Hospital Logistics Support for Operation Iraqi Freedom by Lieutenant Colonel Timothy E. Bateman and Major Song H. Gotiangco Daily logistics support in an Army hospital is a “behind-the-scenes” operation. If all goes well, no one notices. Hospital activity revolves around patients, compliance with standards prescribed by the Joint Commission on Accreditation of Healthcare Organizations, and a plethora of interstaff committees. The Landstuhl Regional Medical Center (LRMC) in Germany, with a staff of 2,000 Department of the Army civilians and military and contractor personnel, is the largest U.S. military medical facility outside of the United States. It is a joint operation, although not designated as such. Personnel from the Air Force’s 86th Medical Squadron and the 212th Mobile Army Surgical Hospital (MASH) hold some of the key command and staff positions. Although the performance of LRMC’s mission, “To serve as America’s beacon of healthcare for its sons and daughters abroad,” has been strained the last several years by conflict, the center continues to be a solid bulwark for Army medicine. Between October 2001 and October 2002, more than 1,000 casualties from Operation Enduring Freedom (OEF) were treated at LRMC. This story was documented in the October–December 2002 U.S. Army Medical Department Journal. However, the staff barely had a chance to read it because, at the time, it was conducting a military decisionmaking process in preparation for a larger mission—supporting Operation Iraqi Freedom (OIF). It became apparent early during the military decisionmaking process that the 212th MASH, several surgical teams, and many LRMC Army and Air Force personnel would have to deploy to support OIF. To support the casualty projections for OIF, the 160-bed LRMC would need 150 more beds, supporting medical equipment and supplies, backfill for the deployed personnel, and augmentees. The Air Force subsequently deployed a 150-bed unit type code (UTC) hospital to LRMC. Army and Air Force backfill personnel, along with the 94th General Hospital (Augmentee Force), began arriving in February 2003. Mission Preparation The entrance point for all patients at LRMC is the Deployed Warrior Medical Management Center (DWMMC), an innovative and highly successful tool that transitions patients from the aeromedical evacuation process into the LRMC patient process. The DWMMC was manned to support OEF with internal LRMC assets. However, it was severely understaffed to support both OEF and OIF patients. During the military decisionmaking process, the LRMC’s Department of Nursing identified tasks that had to be completed before a large patient increase could be accommodated. The Logistics Division organized the tasks and presented proposed logistics missions to the hospital Chief of Staff for approval. Those logistics missions were— • Conduct all previously assigned peacetime table of distribution and allowances (TDA) functions. • With additional personnel, support expanded TDA functions for an increased patient population for an indefinite time by purchasing both medical and nonmedical equipment and supplies to support contingency operations; relocating hospital services and staff; integrating the Air Force UTC hospital and follow-on Department of Defense hospital support package into the LRMC; providing support to the DWMMC and additional staff; and preparing to combine selected TDA functions so all tasks and missions can be performed without the additional personnel. LRMC Logistics Division Organization Unlike most other Army medical centers, LRMC’s Logistics Division is made up mostly of military personnel rather than civilians. The division has a headquarters section and five primary branches. The Medical Material Branch provides medical and nonmedical materiel using the Defense Logistics Agency and private vendors to purchase stock. The Environmental Services Branch provides housekeeping, linen, transportation, and hazardous material management services. The Facility Management Branch provides buildings and grounds maintenance and manages construction projects, utilities, and project design. The Equipment Management Branch provides life-cycle management of equipment, property accountability, clinical engineer management, and medical equipment maintenance. The Logistics Readiness Branch develops and coordinates logistics support plans and manages staff assistance visits and inspections. This branch is the force that binds the other branches and the hospital in contingency operations. As such, it developed, coordinated, and tracked all logistics contingency requirements for LRMC in conjunction with the OIF military decisionmaking process. This allowed the chief of the Logistics Division to plan how to integrate those contingency missions into the division’s core TDA missions. Requirements Phase During the military decisionmaking process, the Logistics Readiness Branch received requirements for over $2 million worth of equipment. Other logistics requirements were identified for new working space, housekeeping services, linens, medical materiel, transportation, and relocation services. The requirements were based on a limited budget and a low casualty figure. No additional staff arrived at LRMC during the military decisionmaking process, so the staff worked hundreds of overtime hours conducting product research, preparing statements of work, and completing purchase requests and commitments. Relocation Phase When the 150-bed Air Force UTC hospital arrived, the Logistics Readiness Branch assembled it, inspected all equipment and supplies, and carefully repacked it for relocation at LRMC. At about the same time, 22 office and storage trailer units and 4 shower and latrine trailer units arrived. After electrical, communications, and plumbing lines were installed, the relocation phase began in earnest. Several clinical and clinical support services were combined or relocated—some within the hospital itself and some outside of the hospital. One clinic was relocated to