Technologies for Tracking and Caring for Injured Soldiers
by Captain Derek C. Cooper
Reductions in force structure and changed perceptions of future battlefields are forcing the Army to place more emphasis on the individual soldier as part of an integrated fighting system. Advancing technology is requiring every soldier to become a systems manager. Consequently, "mean time to repair" increasingly becomes as important for humans as it is for machines. As the centerpiece of our high-tech systems, soldiers are indispensable. Machines are relatively quick and easy to replace, but soldiers take longer to acquire, prepare for use, and replace. Public opinion, now more than ever, demands extremely low or nonexistent casualty rates, and today's soldiers take for granted the presence of world-class medical care on the battlefield.
When serious injuries occur, the difference between life and death often is determined by the care received within the first "golden" hour. Historical studies show that nearly 70 percent of deaths resulting from injuries received in battle occur within the first hour. Joint Health Service Support (JHSS) Vision 2010 states, "The single most critical time for treatment of a casualty is the first ten minutes."
If the Army Medical Department (AMEDD) is going to remain relevant and continue to provide combat health support for the Army, it must undergo a revolution in medical affairs corresponding to the ongoing Revolution in Military Logistics. Much has been said about Army redesign and its associated combat service support (CSS) concepts. Many of the principles that apply to the logistics community also apply to AMEDD. The adoption of advanced technologies is making CSS more efficient. By using embedded diagnostics and prognostics and other data technologies to gain total asset visibility (TAV), velocity management, and improved maintenance capabilities, the Army is reducing its logistics footprint on the battlefield. If, as former Chief of Staff General Dennis J. Reimer said, "soldiers are our credentials," then the Army and AMEDD must develop and apply technologies that will keep our most crucial and indispensable system, the soldier, in the fight.
AMEDD must use evolving medical and logistics technologies to achieve TAV and velocity management to locate and track patients. It must develop fully integrated medical products along with information and communications solutions to link all echelons and all U.S. military services' medical capabilities effectively in a seamless system. To stay relevant, AMEDD must reduce its footprint on the battlefield by improving its capabilities for locating and treating casualties within the golden hour and returning them to duty as soon as possible. AMEDD must search for emerging technologies in three distinct areas: evacuation and treatment platforms, information and communication technologies, and medical care equipment.
Medical Evacuation and Treatment Platforms
Hospitals are vital to saving soldiers' lives, but they are costly in terms of people, equipment, and space. More importantly, hospitals lack mobility and are located significantly to the rear of the battle. Consequently, for the last 50 years, medical evacuation and treatment platforms have been the centerpiece of AMEDD's wartime role. These platforms have been the primary element used to clear the battlefield.
The Army Surgeon General's current number-one priority for modernizing the medical force is the UH-60Q aeromedical evacuation helicopter, followed closely by the armored medical evacuation vehicle (AMEV) and the armored medical treatment vehicle (AMTV). These priorities are driven primarily by lessons learned during Operation Desert Storm. During that operation, AMEDD found that the speed of combat operations greatly extended lines of evacuation and ultimately exceeded the capabilities of its M113 ground ambulance, M577 emergency treatment vehicle, and aeromedical evacuation paltforms. The AMEV, AMTV, and UH-60Q may well resolve this disparity for today's Army, but they likely will leave AMEDD no better off in the year 2010 than it is now. Purchasing large quantities of the AMTV's and AMEV's will be a sure sign that AMEDD is looking to fight the last war.
The AMEV is built on a Bradley fighting vehicle
chassis and has been clocked at 43 miles per hour.
That speed should keep medics close to the warfighters
they support. The AMEV dramatically improves
nuclear, biological, and chemical protection; mobility;
casualty care; and survivability over today's M113 ground
The AMTV, which also is built on a Bradley chassis, is equally impressive. In comparison to the M577 emergency treatment vehicle, it provides much improved survivability, protection, interior design, environmental support, and mobility. However, neither the AMEV nor the AMTV currently has production funding, and both use "creep-ahead" technology. AMEDD leaders are trying to get procurement funding in the budget plans for fiscal years 2002 to 2007. Units then would be equipped sometime between 2005 and 2010. By 2010, these systems will be no more capable than the M113 and M577 were during Operation Desert Storm. AMEDD must integrate its modernization plans with those of the rest of the Army.
