Army report backs upgrades in combat medical units

Army combat medical units operating in Iraq do not have the proper emergency transport equipment, are lacking in training and have a shortage of critical personnel, including lab technicians who must send medical tests to Germany, according to internal Army briefings obtained by Government Executive.

A shortage of lab and pharmacy technicians makes it difficult to conduct tests near the battlefields, according to briefing slides prepared by the Army Medical Department. When the Army can hire lab personnel, they frequently need additional training, according to the briefings. To complete lab tests, the Army must send patients' samples to the Landstuhl Regional Army Medical Center in Germany, a process that can take two to three weeks to return results to medical facilities in Iraq.

Even when lab work can be done in Iraq, it is often conducted on an ad hoc basis. "Blood collection and apheresis [separation of blood components, such as platelets] are 'Hey you' tasks," according to the briefings, which were conducted in February during a mid-year review for Maj. Gen. Ronald Silverman, commander of the Iraq-based Task Force Three Medical Command. The Army Medical Department Center and School conducted the review, which included representatives from major Army commands, divisions and brigade combat team surgeons.

The findings point out deficiencies in what is otherwise a vast improvement in battlefield medicine in the past 15 years. The advances, together with a system of medevac helicopters that can transport a wounded soldier from the battlefield to a field hospital in an hour or less, have boosted the survival rate of Iraq casualties to nearly 95 percent.

Still, the briefings portray a combat medicine operation struggling under inadequate and poor training. For example, the briefings describe combat medics who are poorly trained to perform emergency surgical airways when working in the field. Performing airway procedures is a key component of emergency medicine, which includes insuring that a patient can breathe and stopping a patient's bleeding.

But, according to the briefings, "emergency airways are often performed in field conditions under duress, by inexperienced providers." Many emergency cricothyroidotomies -- an incision in the neck that allows a patient to breathe -- performed in the field were done incorrectly and led to complications, the Army found.

The Army Medical Department also found medevac units operating in Iraq were not equipped with high-tech life-saving equipment and medical personnel because the UH-60 helicopters they use are not large enough. "UH-60 air frames have internal maneuverability limitations which do not allow for more than basic monitoring and treatment of critically ill patients on ventilators and multiple IV preparations," according to the briefings.

In April, Government Executive submitted questions concerning the briefings to public affairs officers at Army headquarters and the Army Medical Department. Army headquarters did not respond by the time this article was posted. Cynthia Vaughn, head of public affairs at the Army Medical Department, declined to respond because she said the briefings were marked "For Official Use Only" and "are not intended for public release, and it would be inappropriate for us to respond to questions relating specifically to this document."

Vaughn defended the Army medical system in general, claiming that "Army medical care is the best in the world . . . . In Afghanistan and Iraq, we have recorded the best casualty survivability rate in modern history. More than 94 percent of those wounded survive, and many return to the Army fully fit for continued service."

Still, the briefings recommend a number of remedies to improve medical care in Iraq. They suggest, for example, that an area medical laboratory be set up closer to the battlefield so test results can be completed more quickly.

Dr. Ronald Blanck, who served as Army surgeon general in 2000 and is now vice chairman of Marti, Blanck & Associates, a health care consulting firm in Washington, said that in considering such a move, the Army "needs to weigh costs and benefits. I would have to see more data [that shows] it is easier and quicker [to run the tests in theater]. And do they really need it."

Blanck downplayed the shortage of lab and pharmacy technicians, saying that "there is always a shortage of pharmacy techs," a situation he said can be alleviated by cross-training medics to also be lab technicians.

More training for all medical specialties is needed to improve medical care, according to the briefings. Concerning the poorly performed cricothyroidotomies, the briefings recommended that more emphasis be placed on nonsurgical procedures, such as placing a tube down the esophagus, when training nonphysician health care providers.

Still, the high number of poorly performed airway procedures must be put into context. The combat medics are young and working in stressful battlefield conditions, compared with Army surgeons, who work in the relative safety of combat support hospitals, said Dr. Robert Suter, professor of emergency medicine at the University of Texas Southwestern Medical Center in Dallas.

The medics are "20-year-old kids who are getting shot at" while conducting cricothyroidotomies, compared with surgeons who have "20 years of experience working in the controlled environment of a [combat hospital]," Suter said. "It's easy to say airways can be improved when no one is shooting at you."

Suter, a former paramedic who served as president of the American College of Emergency Physicians in 2003, said the level of training provided to Army combat medics far surpasses the training that civilian emergency paramedics receive.

But Suter said the Task Force Three Medical Command briefing could serve as a starting point to examine if the Army should provide additional training on airways to combat medics.

Combat medics also need advanced knowledge and skills to treat soldiers while on isolated assignments, according to the briefings. The Army Medical Department recommended that it create a course at its Army Medical Department Center and School to provide combat medics with the autonomous ability to screen and treat minor illness and injury.

But the medical training is losing out to combat survival training, according to the briefings. "Significant focus is placed on pre-deployment survival skills, and less on medical skills," according to the briefings. "Recommend a better balance between the two. Theater specific competencies should be specifically identified and trained prior to deployment."

To bolster medical training, the Army Medical Department recommends that personnel receive pre-deployment training in more medical courses including intensive care, war surgery, flight nurse, as well as training on notebook and desktop computers issued by the Army's Medical Communications for Combat Casualty Care agency.

The Task Force Three briefings illustrate the number of tradeoffs needed to optimize all the competing priorities in battlefield health care, said Dr. Harold Timboe, assistant vice president for research administration and initiatives at the University of Texas Health Science Center at San Antonio. Timboe, who served as commander of the Walter Reed Army Medical Center in 2001, said the tradeoffs include how much training to provide versus training through experience. "When are new medics ready for action, independently or under supervision as part of a team?" he asks.

The Army Medical Department also recommends the service switch from the UH-60 air frames to the larger, twin-rotor CH-47 for medevac operations in Iraq. The CH-47 would provide enough room for a critical care air transport team, which includes flight surgeons and flight medics.

But Maj. John Fishburn, a helicopter pilot with the New Mexico National Guard who flew medevac missions in Afghanistan, said that based on his experience, the UH-60 can support high-tech life saving operations with minor modifications to the interior. Fishburn said his unit removed stanchions in the middle of the UH-60 cabin to provide enough room for patients, ventilators, IVs and medical personnel.

Lt. Col. William Wiggins, an Army spokesman, said the UH-60 is the service's "aircraft of choice" to transport a wounded soldier from the battlefield to a forward surgical team or a field hospital. Wiggins said the Army has "enjoyed great success" with the UH-60 in medevac missions. While he acknowledged the space constraints, he said the CH-47 is designed primarily for cargo missions, and "with its large footprint and downwash characteristics," it is less suitable for transporting wounded soldiers. Also, CH-47s in Iraq are in high demand, mostly to reduce road travel by soldiers, he added.