the Ramstein Air Base medical treatment facility. Many contracted vendors came in on weekends, when the clinics were closed, to relocate the clinics and clinic support services. Because navigating the many halls of LRMC can be confusing, additional internal and external signs were posted to help direct patients and staff. As former clinics and offices became patient-care areas, housekeeping and facilities support services personnel were called in to make sure these areas met Joint Commission on Accreditation of Healthcare Organizations standards. Expansion Phase The order to execute the expansion phase was complicated because it involved both the Army Medical Command and the U.S. European Command, and it was critical to complete the expansion before the patient population overwhelmed existing beds and support. The key for this phase was the arrival of augmentees from the 94th General Hospital, backfill personnel for the 212th MASH, and personnel to operate the Air Force UTC hospital. The LRMC Troop Commander assumed responsibility for finding barracks space for nearly 800 arriving soldiers and airmen. This turned out to be one of the largest logistics challenges LRMC faced. To accommodate everyone, two-man barracks rooms were converted to four-man rooms, and four-man rooms were transformed into eight-man rooms. The post hotel was converted to barracks rooms, and the barracks usually used by LRMC units that had been deployed elsewhere were taken over by arriving personnel. Finally, several post family housing units were converted to barracks. The barracks bed shortage was met until deployed units returned, when it again became acute. Permanent-party noncommissioned officers were given nonavailability statements and moved into housing in local communities. Scheduled renovations of barracks on other posts nearby were delayed so soldiers could move back into them. The 800-person temporary force required additional dining facility support, transportation to the main posts, and other logistics support that was so important to troop morale. While the Troop Command struggled to meet these requirements, the Logistics Division moved the Air Force UTC hospital to LRMC. Then, over a period of several days, the Department of Nursing staff moved equipment and supplies into the various wards. Once the move was completed, the medical staff began training the equipment operators and the logistics staff conducted detailed equipment maintenance training. Medical supplies were inventoried and added to computerized reorder lists. Highly sophisticated new equipment, such as a computerized tomography (CT) unit, required complex installation and technical inspections. As tons of medical supplies arrived, the Medical Material Branch developed push packages for the operating room, surgical clinics, and wards. The Property Management Section maintained accountability of the Air Force UTC hospital and the hundreds of pieces of new automatic data processing equipment and medical and nonmedical equipment arriving monthly. Several new staff elements were created, such as the Family Assistance Center, so the Logistics Division purchased and set up additional furniture packages to support them. Patient Support Phase Although patient support had been ongoing at LRMC since OEF, it began in earnest in April 2003, shortly after the combat phase of OIF started. The hospital received approximately 24 patients a day, most with combat-related injuries. The theater aeromedical evacuation policy helped keep the workload in the Department of Nursing manageable. Patients identified for evacuation to the United States received life-sustaining care, were stabilized, and were evacuated within 3 to 5 days. The length of stay for other patients was longer, usually between 8 and 12 days. Before evacuating patients to the United States, every attempt was made to provide quality medical treatment that would enable them to recover and return to their units or elsewhere in the OIF theater as replacements. During combat operations, the press, Members of Congress, general officers from all services, and patients’ family members began flooding the LRMC. This created new logistics and administrative problems for the LRMC command and staff. The public affairs staff managed the press. The command group and the entire Kaiserslautern military community welcomed Members of Congress, and the medical and nursing staffs assisted general officers who were there to visit patients. LRMC’s Family Assistance Center and the two local Fisher Houses (comfort homes built by the Fisher House Foundation, Inc., and given as gifts to the military services and the Department of Veterans Affairs) took care of visiting family members. For the next month, the words “and evacuated to a military hospital in Germany for medical treatment” were standard language in most national and international news broadcasts. A learning center on post was converted to a press control center. This building was selected because it was near the hospital and had several rooms with required utilities and communications equipment and a parking area large enough to accommodate media vans. During the early phases of OIF, LRMC received thousands of donated clothing articles, both used and new, including underwear, coats, shorts, tennis shoes, socks, pajamas, and robes. The LRMC chaplain’s office became the receiving and distribution point for clothing and toilet articles. The volunteer staff of the chaplain’s office set up a mini department store to distribute the free clothes and toiletries. Patients routinely arrived on litters wearing some form of military pajamas and had no other clothes with them. Although most women could wear medium-size clothes, some of the big, muscular marines needed an extra-large size in everything. Fortunately, the Marine Corps liaison staff at LRMC had access to Marine Corps physical fitness uniforms. Patients did not have access to televisions in the contingency wards, so many local and U.S. vendors, private