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INTRODUCTION and BACKGROUND
Many professions are such that working towards a common goal requires additional hours and much stress. The medical profession is one of these fields. Unfortunately, the medical profession is also one that demands acute attention and clear thinking. When personnel are low and stress is high, these conflicts can produce less-than-satisfactory results. Overworked medical personnel will lack sleep which will affect their performance during the day. According to Hans Van Dongen of the University of Pennsylvania School of Medicine in Philadelphia “people who get by on a modest sleep deficit are often not aware of their shrinking thinking capabilities and don’t feel particularly drowsy”
Never has medical care been more crucial than on overseas military basis in or near combat zones. These soldier/medical professionals frequently see a large influx of sick and wounded individuals known as Mass Casualty. These individuals must be prioritized, transported, treated, and in some cases evacuated, as quickly and efficiently as possible. “Thanks to improvements
in combat-related first aid, helicopter evacuation and personal protective equipment, more casualties are reaching the field hospital alive” (Haberstock, 2006). While everyone is thankful for life-saving technology, the numbers entering the hospitals are going up as a result.
At the United States Marine Corps Charlie surgical company at Al Asad Air Base in Iraq, such a situation exists. This health surgical company is hierarchically organized into seven areas of operation:
o Health Service Support Operations Center
o Shock Trauma Platoon
o Operating Room
o Ancillary Services
All of these service services must work together to provide the best care for the patients and to uphold the mission statement: “to provide critical wartime surgical and medical support including specialty consultation, enroute nursing care, and medical regulating support for the point of injury to Level III for Coalition Forces operation in AO Denver, Iraq in support of OIF 05-07” (Battle Book, 2002).
Unfortunately, some major problems plague Charlie Health Services Company. During mass casualty incidents, organization seems to wane. Like many military medical facilities, there are not enough people to man all the stations. This has resulted in overlapping shifts and responsibilities in multiple areas of operation. Communication with often impeded by non-working equipment. All of this has led to a low state of morale in Charlie Health Services Company.
The objective of this paper is to identify the main areas that need change in the Charlie Health Services Company and to provide researched information to implement this change. IN doing this, we have identified three areas most in need of changes:
· Logistics during Mass Casualty
· Personnel scheduling and morale
· Communication issues
Thus, the first sub-objective is to create a system to speed the flow of patients during mass casualty in order to give them each prompt care according to their priority.
The second sub-objective is to attempt to secure additional personnel and to better assign existing personnel to allow for necessary sleep and personal time (PT)
The third sub-objective is to eradicate communication problems with equipment upgrades and more direct lines to necessary higher level third parties.
The need for change is evident. In the words of Maureen Haberstock (2002), a Canadian military doctor stationed in Afghanistan, “Our hospital staff and surgical teams have routinely performed small miracles in the most difficult circumstances, saved many lives and limbs and spirits, broken new ground in field medicine, and earned the respect and admiration of NATO, our coalition partners and the Afghan people….” These soldiers do all these things under the same dangerous circumstances that landed the patients there in the first place.
In planning for this change, it is necessary to look to how those in similar situations have solved similar problems. To do this, the researchers conducted a literature review of sources from the Ebsco Databases, Military Files and Handbooks, online journals, newspaper accounts and websites.
For the first objective, creating an more efficient and organized system, involves the movement of individuals during a incident involving several injured. While Charlie Company has an organized procedure on paper, it was not being followed by the staff, partially because each situation is different and therefore must be judged individually. When an influx of injured overwhelms the staff, then the system could break down.
Administration of Logistics
A possible solution for this problem comes from a look at the operations of the similar problems if the US 212th Mobile Army Surgical Hospital (MASH) in Central Iraq. This hospital also experienced similar overwhelming circumstances. Their answer was to mobilize personnel without calling an official Mass Casualty. This allowed them to pull personnel from areas of the unit that were not busy to assist with the emergency room needs. The results confirmed that actual surgeons were able to focus on the necessary cases, while others, perhaps from supply, were used for transport, etc. LTC John M. Cho notes “On two separate occasions, 48 patients were admitted to the MASH. These patients were triaged without calling a hospital-wide mass casualty. Soldiers of the service and supply platoon were used, and intensive care unit personnel on duty were brought forward to the emergency department, eliminating the need to mobilize the
entire MASH. This allowed conservation of medical manpower to ensure successful sustained operations for 19 days” (B.B. 2003).
