Document created: 6 December 01
Published Aerospace Power Journal - Winter 2001
Approved for public release; distribution is unlimited.
The Air Force Medical Service
in the Air Expeditionary Era
Lt Gen Paul K. Carlton Jr., USAF, MC, CFS*
*I wish to recognize the coauthors of this article: Col Richard Hersack, USAF, MC, CFS; Col Kerrie Lindberg, USAF, NC; Col Stephen Waller, USAF, MC, FS; Col Joan C. Winters, USAFR, BSC; and Capt Melissa Ulitzsch, USAF, NC.
|Editorial Abstract: Diverse threats to our nation’s security, both at home and abroad, challenge the Air Force’s medical personnel to develop innovative solutions to provide medical support for a wide range of military operations. By using highly portable medical teams and modularizing deployable assets, commanders can tailor medical response to fit the unique features of each situation. Partnering with sister-service and coalition medical services achieves synergistic effectiveness.|
AS COLD WAR scenarios fade from memory and dozens of small-scale contingencies around the world challenge deployed military med-ics, military medical services are rethinking their readiness philosophies to fit a new paradigm. Each service must prepare for a spectrum of operations much broader than the traditional wartime role. What are the diverse missions faced by the military medics who must support these operations? What are the readiness roles in these uncertain times?
The National Military Strategy of the United States, Joint Vision 2020, and Air Force Vision 2020 all point to continued global, proactive engagement by Air Force people. Because this cannot happen without effective medical support, the Air Force Medical Service (AFMS) is transforming itself in order to develop the necessary expeditionary culture.
My “vision” for the AFMS emphasizes that Air Force medical personnel must be able to support the Air Force mission throughout the full continuum of military operations in which airpower may be employed, as described in Air Force Doctrine Document 2, Organization and Employment of Aerospace Power, 17 February 2000. To do this, medics must be able to provide support across three broad categories of deployment scenarios: humanitarian and civic assistance (HCA), medical response to disasters, and support of traditional wartime operations. These scenarios also directly support Air Force Vision 2020. For example, HCA missions demonstrate vigilance by promoting democracy, peaceful relationships (military-to-military and military-to-civilian), and economic vitality—a sort of “preventive medicine” against war. We demonstrate reach by responding promptly and appropriately to disasters when invited by an allied country and when called upon to augment disaster response by civil authorities at home. Both HCA and disaster-response missions create opportunities for our medical personnel to gain valuable experience during deployments that carry over to support wartime operations. Thus, they support power, our traditional readiness mission.
Medics face diverse and frightening challenges as our military increases its participation in nontraditional roles. Potential scenarios could involve weapons of mass destruction, natural disasters, and complex technological/ political/natural crises. A regional or worldwide epidemic, such as the outbreak of influenza in l918, could have enormous impact on all medical personnel. None of us need to be reminded of the recent tragic consequences of terrorism that put medical response to a severe test. Controlling such events can avert worldwide economic catastrophe and subsequent potential conflict.
Since each situation is unique, lessons learned from previous disasters will not solve all the problems of a new crisis. But one can learn general lessons and apply them to the development of generic plans for responding to different types of disasters. On the one hand, earthquakes, for example, can result in major surgical casualties, particularly in the first three days after the event. The need for intensive care and renal dialysis may overwhelm the civilian medical system’s capability. On the other hand, a flood or hurricane may cause few surgical casualties but increase demand for emergency-room and public-health services as well as ongoing basic health-care needs, such as refilling prescriptions.
Medics face diverse and frightening challenges as our military increases its participation in nontraditional roles.
This scenario, combined with the potential loss of medical infrastructure, may overwhelm the local civilian medical system, as recently demonstrated when floods struck Houston, Texas, during Tropical Storm Allison. The Air Force deployed a 25-bed field hospital within 24 hours of receiving urgent requests from Texas and the Federal Emergency Management Agency. In such cases, the rapid insertion of lightweight, rapidly deployable, well-equipped surgical teams and field hospitals may prove critical to saving as many victims as possible while decompressing the civilian health-care system enough to give it a chance to recover. Most disasters create chronic needs for the local population that require long-term development work for full recovery. As the civilian health-care sector’s ability to respond to sudden increases in casualties declines, senior government officials and citizens more than likely will expect military medics to assist quickly.
