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Role of human health care providers and medical treatment facilities in military working dog care and accessibility difficulties with military working dog blood products.

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ROLE OF THE MILITARY WORKING DOG

Military working dogs (MWDs) are used in unprecedented numbers in current military operations, and play a vital role in both protecting human lives and supporting military objectives. (1,2) Military working dogs are trained to perform a variety of roles such as explosive, mine, and narcotic detection, patrol/attack work, special operations support, and animal assisted therapy for physical and emotional injuries, to name just a few. (1) Similar to the human service members they serve, MWDs are susceptible to both combat and noncombat related injuries in the operational environment. Contract working dogs (CWDs), which are owned by a private entity and perform a Department of Defense (DoD) mission, are also used extensively, typically performing a non-combat security mission. The need for effective MWD teams has increased significantly with the prevalence of improvised explosive devices (IED) in recent years. In 2008, GEN David Petraeus aptly noted:
   The capability that military working dogs bring to the
   fight cannot be replicated by man or machine. By all
   measures of performance, their yield outperforms any
   asset we have in our inventory. Our Army would be remiss
   if we failed to invest more in this incredibly valuable
   resource. (3)


At a time when IEDs represent one of the most significant threats to our service members, MWDs remain our greatest countermeasure to that threat. It is important to remember that the purpose of the MWD is to save human lives, and maintaining their health and proficiency is critical to military operations. Anytime an MWD team detects an explosive device before it detonates, the result is that humans are not killed, maimed, or injured.

OVERVIEW OF MILITARY WORKING DOG CARE IN AN OPERATIONAL ENVIRONMENT

Veterinary care in a developed operational environment is provided by the Medical Detachment Veterinary Service Support (MDVSS). This organization has 5 Veterinary Service Support Teams with one general practitioner veterinarian (AOC * 64A) and one animal care specialist (MOS * 68T) each, to provide Role 1 and Role 2 veterinary care. There is one Veterinary Medicine and Surgery Team with a veterinary clinical medical officer (AOC 64F) and 3 animal care specialists providing Role 1-Role 3 veterinary care. As delineated in Field Manual 4-02, (4) Role 1 care is nonsurgical treatment by an animal care specialist or veterinarian for minor wounds, injuries, or illnesses, preventive medicine, analgesia, emergency intervention for airway, hemorrhage, and fracture immobilization. Role 2 veterinary care includes veterinarian-directed resuscitation and stabilization and may include advanced trauma management, emergency medical procedures, and emergency resuscitative surgery. Role 3 veterinary care includes consultation and referral for advanced veterinary diagnostic, therapeutic, and surgical procedures. This level of care requires a veterinary clinical medical officer with training in surgery, internal medicine, or critical care. In the combat theater, this facility is typically collocated with a Role 3 human hospital for equipment and technical support. There is frequently only one or a partial MDVSS in a combat theater. At the height of Operation Enduring Freedom, there were 2 MDVSS units deployed to Afghanistan. Consequently, there are typically very limited numbers of veterinary providers in theater, and MWDs are often geographically separated from immediate veterinary support. The doctrinal basis of allocation is one mDvsS per 60,000 troops or 50 MWDs, which is rarely met based on the MWD numbers. Additionally, the ratio of MWDs to troops has increased dramatically in recent years due to the widespread use of IEDs.

Both MWDs and CWDs are eligible for veterinary care and medical evacuation within the combat theater (CWDs based on the provisions of the government contract). Military working dogs are also eligible or aeromedical evacuation (AE) out of the theater, however, for CWDs it is the responsibility of the owning entity to evacuate them from theater. Similar surgical principles for combat injuries are followed for MWDs and human service members, in that definitive care for significant trauma and for high-energy and contaminated wounds is often delayed until the patient is out of the combat theater. This is not the case for CWDs as they often receive definitive care and recover in theater. Procedures are occasionally performed on CWDs in theater as an alternative to euthanasia due to the expense and delay that accompanies private transport out of theater. While there is not a provision for AE of CWDs out of theater, there is a mechanism for AE of human contractors when medically indicated.

HISTORY OF THE MILITARY WORKING DOG CLINICAL PRACTICE GUIDELINES

Early in the operations in Afghanistan and Iraq, it became apparent that human medicine health care providers (HCPs) frequently encounter sick or injured MWDs before veterinary providers. Consequently, each veterinary detachment developed an MWD care SOP to provide guidelines for HCPs treating working dogs in the absence of veterinary personnel. With this system, the veterinary guidance and authorized HCP scope of practice for MWDs varied with each rotation. The first MWD clinical practice guideline (CPG) was published in 2011, entitled "Canine Resuscitation," and posted on the Joint Trauma System CPGs. (5) This document served as a provisional MWD CPG until a comprehensive product could be developed. In March of 2012, the "Clinical Management of Military Working Dogs" was published replacing the initial CPG. (6) This document is a comprehensive CPG consisting of 106 pages and 16 appendices, which contains the full range of MWD medical topics within one CPG. The DoD Military Working Dog Veterinary Service (DoDMWDVS) served as the MWD CPG proponent and the initial tasks were authored by the instructors from the Animal Health Branch, Department of Veterinary Science, US Army Medical Department Center and School (AMEDDC&S). The CPG received extensive peer review from a broad range of veterinary corps officers (VCOs), animal care specialists, and HCPs. The DoDMWDVs continues to serve as the proponent for the MWD CPGs. The next revision will be published in 2016.