Regardless, quick decision making is key to effective management of time in a crisis. The chain of command need not be so long when these situations are at hand. Researchers note that administrative beuaucracies are the main problems behind field level problems (Finfgeld, 1991).
The shortage of medical professionals in the military is affecting many countries in addition to the US. In Canada, the government is considering pay bonuses to lure physicians and even nurses into the field (Army Combats Shortages, 2004). “Newly minted family medicine residents may soon be offered signing bonuses worth from $75 000 to $100 000 for 4 years’ service. In another move, some medical officers may also receive pay raises of up to 30%, an increase that would see captains in the medical service earning more than brigadier-generals in other branches” (Sullivan, 1999). Increasing pay for medical professionals who agree to be in active duty would be one way to reduce the personnel overload in existing medical surgical unit such as Charlie Company.
The 212th MASH also adds a possible idea. They sought to increase the number of orthopedic surgeons in relation to thoracic surgeons, claiming that the majoring of the injuries needing surgery occur to the extremities. Direct chest or head injuries either result in death or the need to medivac to a Level III unit. (Charlie only serves Level I and Level II patients). Adding additional orthopedists to the staff will enable two or three OR tables to be used at once, which will prevent a back up of patients and overworked surgeons and assistants.
This is precisely what the 212th did. They concluded that “effective personnel, space, and time utilization of the OR was demonstrated by simultaneously using two OR tables in one ISO OR. All injured patients were assumed to have contaminated wounds. Two separate surgical teams were used to prepare for each surgical patient. As a result, the third OR table, located in the emergency department section, was needed only twice. We found that taking patients immediately to the OR once it was determined that there was an indication for surgery was the best way to prevent a backlog of surgical cases” (Cho, 2005). Charlie Company only has one orthopedic surgeon. Bypassing unnecessary clerical and hierarchical step increased the efficiency on this base.
The US recognized the nursing shortage before the war in Iraq even began. As many speculated that a shortages of nurses would disable military medical operations, suggestions to contract nurses to the field may be a solution.
This problem takes on two prongs – physical communication capabilities and access to higher level administration. The Charlie Company Battle Book notes, “Communications continuous [sic] problems for us and our predecessors. The phones work at times, but oftentimes will not connect to other switches on Al Asad, creating difficulties to conduct business. As a result, the HSC is very reliant on the Marine Internet Relay Chat program and email to contact other units and ROBs supported by the Health Services Company.” This lack of communicative ability can also affect medical supplies with a turnaround time often in excess of twenty days. Charlie Company has only four phone lines, one AN/GRA-39 radio, three computers and 13 hand-held radios.
Administratively, the chain of command is very complex. The upper levels of administration demand that reports be accurate and timely. Constant briefings and reportings rob physicians and nurses of valuable PT.
Decision making at Charlie Company will be decentralized to allow for on-site interpretation of emergency situations. This individual may be a head physician/officer
Individuals will continue to work at multiple tasks as directed by the head physician/office.
“Surgical staffing is based on a compromise between a worst case scenario and daily peacetime care. Many conditions change in the field environment” (Grosso, 2002). For this reason,
the US government will undertake plan to recruit and pay contract wages to nurses and physician assistants to work in field hospitals such as Charlie Company.
Charlie Company will employ at least 1 additional orthopedic surgeon and at least 1 additional emergency medical physician. At least three additional nurses and 2 additional physicians’ assistants will also be deployed.
As equipment is upgraded, so should the training of these individuals. “Now that field hospitals and rescue stations have been provided with state-of-the-art equipment, it is important to tailor the medical qualifications of military surgeons to the specific requirements” (Horst, Heinz, and Schwab, 2005).
