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The December, 2005 issue of Proceedings from the Naval Institute contains a scathing report of upper echelon Navy Medicine leadership (or the absolute lack thereof).
The author (an active duty physician, former nuke sub driver) obviously knew what he was doing, when he submitted this career-ending article for publication.
http://www.usni.org/proceedings/Articles05/Pro12Rappold.html
FRSS, BAS, STP, FST, CRTS . . . . This amalgam of abbreviations and acronyms describes Navy Medicine's warfare assets. Their use is symptomatic of the difficulty the Navy Medical Department has in adequately supporting combat operations in the 21st century.
The events of 11 September 2001 forever changed the military"s approach to combat operations. Warfare no longer consists of slowly moving fronts against enemies that can be clearly recognized by the uniforms they wear. The enemy is difficult to identify, often camouflaged as non-combatants and hiding in unconventional terrain. This asymmetric style of warfare cannot be supported by traditional means. It requires a paradigm shift in our approach to casualty care. Unfortunately, the medical departments of the Army, Air Force, and, in particular, the Navy have all failed to adapt. The ongoing operations in Afghanistan and in Iraq have exposed our deficiencies in adequately planning for, mobilizing, and deploying the right mixture of medical assets capable of operating within a constantly changing and highly mobile battlefield environment.
The Failure of Navy Medicine
During the weeks and months leading up to the maneuver warfare portions of Operation Enduring Freedom and Operation Iraqi Freedom, Navy medical leadership failed to meet the challenges it faced. Casualty receiving platforms and Marine Corps medical support were not mobilized or tasked in a stepwise and thoughtful fashion. The assignment of personnel was haphazard, directed more by the whim of those in power rather than according to the qualifications and skills of the individuals involved. Requisite training prior to deployment was frequently waived or ignored. These actions resulted in feelings of anger, confusion, and doubt within the Navy medical community. Once deployed, many of the medical units did not have a command and control structure that enabled them to optimize their capabilities and smoothly carry out their missions. Combatant commands did not understand their medical resources and used them poorly. As a result, the lives of injured sailors, Marines, soldiers, and airmen were put at risk. Only through the diligence, professionalism, and dedication of individual hospital corpsmen, nurses, and physicians were the injured able to recover.
In the now mature combat theater of Iraq, Navy medical assets continue to be poorly staffed and used. Despite advanced levels of care rapidly available from Air Force and Army facilities, top Marine Corps line officers are unwilling to divest themselves of the rapidly mobile but less capable Navy units used during the attack phase. These units, which have no data to support their effectiveness during the maneuver phases of combat, are now clearly inferior to the higher echelons of care currently available in theater.
Unfortunately, the cost of manning these surgical units has come in the form of poor retention and recruitment of critical wartime medical specialties. Navy physicians, dentists, nurses, and corpsmen are voting with their feet, and no amount of bonus money will correct the true underlying probleman absolute lack of leadership and planning on the part of Navy Medicine. Combine this with the inability of the recruiting command to attract and award the Health Professions Scholarships to incoming medical students, and the Navys ability to support combat medical operations in the future is clearly in question.
Fixing the Problem
What follows are suggestions on the direction Navy Medicine should take to successfully support combat operations in the 21st century.
DoD-level command and control. There should be a single individual at the level of the Joint Chiefs of Staff (JCS), who must also be a physician with broad operational combat experience and respected clinical skills, and who has the authority to deploy and control DoD-wide assets independent of the inter-service rivalries that inevitably develop. This includes the ability to deploy operational assets regardless of service affiliation. There is no reason an Air Force trauma team cannot support a U.S. Marine Corps expeditionary unit and no reason an Army team cannot support a carrier battle group. What is of fundamental importance is the deployment of the right asset, with the right personnel and training, at the right time. The color of ones uniform is not important when lives are at stake.
Inter-service communication. If we are to function as a combined military medical system, we must have the capability to communicate with our sister services in the combat environment. Our patient information and medical data systems need to be fully compatible, as do the communication systems we use for medical regulation and transport. Better communication would eliminate redundancy and improve patient care. It is unacceptable for a Marine Corps medevac helicopter crewa flight of opportunity by doctrineto fly directly over a fully staffed Army medical facility, simply because they either werent aware of its presence or because they couldnt directly communicate with it. This is an issue that must be corrected immediately.
Consolidate the bureaucracy. Supporting asymmetric warfare requires us to foster creative thinking. At last count, six codes at the Navy Bureau of Medicine are involved to some degree with operational medicine and in the development of combat trauma skills. This fragmentation creates so much cumbersome bureaucracy and red tape that truly innovative change is impossible. Training for combat medicine must be placed under the command of single individual with direct access to the Surgeon General. Creative thinkers, particularly those with recent combat casualty care experience, need to be heard.
