEF, OIF, OND) TOTAL NON-HOSTILE ARMY NAVY MARINES AIRFORCE DOD 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 OEF=OPERATION ENDURING FREEDOM; OND=OPERATION IRAQI FREEDOM; OND=OPERATION NEW DAWN
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|Author:||Murray, Clinton K.; Jones, Stephen L.|
|Publication:||U.S. Army Medical Department Journal|
|Date:||Apr 1, 2016|
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