Although senior Army leaders already are looking for successors to the Abrams tank and Bradley fighting vehicle, they are not planning to replace these aging systems in the next 10 years. Instead, they are investing in future technology. According to the Army Science and Technology Master Plan, "while contributing to both the survivability and lethality of combat vehicles, mobility technology plans call for doubling the cross-country speed of combat vehicles; [and] by 2005, a 40-percent increase of cross-country speed of a 40-50 ton combat vehicle will be demonstrated." In 1997, General Reimer said of traditional technologies
All services should commit to a force development strategy that eschews marginal improvements in capabilities that result from the incorporation of "creep-ahead" technologies and focus instead on an approach [that] produces revolutionary improvements in capabilities through the incorporation of "leap-ahead" technologies . . . Our current capabilities are adequate with some focused enhancements to successfully implement the NMS [National Military Strategy] at least through the year 2010. Accordingly, it appears prudent to delay large-scale modernization of some capabilities during the next decade while we invest more significantly in the development of leap-ahead capabilities.
General Eric K. Shinseki, the current Chief of Staff, is considering the possibility of replacing many tracked vehicles in the Army inventory with wheeled vehicles that weigh 50 to 70 percent less. By 2010, the Army likely will begin fielding new combat vehicles; if AMEDD purchases the AMEV's and AMTV's, it will have shiny new vehicles that still will not keep up with supported units. AMEDD must work closely with the maneuver community to develop new ground evacuation platforms on the same chassis as the new combat vehicles.
AMEDD also must work with the joint community to develop its next aeromedical evacuation platform. AMEDD ownership of a fleet of aeromedical evacuation platforms is absolutely essential to saving lives. An aeromedical evacuation platform that allows for en route care fulfills multiple requirements: evacuation, treatment, communication, and speed. For the first time, the UH-60Q program incorporates an advanced medical capability into an Army helicopter. A concern with the UH-60Q is that it is built using the existing UH-60 airframe. Department of Defense is considering establishing a Joint Rotorcraft Technology Office, which could make the UH-60Q a bad long-term investment. The Joint Chiefs of Staff are pushing the services to build a single new platform to replace aging aircraft. They believe they can field a new aircraft "well before 2015." A helicopter with on-board medical equipment is leap-ahead technology; however, purchasing old airframes is counterproductive. Before large aircraft purchases are made, additional research should be conducted to determine the feasibility of establishing forward surgical teams on medium-lift helicopters. Making surgical capability mobile and closer to the patient certainly will aid in treating casualties within the golden hour.
Evacuation platforms long have been, and will continue to be, vital to AMEDD's ability to accomplish its mission. However, the vehicles currently under consideration require long acquisition lead times and are very costly to field. AMEDD can make greater strides in improving battlefield life expectancy, shortening evacuation times, and reducing its footprint on the battlefield by using information and communication technologies.
Information and Communication Technologies
In addition to simply moving casualties faster, it is crucial for AMEDD to identify and track casualties better. Integrating information technologies into combat health support systems will allow AMEDD to project the expert care necessary to sustain future forces. AMEDD must make advances in casualty identification and tracking systems similar to those Army logisticians are making regarding supplies and equipment. Technologies such as global positioning systems (GPS's) for individuals, personal information carriers, and telemedicine make it possible to improve battlefield life expectancy significantly and reduce the AMEDD footprint.
Global positioning system. TAV permits operational and logistics managers to determine and act on timely and accurate information about the location, quantity, condition, movement, and status of materiel. It includes assets that are in storage, in process, and in transit. For AMEDD, soldiers are the assets on which it must have continuous location, condition, and status information.
This technology is now available commercially. General Motors' OnStar system uses a GPSa satellite-based system used for accurate positioning and navigationwith hands-free cellular telephone communications systems to track vehicles continuously. Using embedded diagnostics and sensors, OnStar can send emergency crews directly to a vehicle in distress without being contacted by the vehicle operator. Spacelabs Medical, Inc., of Redmond, Washington, provides systems that track patient movement within a hospital. Their advanced systems monitor and transmit patients' vital signs using wireless technology.
The Army already is testing personnel tracking with the Land Warrior System. This system will provide dismounted soldiers with complete real-time battlefield situational awareness. In his 1998 Army Green Book article, "Army Modernization: Preparing Today For Tomorrow," Assistant Secretary of the Army for Acquisition, Logistics, and Technology, Paul J. Hoeper, states that within the Land Warrior system, "GPS provides the soldier's location to the computer, integrates the soldier's position with location reports from other soldiers to provide situational awareness, and displays the information on a digital map in the soldier's helmet-mounted display." Using a GPS, Land Warrior communicates information instantly, unlike slow radio or message modes. With TAV for soldiers, AMEDD could identify casualties instantly and move to provide medical care in the first few critical minutes after injury.