The Charlie company should purchase the following: two more base radio units, three more computers, and six more phone lines. An agency should be contracted to analyze the communication needs and provide updated, working equipment as necessary
Reduce the number of meetings to “as necessary” status. Allow for flexibility in filing reports and perhaps assign additional personnel to this task.
Continue to utilize the US Navy-Marine Corps research program and Theater Medical Registry Record to consistently and strategically review needs. As Grosso (2002) notes, “the changing needs of the population served continued to require reassessment of the scope of practice available at these field surgical hospitals.”
Encouraging civilian medical professionals to serve in military hospitals would involve legal and ethical barriers. For example, these individual are civilians and would not be held accountable to military rule as would other soldiers. They would, of course, be expected to follow protocol, but the punishments for violations would not be as severe, so they would have less reason to feel compelled to endure such stress and hardship. Secondly, what repercussions would occur if one of these individuals acted with negligence? The planning for this stage would have to involve input from both military and civilian medical and legal professionals.
Next, the doctors and nurses would be pulled away from their civilian places of employment. This would create a burden on civilian society that perhaps the military would not have the ethical justification to do. After all, the medications and supply that the doctors use on the military bases are the same ones that are in short supply here in the US (Siegal, 2003). It is difficult to sell that kind of sacrifice to the American people. The nursing and doctor shortage has been a longstanding problem; it was a problem in 1942 and it is still a problem. Luring nurses and doctors to Iraq may be seen as robbing Peter to pay Paul. The balance may be hard to find.
The mission of the Army Medical Department is to
“conserve the fighting strength.15 Combat health support maximizes the system’s ability to maintain presence with the supported soldier, return injured, sick, and wounded soldiers to duty, and clear the battlefield of soldiers who cannot return to duty. Patients are examined, treated, and identified as return to duty or nonreturn to duty as far forward as is medically possible.15 Adaptation of combat health support to this peacekeeping mission has enabled field surgical hospitals to treat patients in the theater of operations and return them to duty for noncombat– related conditions” (Grosso, 2002).
This duty is taken very seriously by the US government, but sometimes field situations require change.
Problems of morale will fix themselves if attention is taken to equate the reward with the task. Military hospital personnel put their lives in danger every day to save lives of sons, daughters, husbands, wives, fathers and mothers who are serving their country. Adding additional personnel, reducing bureaucracy and improving communication both physically and administratively will go a long way to reducing the pressures and stresses that cause additional problems among field hospitals.
The references from this study were chosen because of their recency (only one is more than 10 years old) and for their relevance. One science publication was used to analyze the problem with sleep debt on perception as that applies to stresses in the field. Nursing journals discussed particular problems from the standpoint of nurses, while military medical journals addressed the problems form a military standpoint. Finally primary source documents from Charlie Company itself were used to examine this specific problem area and compose a plan of attack.
Army Combats Shortages. (2004). Nursing Standard 18.25
B.B. (2003). Sleep debt exacts deceptive cost. Science News 163.14
Battle Book. (2002). Charlie Health Surgical Company CLB-1. A Asad Air Base, Iraq.
Cho, J.M. (2005). Operation Iraqi Freedom: Surgical Experience ofthe 212th Mobile
Army Surgical Hospital. Military Medicine 179. 4:268-272
Finfgeld, D. (1991). What does a Military Nursing Shortage Mean to us? Nursing Economics 9.1: 44-47
Grosso, S. (2002). U.S. Army surgical experiences during the NATO peacekeeping mission in Bosnia-Herzegovina, 1995 to 1999: Lessons learned. Military Medicine. July. Retrieved from http://findarticles.com/p/articles/mi_qa3912/is_200107/ai_n8993137/print
Haberstock, M. (2006). A Year in the Life of Canadian Forces Health Services. Canadian Medical Association Journal 175.11: 1345
Horst, P.B., Heinz, G., and Schwab, R. (2005). The Challenge of Military Surgical Education.
World Journal of Surgery 29.
Siegal, M. (2003). Supply the Troops, but Give Hospitals Fair Warning. The Washington Post. B.04
Sullivan, P. (1999). Military set to offer large signing bonuses, higher pay in face of unprecedented MD staffing crisis. Canadian Medical Association Journal 160.6