Medical-response missions could occur either just outside a domestic military base or overseas. Requests for domestic civil support would originate from local and state governments to appropriate federal agencies, which would then route the requests to the Defense Department. Overseas, these types of requests would come through the State Department, as they did after Hurricane Mitch struck Nicaragua in l998 and floods swept through Mozambique.
Responding appropriately and rapidly—a new paradigm for the military’s medical personnel—requires the efficient use of limited airlift so that critical medical supplies and assistance reach the people who need it most. Since moving large field hospitals may not satisfy this requirement, the answer lies in light, lean, and mobile medical teams with a small footprint that can make modular, “tiered and tailored” responses.
This way, one can literally custom-build medical support for each mission. By creating small, multifunctional teams, the medical service can provide the on-scene commander with a flexible response tailored for the specific contingency. These “medical building blocks” permit problem-specific treatment—analogous to the flexibility available from the modern practice of using blood components rather than the traditional whole-blood treatments of the World War II era. Small, portable medical teams extend limited resources and maximize options for commanders, public-health officials, or host-nation governments. No longer is it necessary to task eight C-130s to haul a large air-transportable hospital when a five-person, backpack-portable surgical team can provide the needed care. After hurricanes or floods, for example, one may have a great need for public-health and preventive-medicine assessment. Deploying a two-person aerospace-medicine/ public-health team or several such teams may be the ideal response, as was the case after Hurricane Mitch. The first tier of disaster response comes from local and host-nation sources, followed by additional tiers of teams, as needed. The availability of modular teams allows host nations to request specific, focused medical teams tailored to the unique disaster scenario at hand.
Such modular-response teams take full advantage of revolutionary medical electronic equipment. Instruments formerly too large to move are now carried in one hand. Patient monitoring, once confined to an intensive-care unit, can now be done under field conditions. These improvements and careful logistics allow a small team with backpacks to provide impressive medical care quickly in any corner of the world. Personnel can even travel with the 70-pound packs as normal luggage on a commercial airliner if military airlift is not available. Historically, relief workers have experienced inevitable delays before they could reach the site of a disaster. Yet, a team of military medics with man-portable medical equipment will be able to meet the initial disaster-response needs of the community and then pass control on to other, larger relief agencies or sister-service medical units when they are able to respond.
Expeditionary medical support (EMEDS) consists of numerous modular teams ranging in size from just two personnel with equipment in backpacks to components of the modular Air Force theater hospitals (AFTH). Specifically, the two-person preventive medicine/ aerospace medicine (PAM) team can provide initial medical assessment of disasters, public health/preventive medicine, and emergency/ flight/primary-care medicine. Ground critical- care teams (GCCT), three-person intensive-care units based on critical-care air-transport teams (CCATT), have performed critical care and patient transport in hundreds of real-world missions. The five-person mobile field surgical team (MFST) provides emergency general and orthopedic surgery to 10 patients. Together, these teams—PAM, GCCT, and MFST—make up the 10-person small portable expeditionary aeromedical rapid-response (SPEARR) team, a disaster-response “force package” that travels with backpacks only (no pallet space) or with a small trailer (one pallet– equivalent) that can be loaded by a sling. It does not require a forklift, and one can pull it with a standard pickup truck or airlift it by helicopter. The team provides a broad scope of care and has intrinsic communication capability for aeromedical coordination, consultation, or resupply. The SPEARR team has completed its development process, including successful field-validation tests in both San Antonio, Texas, and Alaska, and has exercised side by side with the international medical and surgical response team, a volunteer unit from Massachusetts General Hospital tasked with responding to medical emergencies overseas. Finally, the AFTH consists of additional modules of personnel with palletized equipment. Building around the SPEARR, EMEDS-Basic adds two pallets with a holding capacity of four beds. Beyond that, AFTH+10 and AFTH+25 boast 10 and 25 beds, respectively. Indeed, the EMEDS system is designed to build incrementally up to AFTH+500.
One must understand that these medical teams provide essential rather than definitive care in the field. In high-paced scenarios, the military finds it more efficient to evacuate and replace personnel who cannot be returned to duty in a reasonable period of time. Providing definitive care at a forward location in order to avoid evacuation requires vast amounts of logistical support and, thus, more airlift than is realistically available when the military must meet other operational needs. Hence, the Aeromedical Evacuation System (AES) is shifting patient-care doctrine and reducing the holding capability in the AFTHs. This action has two implications: (1) the AES must be able to transport critically ill or injured patients and (2) to maintain proper patient flow, it must undergo modularization to build incrementally, as do the EMEDS modular teams. Thus, the AES has modularized the components of the basic mobile aeromedical staging facility (MASF) into rapidly deployable and, in some cases, man-portable teams.