Personal information carrier. AMEDD could use TAV to develop a system that provides instant identification of each casualty and tracks him continuously from the point of injury. A personal information carrier (PIC) is a small (2¼ square inches) storage device that works on a principle similar to a floppy disc. It can carry a soldier's medical records and other personal and financial information. A PIC could be used to provide in-process and in-transit visibility, serving as just one element of a digitized medical environment connecting the foxhole to the stateside hospital. PIC's could be integrated with systems such as the GPS and Land Warrior personal status monitors to provide real-time in-transit visibility for every casualty and every healthy soldier on the battlefield.
Telemedicine. The last link needed to provide world-class medical support to casualties at the point of injury from a stateside hospital is telemedicine. Combat medics currently provide far-forward medical care on the battlefield with virtually no supervision. Their limited training and experience is focused on life-saving procedures and patient evacuation. Telemedicine can help medics save lives by providing on-site consultation with experts located anywhere in the world. With telemedicine, patient information, such as xrays and vital statistics, is sent digitally to a specialist at a hospital. The specialist provides the on-site medic the expertise needed to treat the patient. Telemedicine can provide the knowledge, experience, and judgment needed for consultation, thus reducing the need for medical evacuation. It also can improve the collection and transfer of medical data. Dr. Stephen Joseph, Assistant Secretary of Defense for Health Affairs, stated that telemedicine will allow for "the obliteration of time and space by electronic means for the care of our patients."
When compared to evacuation platforms and hospitals, commercial-off-the-shelf information and communication technologies are relatively inexpensive. More importantly, by combining the OnStar GPS, PIC, and telemedicine technologies, AMEDD could create a revolutionary new medical system. Investing in these leap-ahead technologies would create a seamless system for identifying, tracking, and providing medical care to soldiers on the battlefield. With the advances provided by these systems, acquiring and inserting advanced medical technology far forward on the battlefield would be practical and desirable for the first time.
Medical Care Equipment
JHSS Vision 2010 calls for changing the concept of "definitive care in theater" to a concept of "essential care in theater and definitive care in CONUS [continental United States]." To make this change in philosophy and doctrine, AMEDD must have adequate evacuation platforms and excellent information and communications systems. But more importantly, it must have state-of-the-art medical equipment on the battlefield. Tracking and evacuating a casualty are critical. However, if adequate medical supplies and equipment are not readily available to treat the casualty, tracking and evacuation will not save his life. More rapid evacuation of patients requires advanced en-route care equipment that is state of the art, lightweight, safe to use, and compatible with all services' evacuation platforms. Advanced technologies such as noninvasive sensors, data infusion, image recognition, and miniaturization are being explored currently and should be acquired and fielded rapidly.
LSTAT. One of the most promising pieces of medical equipment today is the life support for trauma and transport (LSTAT). The LSTAT will increase survival rates by getting sophisticated trauma equipment in the hands of the medic on the battlefield. The LSTAT is equipped with an array of monitoring and patient care capabilities never before employed at the medic level. It integrates several miniaturized, commercially available medical devices into a self-contained platform (litter) that allows seamless transfer of a wounded soldier from one echelon of medical care to the next. In exercises at Walter Reed Army Medical Center in Washington, D.C., the LSTAT was tested as a mini-intensive care unit that allows surgery to be performed within a few miles of the front. Immediate, life-saving surgery could stabilize patients for long-haul transport, using the actual platform where the surgery took place, to a hospital anywhere in the world. Furthermore, the LSTAT is relatively inexpensive compared to vehicles and hospitals. It is just one of the many emerging technologies that will make medical units smaller, lighter, and more mobile.
The LSTAT can provide advanced life support to the patient from the point of injury until he arrives at a medical treatment facility.
Ultrasound. To further improve future clinical capabilities on the battlefield, AMEDD must focus on ways to diagnose and treat complications that develop during evacuation. A Marine Corps' mobile medical monitoring study indicated that "ultrasound and Doppler have proved to be of great value in early examination, diagnosis, treatment and triage of combat casualties." Ultrasound also could provide the capability to diagnose respiratory complications and assess blood flow into extremities during evacuation. With advances in technology, ultrasound, which never has been on the battlefield because of its sensitivity, size, and cost, could become a life-saving reality.
Personal status monitors. These have been used for years in hospitals to monitor patients and by the National Aeronautics and Space Administration to monitor astronauts. Personal diagnostic equipment is being developed for military use. When worn by a soldier as a watch or other piece of his uniform, the diagnostic device could collect data such as the soldier's blood pressure, pulse, oxygen level, and tension. When linked with information and communication technologies, the personal status monitor could track a soldier's vital signs and send out an alert in case of a wound or other trauma. An embedded GPS receiver could provide the wounded soldier's precise location. This system would resemble the embedded diagnostics that logisticians use in military equipment. Noninvasive output monitors and systems are essential to providing hospital-level, world-class medical care to critically injured soldiers on the battlefield. These are minimum requirements for the 21st century Army.