Train like we fight. Though often mentioned in the pages of Proceedings with regard to warfare officers, physicians, nurses, and corpsmen practice their craft every daybut is it the right practice for our wartime mission? Wartime means trauma. What we dont have access to is daily exposure to critically injured patients. Not one of the three major Navy teaching hospitals participates in its respective communitys trauma system. We must immediately begin the process of integrating our military teaching hospitals into their civilian counterparts trauma systems. Regular exposure to critically injured patients at our major teaching facilities, along with the Navy/University of Southern California Joint Trauma Training Center (NTTC) will allow us to practice and improve our wartime skills on a continuous basis. In this era of asymmetric warfare, we no longer have the time to spend the first six weeks to six months of a conflict relearning the mistakes of our last conflict.
Decommission the hospital ships. The Mercy and the USNS Comfort (T-AH-20) are obsolete. They were designed to support traditional wars, and their role in todays high-intensity, short-duration conflicts is dubious. They are poorly used and are a huge drain on already scarce resources. Additionally, their presence makes them a ripe target for politicians to deploy to the latest disastereither natural or man-madeas seen most recently during the Hurricane Katrina relief operations. With limited resources we cannot be all things to all people.
DoD-wide trauma system development. It is imperative that we develop a comprehensive tri-service trauma system. We must put into place a coordinated and effective system for the care of our wounded. DoD must demand that all three services create a fully integrated trauma system that effectively uses resources and coordinates care from the point of traumatic injury through return to duty or discharge. In this era of limited resources, duplication of effort should not be tolerated.
DoD-wide casualty data collection system. With the complexity of modern casualty care it is imperative that we develop a single tri-service casualty data collection system. Ideally, this system would be either PC or personal digital assistant (PDA) based, easy to use, and readily available to DoD researchers. Only through continuous evaluation and research of casualtiestheir wounds, care, and outcomescan we hope to improve care for the next generation of warriors. The birth of the combat trauma registry has begun, but it must be fully implemented across service lines. And we need to ensure that not only the data is filled out correctly but that it is readily available to all military medical department personnel for review and educational purposes.
Tri-service medical department. We should seriously consider combining the medical departments of the three services under one Surgeon General. Though intense parochial feelings often prevent us from doing so, only when we speak with one voice will we achieve true interoperability.
With the advent of short-duration, high-intensity warfare, Navy Medicine must make the changes required to ensure our sailors and Marines receive the right care, in the right location, by the best trained personnel. They deserve no less, and the country they defend will accept nothing else.
Commander Rappold is a former nuclear submarine officer, board certified in both general surgery and trauma/surgical critical care. He is currently Chairman of the Department of Surgery and director of the Surgical Intensive Care Unit at Naval Medical Center San Diego.
The author (an active duty physician, former nuke sub driver) obviously knew what he was doing, when he submitted this career-ending article for publication.
http://www.usni.org/proceedings/Articles05/Pro12Rappold.html
FRSS, BAS, STP, FST, CRTS . . . . This amalgam of abbreviations and acronyms describes Navy Medicine's warfare assets. Their use is symptomatic of the difficulty the Navy Medical Department has in adequately supporting combat operations in the 21st century.
The events of 11 September 2001 forever changed the military"s approach to combat operations. Warfare no longer consists of slowly moving fronts against enemies that can be clearly recognized by the uniforms they wear. The enemy is difficult to identify, often camouflaged as non-combatants and hiding in unconventional terrain. This asymmetric style of warfare cannot be supported by traditional means. It requires a paradigm shift in our approach to casualty care. Unfortunately, the medical departments of the Army, Air Force, and, in particular, the Navy have all failed to adapt. The ongoing operations in Afghanistan and in Iraq have exposed our deficiencies in adequately planning for, mobilizing, and deploying the right mixture of medical assets capable of operating within a constantly changing and highly mobile battlefield environment.
The Failure of Navy Medicine
During the weeks and months leading up to the maneuver warfare portions of Operation Enduring Freedom and Operation Iraqi Freedom, Navy medical leadership failed to meet the challenges it faced. Casualty receiving platforms and Marine Corps medical support were not mobilized or tasked in a stepwise and thoughtful fashion. The assignment of personnel was haphazard, directed more by the whim of those in power rather than according to the qualifications and skills of the individuals involved. Requisite training prior to deployment was frequently waived or ignored. These actions resulted in feelings of anger, confusion, and doubt within the Navy medical community. Once deployed, many of the medical units did not have a command and control structure that enabled them to optimize their capabilities and smoothly carry out their missions. Combatant commands did not understand their medical resources and used them poorly. As a result, the lives of injured sailors, Marines, soldiers, and airmen were put at risk. Only through the diligence, professionalism, and dedication of individual hospital corpsmen, nurses, and physicians were the injured able to recover.
In the now mature combat theater of Iraq, Navy medical assets continue to be poorly staffed and used. Despite advanced levels of care rapidly available from Air Force and Army facilities, top Marine Corps line officers are unwilling to divest themselves of the rapidly mobile but less capable Navy units used during the attack phase. These units, which have no data to support their effectiveness during the maneuver phases of combat, are now clearly inferior to the higher echelons of care currently available in theater.