Shifting from definitive to essential care permits the evacuation of more patients in “stabilized” rather than “stable” condition. In other words, the fact that they may require much more than basic nursing care during evacuation drives a requirement to provide a critical-care-capable patient-evacuation system. The AES now has CCATTs that literally convert any airframe into a flying intensive-care unit. These teams have successfully conducted missions, including transoceanic flights lasting several hours, that have evacuated hundreds of critically ill and injured patients.
Modularity and global engagement are having a dramatic international impact. Other nations have modeled their own modular disaster-response capability after that of the AFMS teams.
In support of Air Force Vision 2020, the AFMS is also focusing on global engagement. Specifically, it has developed the international health specialist (IHS), a new career track and specialty code modeled after the US Army’s foreign area officers (FAO) program. IHS team members, handpicked from all corps and ranks for their expertise (language, culture, politics, military, economics, medicine, and regional issues) in the area of responsibility (AOR), are interwoven with medical-readiness shops and platforms through-out each commander in chief’s (CINC) AOR. Teams are specifically tasked to support the CINC’s theater engagement plan, create partnerships with medical colleagues from nations within their region, facilitate military-to-military and military-to-civilian interactions, and support medical-planning operations and deployment execution within their AOR.
The first group of 26 IHSes is receiving new duties within the AOR and getting up to speed on responsibilities. Team members will be called upon to act as advisors and advanced-echelon personnel or to facilitate HCA, humanitarian medical relief operations (HMRO), or other missions into the region of their expertise. IHS personnel will maintain individual clinical competency and provide regional medical expertise throughout their careers. This career track will become a key credential for a successful Air Force medical career in future years as the international role continues to expand.
Modularity and global engagement are having a dramatic international impact. Other nations have modeled their own modular disaster-response capability after that of the AFMS teams. For example, the Chilean air force has created an interoperable team, the Escuadrilla de Redespliegue Sanitario Modular, a 25-person complete hospital in two pallets, which can respond to disasters in Chile and neighboring countries.
In essence, the AFMS has created an exportable commodity that potentially could lead to the development of a worldwide, regionally focused, coalition-based medical disaster-response system.
In addition, US Air Force medics taught regional disaster-response and trauma-systems courses, sponsored by the Expanded International Military Education and Training Program of the Defense Security Cooperation Agency, to nearly 700 students in Ecuador, El Salvador, the Czech Republic, and South Africa. Furthermore, military and civilian medics from adjacent countries have attended and participated in the discussion and laboratory exercises. The courses emphasize regional (multinational) involvement, disaster response, trauma care, leadership, civilian-military collaboration, resource management, and “train-the-trainers” skills. In El Salvador, host-nation graduates of the first course, held in 1999, taught over 100 colleagues and completely redesigned the emergency department of their Central Military Hospital to handle trauma patients more efficiently. When earthquakes devastated that country in January and February of 2001, medics and hospitals were ready, and graduates of the Air Force course from adjacent countries returned to San Salvador to help with medical care and save lives. Clearly, this type of partnership and training can benefit all nations and create regional political stability and economic prosperity, thus reducing the likelihood of future conflict.
In essence, the AFMS has created an exportable commodity that potentially could lead to the development of a worldwide, regionally focused, coalition-based medical disaster-response system. Providing the modular concept as well as the training and education necessary to facilitate casualty care and management will help ensure that deployed personnel receive high-quality medical care if and when they need it, no matter where they are or which nation responds with teams.
Military medics have now become the “tip of the spear.” For example, an Air Force HCA deployment in Nicaragua in June l996 represented the first US military presence in that country in 17 years! Two more HCA teams followed in 1997 and 1998, and during recovery efforts following Hurricane Mitch, the Nicaraguans reported that military medical teams had created a climate of trust that benefited US military civil-engineering teams. Thus, the HCA missions provided the basis for a mutually beneficial liaison with a new partner nation.