Advanced medical technologies can provide better point-of-injury care within minutes after a soldier becomes a casualty and ultimately will save lives. To do so, however, AMEDD must no longer "let technology drive strategy, rather than letting strategy determine technology," which Alvin and Heidi Toffler call the military's biggest problem in their book, War and Anti-War. AMEDD must determine the technologies and systems it needs and implement changes that will allow for fewer healthcare pro-viders on the battlefield and will free critical transportation space for moving warfighters into and around the theater. By incorporating these medical technologies, AMEDD could begin to comply with General Shinseki's intent, ". . . to aggressively reduce the size of our deployed support footprint . . ."
Reducing the AMEDD Footprint
General Shinseki's statement at the October 1999 meeting of the Association of the United States Army, "If we don't deploy it, some maneuver commander won't have to feed it, fuel it, move it, house it, or protect it," provides the foundation for the effort AMEDD must make to reduce its footprint on the battlefield.
Many opportunities to reduce the AMEDD footprint are available through advanced information, communication, and medical technologies. Once these technologies are integrated into a complete system, the number of deployed medical maintenance technicians can be reduced. Optical fabrication (making lenses for glasses and mask inserts) likely could be removed from the theater altogether. By using personal status monitors, LSTAT's, and telemedicine, medical personnel can stabilize casualties in theater and prepare them for transport to CONUS, eliminating the need for intermediate care between the point of injury and CONUS. Such practices certainly will challenge the notion stated in Field Manual 8-10, Health Service Support in a Theater of Operations, that "routinely bypassing available triage and care [provided by intermediate facilities] will not be practiced." However, implementing advanced technologies will reduce the number of hospitals and healthcare providers required to deploy to an area of operations.
Recommendations for Using the Latest Technologies in Far-Forward Care
1. Discontinue the armored medical treatment vehicle (AMTV) and the armored medical evacuation vehicle (AMEV) procurement programs scheduled for fielding in fiscal years 2002 to 2008.
2. Upgrade the AMEDD's current UH-60 Black Hawk helicopter fleet, rather than purchase new UH-60Q helicopters, until full-scale procurement of a new airframe can begin.
3. Aggressively pursue the development of a personnel total asset visibility system that will interface with the digital battlefield and provide seamless and continuous patient tracking and far-forward care using telemedicine.
4. Recognize the value of the life support for trauma and transport (LSTAT) litter, the personal status monitor, and ultrasound for providing far-forward care never previously provided on any battlefield. Use commercial-off-the-shelf systems, with minor adjustments for battlefield hardening, to acquire and field these essential capabilities rapidly to our medical forces in all services.
5. Ensure that all medical projects and technologies adopted are considered for use in a joint environment.
A revolution in medical affairs will force AMEDD leaders to re-examine the AMEDD structure and challenge the long-accepted basis of resource allocation, doctrine, and organizational structures in order to remain relevant in the future. Many ideas and technologies are being developed and tested in stovepipe programs within DOD today. These efforts should be merged into a single system where joint service coordination is mandatory.
Embedding information and communication systems into evacuation platforms, soldiers' gear, and state-of-the-art miniaturized medical equipment will provide real-time location and status of all personnel and medical assets. These new technologies will allow DOD medical services to coordinate very complex, time-sensitive, high-tempo medical procedures across the full spectrum of operations. Having a clear picture of the battlefield will allow medical planners to allocate assets more accurately, quickly, and efficiently. More importantly, an integrated system will conserve the use of scarce resources by moving information rather than people and equipment. The system will provide state-of-the-art, highly trained medical capabilities to a theater without actually deploying large numbers of personnel or equipment.
AMEDD must continue to provide medical support to soldiers on the battlefield that is comparable to the best civilian standards. The technologies and ideas available today can make that goal a reality if properly integrated into a seamless structure that can provide world-class support to the point of injury from any American hospital in the world.
While the cost of implementing new healthcare technologies may seem daunting, they must be pursued, because the American people expect soldiers to receive world-class care regardless of their location or condition. AMEDD must approach patient tracking and far-forward care technologies aggressively and openly. If AMEDD is to reduce its footprint and still locate and treat casualties within the golden hour, it must exploit and adopt tomorrow's technologies today. ALOG
Captain Derek C. Cooper is assigned to Madigan Army Medical Center at Fort Lewis, Washington. He has a bachelor's degree in aeronautical science from Embry-Riddle Aeronautical University in Arizona and a masters degree from the Florida Institute of Technology. He is a graduate of the Army Medical Department Officer Basic and Advanced Courses, the Medical Logistics Management Course, and the Army Logistics Management College's Logistics Executive Development Course, for which he completed this article.