Unfortunately, the cost of manning these surgical units has come in the form of poor retention and recruitment of critical wartime medical specialties. Navy physicians, dentists, nurses, and corpsmen are voting with their feet, and no amount of bonus money will correct the true underlying probleman absolute lack of leadership and planning on the part of Navy Medicine. Combine this with the inability of the recruiting command to attract and award the Health Professions Scholarships to incoming medical students, and the Navys ability to support combat medical operations in the future is clearly in question.
Fixing the Problem
What follows are suggestions on the direction Navy Medicine should take to successfully support combat operations in the 21st century.
DoD-level command and control. There should be a single individual at the level of the Joint Chiefs of Staff (JCS), who must also be a physician with broad operational combat experience and respected clinical skills, and who has the authority to deploy and control DoD-wide assets independent of the inter-service rivalries that inevitably develop. This includes the ability to deploy operational assets regardless of service affiliation. There is no reason an Air Force trauma team cannot support a U.S. Marine Corps expeditionary unit and no reason an Army team cannot support a carrier battle group. What is of fundamental importance is the deployment of the right asset, with the right personnel and training, at the right time. The color of ones uniform is not important when lives are at stake.
Inter-service communication. If we are to function as a combined military medical system, we must have the capability to communicate with our sister services in the combat environment. Our patient information and medical data systems need to be fully compatible, as do the communication systems we use for medical regulation and transport. Better communication would eliminate redundancy and improve patient care. It is unacceptable for a Marine Corps medevac helicopter crewa flight of opportunity by doctrineto fly directly over a fully staffed Army medical facility, simply because they either werent aware of its presence or because they couldnt directly communicate with it. This is an issue that must be corrected immediately.
Consolidate the bureaucracy. Supporting asymmetric warfare requires us to foster creative thinking. At last count, six codes at the Navy Bureau of Medicine are involved to some degree with operational medicine and in the development of combat trauma skills. This fragmentation creates so much cumbersome bureaucracy and red tape that truly innovative change is impossible. Training for combat medicine must be placed under the command of single individual with direct access to the Surgeon General. Creative thinkers, particularly those with recent combat casualty care experience, need to be heard.
Train like we fight. Though often mentioned in the pages of Proceedings with regard to warfare officers, physicians, nurses, and corpsmen practice their craft every daybut is it the right practice for our wartime mission? Wartime means trauma. What we dont have access to is daily exposure to critically injured patients. Not one of the three major Navy teaching hospitals participates in its respective communitys trauma system. We must immediately begin the process of integrating our military teaching hospitals into their civilian counterparts trauma systems. Regular exposure to critically injured patients at our major teaching facilities, along with the Navy/University of Southern California Joint Trauma Training Center (NTTC) will allow us to practice and improve our wartime skills on a continuous basis. In this era of asymmetric warfare, we no longer have the time to spend the first six weeks to six months of a conflict relearning the mistakes of our last conflict.
Decommission the hospital ships. The Mercy and the USNS Comfort (T-AH-20) are obsolete. They were designed to support traditional wars, and their role in todays high-intensity, short-duration conflicts is dubious. They are poorly used and are a huge drain on already scarce resources. Additionally, their presence makes them a ripe target for politicians to deploy to the latest disastereither natural or man-madeas seen most recently during the Hurricane Katrina relief operations. With limited resources we cannot be all things to all people.
DoD-wide trauma system development. It is imperative that we develop a comprehensive tri-service trauma system. We must put into place a coordinated and effective system for the care of our wounded. DoD must demand that all three services create a fully integrated trauma system that effectively uses resources and coordinates care from the point of traumatic injury through return to duty or discharge. In this era of limited resources, duplication of effort should not be tolerated.
DoD-wide casualty data collection system. With the complexity of modern casualty care it is imperative that we develop a single tri-service casualty data collection system. Ideally, this system would be either PC or personal digital assistant (PDA) based, easy to use, and readily available to DoD researchers. Only through continuous evaluation and research of casualtiestheir wounds, care, and outcomescan we hope to improve care for the next generation of warriors. The birth of the combat trauma registry has begun, but it must be fully implemented across service lines. And we need to ensure that not only the data is filled out correctly but that it is readily available to all military medical department personnel for review and educational purposes.
Tri-service medical department. We should seriously consider combining the medical departments of the three services under one Surgeon General. Though intense parochial feelings often prevent us from doing so, only when we speak with one voice will we achieve true interoperability.
With the advent of short-duration, high-intensity warfare, Navy Medicine must make the changes required to ensure our sailors and Marines receive the right care, in the right location, by the best trained personnel. They deserve no less, and the country they defend will accept nothing else.
Commander Rappold is a former nuclear submarine officer, board certified in both general surgery and trauma/surgical critical care. He is currently Chairman of the Department of Surgery and director of the Surgical Intensive Care Unit at Naval Medical Center San Diego.