organizations, and individuals donated televisions and stands. During the requirements phase, LRMC had limited funding, so the primary emphasis was on obtaining essential medical equipment, supplies, beds, and expansion buildings. When the war began, LRMC was given unlimited funding, which was carefully managed in a way that would survive the scrutiny of any future audit. This funding allowed LRMC to buy patient comfort items and support the bulging staff. As the patient load increased exponentially each month, it became apparent that the expansion was going to be a long-term operation, so the requirements phase was repeated with unlimited constraints. The average monthly operating bill was over $300,000, so millions of dollars would be needed to support LRMC’s personnel and equipment. Medical materiel purchases became increasingly difficult during May. The supporting contracting agency could not keep up because it still was staffed at peacetime levels. Blanket purchase agreements with vendors were developed to lower the number of purchase requests being processed. The Medical Material Branch’s local procurement office, in conjunction with the Europe Regional Medical Command Contracting Cell, located many European vendors of U.S. medical products, which significantly reduced shipping time. However, the huge volume of medical materiel requirements continued to be a major problem for the procurement system. Beginning in June, the outpatient clinics began to show stress from the sustained workload increase. Most clinics were not staffed or prepared to accept a huge workload increase. Because the population at risk had quickly changed from active-duty personnel to Reserve-component personnel, who sometimes were not as fit, unforecasted requirements, such as cardiology supplies, placed a heavy demand on the medical materiel supply system. Seriously injured and extremely ill patients arrived with various items of medical equipment attached to their bodies. The Patient Movement Item (PMI) system is well prepared and works well during peacetime operations. (“PMI” refers to the medical equipment and supplies needed to support patients during evacuation.) However, patients from OIF soon overloaded the PMI system. In theory, PMI from an Army combat support hospital was to be swapped at the departing airfield in the OIF theater by the Air Force. However, Army and Air Force PMIs often are identical and sometimes were identified incorrectly while patients were loaded into and unloaded from aircraft or vehicles. As a result, Army PMIs sometimes were still with patients when they arrived at LRMC and LRMC PMIs sometimes were evacuated back to the United States with patients. Unfortunately, the Army’s system for tracking PMI equipment is not as efficient as the Air Force’s. In June, LRMC received approximately 50 new patients a day and the total number of patients averaged around 200, which was more than twice the average daily patient population before the war. Because the DWMMC was severely understaffed, the logistics section supporting it assumed responsibility for controlling and storing baggage and sensitive items, issuing uniforms, and providing linens, housekeeping, transportation, and office supplies. Baggage and sensitive item control quickly became a manpower and storage problem. Many patients arrived on litters and were sent directly to the intensive care unit. Their bags and personal items were moved from the patient bus to the baggage storage area, often without identification tags. Some patients arrived with issued or personal knives, while others arrived with their issued nuclear, biological, and chemical supplies. Many patients arrived with only a few personal items in trash bags, and others arrived with several duffle bags full of clothing and individual equipment. Hundreds of items arrived daily, so the logistics personnel established a simple but effective tag system and recorded the items manually in a register. As patients were evacuated from LRMC, a second problem developed: Patient bags were not always sent with the patient. To correct this problem, personal items of patients leaving LRMC now are mailed at a rate of 50 pounds a day back to the patients’ last known continental United States military unit. Finding bed space for the flood of patients overwhelmed the LRMC’s resources. The 415th Base Support Battalion was instrumental in providing temporary barracks for patient use. But these barracks were at Kleber Kasserne, 20 miles away. Buses were contracted to shuttle patients from Kleber Kasserne to the hospital and to the post exchange and other life support activities in Vogelweh. This was a long bus ride, and the bus ran all too infrequently, but it was better than paying $40 for a taxi ride. As the patient population continued to expand, two-person rooms became four-person rooms. The growing patient population created a huge drain on linen and housekeeping support. Now, months later, the number of patients arriving at LRMC from OIF is even higher. Obtaining staffing to keep up with increasing patient loads is difficult. However, the logistics support personnel at LRMC will continue to meet new challenges by putting new systems in place to minimize patient difficulties and improve current systems so the logistics support provided is seamless and invisible to staff and patients. ALOG Lieutenant Colonel Timothy E. Bateman is the Chief of the Logistics Division of the Landstuhl Regional Medical Center in Germany. He is a Medical Services Corps Officer and is educated in emergency medical services administration. Major Song H. Gotiangco is the Chief of the Medical Material Branch of the Logistics Division of the Landstuhl Regional Medical Center. She has a B.A. degree in psychology from Trinity University in Texas. She is a graduate of the Army Medical Department Officer Basic and Advanced Courses, the Medical Logistics Management Course, the Combined Arms and Services Staff School, and the Army Command and General Staff College.