The MWD CPG begins by outlining the conditions in which an HCP should provide emergent care to an MWD, namely, in the absence of veterinary personnel when MWD life, limb, or eyesight are at risk, and to prepare the dog for emergency evacuation to definitive veterinary care. (6) Healthcare providers are not authorized to perform routine medical, surgical, or dental care to MWDs without prior veterinary coordination and approval. Healthcare providers are cautioned that many MWDs are trained to attack and any animal that is ill or injured may respond to treatment with aggression. Military working dogs should always be accompanied by a handler. However, handlers may be killed or injured in combat and MWDs, injured or not, are a significant risk when separated from a handler. If the assigned handler is not present, it is important to identify an alternate handler as soon as possible. The MWD CPG provides information on normal clinical parameters and includes management of a number of emergency conditions, such as airway, CPR, shock, gastric dilation volvulus, anesthesia, analgesia, and even humane euthanasia, to name a few. (6) Healthcare providers are cautioned to only perform procedures on MWDs that fall within their clinical skill set.

ARE THE MILITARY WORKING DOG CLINICAL PRACTICE GUIDELINES USEFUL?

Anecdotally, the MWD CPGs are very helpful in providing appropriate guidance to HCPs on managing MWD emergencies. However, it is unknown how many times HCPs have provided emergent care to MWDs. Appendix Q of the CPG mandates that providers complete an after-action review (AAR) within 48 hours and provide it to the supporting veterinary unit. This self-reporting either does not occur or, if it does, is not reported to the DoDMWDVS. As part of the MWD CPG revisions going forward, AARs should go to the Defense Trauma Registry, formerly Joint Theater Trauma Registry, and DoDMWDVS.

MILITARY WORKING DOG CLINICAL PRACTICE TRAINING VENUES

The VCOs in theater are active in providing training to HCPs in MWD care. It is also common for HCPs to spend time in the veterinary hospital to gain experience. The AMEDDC&S Joint Forces Combat Trauma Management Course includes an introduction to the MWD CPGs. In recent years, VCOs have been invited to military medicine trauma symposia for MWD training. Training is always available to units, both in garrison and deployed, upon request from local or supporting veterinary units. A new development in 2015 was the addition of 15 MWD emergency critical tasks to the Critical Care Flight Paramedic (CCFP) critical task list. This is the first time HCPs have been formally assigned MWD emergency tasks and it is incorporated into the CCFP Course.

MILITARY WORKING DOGS IN MILITARY TREATMENT FACILITIES

Military working dogs in deployed settings are frequently treated in human medical treatment facilities (MTFs). This is often a necessity due to lack of veterinary facilities or existing veterinary facilities may lack needed equipment. The MWDs may require MTF support for imaging, laboratory, surgery, medical procedures, or instrument sterilization. Currently there is no DoD policy outlining MWD access to care in MTFs. While most hospitals are extremely supportive, there is often confusion and MWD access may be dependent upon case by case negotiation with MTF leadership or departmental staff. Military working dogs in garrison typically only require MTF access for advanced imaging modalities, such CT and MRI, which are beyond the scope of the military veterinary facilities. There are Centers for Disease Control and Prevention recommendations for animals as patients in healthcare facilities which may serve as a basis for a DoD policy. (7) Military working dogs are a crucial life-saving asset to humans serving in harm's way and it is important to ensure they have MTF facility and equipment support when the need arises.

MILITARY WORKING DOG BLOOD MANAGEMENT IN AN OPERATIONAL ENVIRONMENT

Management of MWD blood products differs greatly from the human counterpart in there is no feasible means to ship MWD blood components into the operational theater. The military logistical chain exists for cold-chain shipping of human blood components, but animal blood products are not permitted to accompany those shipments. Private transport of canine blood components is too cost prohibitive to be a solution. The organic capability of the MDVSS only supports the collection and administration of fresh whole blood (FWB). Fresh whole blood is suitable for many clinical conditions in the MWD, however, there are times when fresh frozen plasma (FFP) or platelets are a critical need. There are currently no shelf stable canine blood components available that serve as a suitable substitute.

The FWB need has been reasonably met by the MDVSS instituting a walking blood bank and prescreening donors to be available when the need for transfusion arises. This obviously takes more time than would be required if packed RBCs were available. Previously, MWDs were screened for infectious disease according to the American College of Veterinary Internal Medicine guidelines for blood donors, which involved sending out serology to Germany. (8) The cost to support the laboratory analysis for MWDs in OIF/OEF was initially absorbed by Dog Center Europe, the Role 3 veterinary referral center located at Pulaski Barracks in Kaiserslautern, Germany. Due to fiscal constraints of the Public Health Command, that was no longer funded as of 2013. The MDVSS in Afghanistan could not secure funding by any other means for donor screening. Consequently, after 2013, MWDs selected for blood donors only received a limited disease screening based on point of care tests available to the MDVSS, putting the blood supply at greater risk for infectious disease. It is not known if any diseases have been transmitted to MWDs through this process.