As Air Force medics continue to fulfill the global-engagement mission, we will need other international partnerships. Acting in my capacity as the Air Force surgeon general at last summer’s meeting of the International Committee of Military Medicine (ICMM), I proposed creating regional disaster-response networks among the membership and reporting the results of this effort at the next meeting in 2002. The membership’s developing nations, particularly those devastated by disasters in recent years, strongly supported this proposal. In fact, national representatives voted unanimously to adopt the plan, opening a new era of regional and worldwide cooperation among military medical services.
The upcoming ICMM meeting in South Africa in 2002 will focus upon regional-response networks and some of the principles for success, such as establishing and building international coalition partnerships; building international medical “bridges” of friendship and cooperation; facilitating disaster preparedness among partner nations; and developing regional-response systems, whose value has been proven through mutual exercises and responses to regional disasters. Following these principles allows successful networks among neighboring nations’ military medical services to support the political and economic goals of member governments.
These successes, along with many others, are impressive and hold great hope for the future. After the recent earthquake in Turkey, both Egypt and Israel responded promptly with portable medical teams; this effort not only saved lives but also provided military medical personnel with valuable readiness training. Quick response requires good prep-aration, planning, and execution, including the establishment of diplomatic agreements and the efficient packing of critically needed supplies and equipment.
Optimal medical readiness also demands rapid deployment of appropriate technology. Military medics must capitalize on advancements in computers and surveillance equipment to ensure real-time, state-of-the-art surveillance and monitoring for biological pathogens or chemical toxins. Medics must involve themselves in scientific inquiry to meet the needs of citizens, governments, and military commanders/war-fighting CINCs. The Air Force’s medical-readiness officers have embraced this tasking as part of the mission.
To promote the process, the Developmental Center for Operational Medicine at Brooks Air Force Base in San Antonio, Texas, is charged with inserting innovative technology into readiness platforms. It also serves as a liaison with civilian disaster-response agencies, seeking to improve the capabilities and interoperability of both civil and military medical teams.
Finally, to optimize disaster response, AFMS must avoid redundancy with agencies of the United Nations, private volunteer groups, and nongovernmental disaster-relief organizations by offering “what we do best” to regional coalitions. By building on each member’s strengths, the regional disaster-response network achieves synergy. Using the proper chain of command and government channels, the AFMS must communicate with other organizations before, during, and after each disaster response so that neighbors can benefit from each other’s successes and failures. This includes training together in realistic exercises so that military medics of coalition nations can learn to work efficiently with new technologies and procedures shared by medical experts from various organizations and nations. This effort should result in a better worldwide medical system.
It goes without saying that full implementation of the AFMS vision for expeditionary medical support and global engagement requires involvement of the Total Force. The AFMS’s fundamental concern entails developing the capability to complete the mission, regardless of where modular teams are assigned. In other words, whether a SPEARR, EMEDS-Basic, AFTH+10, MASF, or some other modular component is assigned to Guard, Reserve, or active duty units, it must be able to fulfill its role according to the concept of operations. Even though a particular concept of operations may seem to make certain modular teams especially well suited for Guard and Reserve units, the emphasis must remain on providing an overall, integrated capability for medical support. This philosophy will ensure the AFMS’s overall success in the Air Force vision for global engagement.
Readiness remains the fundamental core competency of Air Force medics. Building reliable regional coalitions through partnerships and training as well as developing interchangeable medical teams that can respond by invitation to assist each other in emergencies are tasks that we can accomplish now. By utilizing new tools, we can fulfill our diverse readiness missions and engage the full spectrum of operations in the new millennium.
Lt Gen Paul K. Carlton Jr. (USAFA; MD, University of Colorado at Denver) is the surgeon general of the Air Force, Headquarters, USAF, Bolling AFB, D.C. He serves as functional manager of the USAF Medical Services (AFMS). He advises the secretary of the Air Force and Air Force chief of staff, as well as the assistant secretary of defense for health on matters pertaining to the health of Air Force people. The general has authority to commit resources worldwide for AFMS, to make decisions affecting the delivery of medical services, and to develop plans, programs, and procedures to support peacetime and wartime medical-service missions. He exercises direction, guidance, and technical management of more than 42,400 people assigned to 78 medical facilities worldwide.
The conclusions and opinions expressed in this document are those of the author cultivated in the freedom of expression, academic environment of Air University. They do not reflect the official position of the U.S. Government, Department of Defense, the United States Air Force or the Air University.
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