The need for FFP was temporarily abated in OEF by use of plasma apheresis. In 2011, initial efforts began to develop an FFP collection and distribution program out of Kandahar Airfield (KAF). In 2012, the MDVSS obtained their own apheresis unit and it was designated for animal use only. The KAF apheresis team was instrumental in helping to establish this capability in training veterinary personnel to operate the unit. This enabled the collection and storage of FFP at KAF and subsequent distribution to other veterinary sites throughout Afghanistan. Additionally, this apheresis unit was used to collect platelets when the clinical need occurred. This capability has been a tremendous asset for treating sick and injured MWDs in Afghanistan, however, it is an ad hoc capability that only exists in Afghanistan. It is not organic to the MDVSS for other operational environments.

At a recent Veterinary Equipment Set (VES) review conducted by the Capability Development Integration Development (formerly the Directorate for Combat Doctrine and Development) in 2015, no additional equipment or capability to support FFP collection was added to the set due to limitations in cost and weight of the VES. A plausible suggestion by the review panel was to establish an apheresis equipment push-package at Fort Sam Houston, TX, that could be shipped to a deployed MDVSS upon request.

CONCLUSION

In this article, several aspects of Doctrine, Organization, Training, Material, Leadership, Personnel, Facilities are relevant. The MWD CPGs pertain to doctrine and training. The advent of the MWD CPGs are a very useful tool to HCPs and this practice should continue. Additionally, we should maximize hands-on training opportunities for HCPs that are likely to encounter or treat MWDs. The issue of MWDs as patients in MTFs pertains to doctrine. Currently, there is no DoD policy regarding access for MWDs to MTFs. A baseline policy will ensure MWDs have appropriate access when needed, and that MTFs can implement proper infection control measures. Establishing the capability for the MDVSS to generate blood components for MWDs, most importantly FFP, relates to materiel. While it is not currently feasible to outfit every MDVSS with apheresis capability, establishing a centralized push-package is a reasonable solution until alternate shelf-stable products become available.

REFERENCES

(1.) Giles JT. Treatment of battlefield injuries in the military working dog: initial stabilization. Veterinary Symposium. American College of Veterinary Surgeons 2014 Surgery Summit. Red Hook, NY: Curran Associates, Inc; May 2015:423-425. Available at: http://www.proceedings.com/24966.html. Accessed March 21, 2016.

(2.) Giles J. Medical evacuation of the military working dog. In: Military Veterinary Services. Borden Institute: Joint Base San Antonio-Ft Sam Houston, TX. In press.

(3.) Crippen L. Military working dogs: guardians of the night [internet]. US Army website news archives. May 23, 2012. Available at: http://www.army.mil/ article/56965/Military_Working_Dogs__Guard ians_of_the_Night/?con=&dom=pscau&src=syndi cation. Accessed September 26, 2015.

(4.) FieldManual 4-02: Army Health System. Washington, DC: US Department of the Army; August 2013:112-11-5 Available at: http://armypubs.army.mil/doc trine/DR_pubs/dr_a/pdf/fm4_02.pdf. Accessed March 21, 2016.

(5.) Joint Theater Trauma System Clinical Practice Guideline. Canine Resuscitation. Fort Sam Houston, TX: US Army Institute of Surgical Research; April 18, 2011. Available at: http://usaisr.amedd.army. mil/cpgs/Canine_Resuscitation_18_Apr_2011.pdf. Accessed September 26, 2015.

(6.) Joint Theater Trauma System Clinical Practice Guideline. Clinical Management of Military Working Dogs. Fort Sam Houston, TX: US Army Institute of Surgical Research; March 12, 2012. Available at: http://usaisr.amedd.army.mil/cpgs/Clini cal_Mgmt_of_Military_Working_Dogs_Com bined_19_Mar_12.pdf. Accessed September 26, 2015.

(7.) Schulster L, Chinn RYW. Guidelines for environmental infection control in health-care facilities. Recommendation of CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR. 2003;52(RR-10):28-30. Available at: http:// stacks.cdc.gov/view/cdc/32395. Accessed March 21, 2016.

(8.) Wardrop KJ, Reine N, Birkenheuer A, et al. Canine and Feline Blood Donor Screening for Infectious Disease. J Vet Intern Med. 2005;19(1):135-142.

* AOC indicates area of concentration (an Army designation); MOS indicates military occupational specialty.

Author

LTC Giles is Chief of Surgery, DoD Military Working Dog Veterinary Service, Joint Base San Antonio-Lackland Air Force Base, Texas.
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Title Annotation:Veterinary Care
Author:Giles, James T., III
Publication:U.S. Army Medical Department Journal
Geographic Code:1USA
Date:Apr 1, 2016
Words:2615
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