Army Medical Department Transformation: Executive Summary of Five Workshops


A series of Army Medical Command workshops assessed the effect of the Future Force doctrine on the Health Service Support system's ability to deliver medical care on the battlefield. The authors summarize these assessments and present conclusions based on the scenarios and the data gathered during the workshops.

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A series of Army Medical Command workshops assessed the effect of the Future Force doctrine on the Health Service Support system's ability to deliver medical care on the battlefield. The authors summarize these assessments and present conclusions based on the scenarios and the data gathered during the workshops.

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Product Details

  • ISBN-13: 9780833039064
  • Publisher: Rand Publishing
  • Publication date: 4/2/2006
  • Pages: 63
  • Product dimensions: 6.74 (w) x 8.98 (h) x 0.22 (d)

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Army Medical Department Transformation

Executive Summary of Five Workshops
By David E. Johnson Gary Cecchine Jerry M. Sollinger

Rand Corporation

Copyright © 2006 RAND Corporation
All right reserved.

Chapter One



All of the military services are in the process of transforming, moving away from force organizations and operational concepts of the Cold War to ones better suited to the security threats the United States faces today. The Army, arguably, is undertaking the most sweeping transformation of any of the services. Not only is it attempting to field radically different equipment, but also it is planning on fighting in different ways. One hallmark of the new operational concepts contemplated by the Army is forces that are carrying out fast-paced operations and that are spread widely across a battlefield devoid of the linear boundaries that characterized most past operations.

The concept of fast-paced operations on a dispersed battlefield poses substantial problems for the units that support the combat forces. Medical units face challenges that are greater than those of most other support units. Finding casualties quickly, treating them promptly, and evacuating them rapidly will be difficult. But each of these tasks will be crucial to keeping mortality and morbidity low.

In 1998, the Army Medical Department (AMEDD) started an analytic process to identify the specific challenges these new concepts will pose to providing Health Service Support (HSS). To do so, the AMEDDconducted war games and workshops. These efforts resulted in a list of issues to be rank ordered by a council of colonels. Researchers from RAND were asked to comment on and assess the proceedings and the conclusions.

The researchers determined that the issues identified by the AMEDD process fell into two categories: the level of medical risk posed and the AMEDD's role in mitigating that risk. Medical risk refers to the potential casualties-including soldiers, enemy prisoners of war, and civilians-and their outcomes. RAND researchers suggested that the AMEDD take the approach of scenario planning, which is a strategic management tool that assumes a largely unknowable future. It is a group process that attempts to learn about the future by understanding the most important influences affecting it. The goal is to consider as many perspectives as possible. In that sense, it is the polar opposite of a view that assumes a specific future outcome and identifies the steps along the way to reach that specific end.

The AMEDD accepted this recommendation and asked its researchers to design a series of AMEDD Transformation Workshops (ATWs) to begin an assessment of the medical risks associated with the emerging Army operational concepts and the capability of the HSS system to mitigate them. The underlying goal was to identify the gaps between the HSS concepts for the Future Force and the requirements for that force, and to gauge the medical risk those gaps pose. Figure 1.1 depicts the general process used in these workshops.

Each workshop employed a combat simulation that produced results in terms of soldiers and vehicles being struck by enemy weapons. Workshop participants then used a process to determine what those combat results meant in terms of casualties, to include the type of casualty and when and where it occurred. Teams of subject matter experts, informed by the assumptions made about the HSS system, then took the casualty data and deliberated on what type of treatment and evacuation was required and feasible at each stage of a casualty's progress through the HSS system, from treatment by the first responder through the forward surgical teams and UA medical companies.

The results and implications of these workshops depend in important ways on the scenarios and the models. First, the small number of scenarios examined and the limited number of models used impose a significant methodological limitation, and the insights derived are sensitive to it. Second, the workshops employed a relatively sophisticated array of analytic assets to track the flow of patients through the HSS system. Clearly, the results depend heavily on particular features of this layered approach. For example, the number of casualties depended in part on the combat outcomes of the combat models and on data about casualty distribution drawn from the historical literature. Table 1.1 lays out these dependencies. Future attempts to refine the analysis of these issues should take these dependencies into account.


Between April 2002 and May 2004, the AMEDD conducted five workshops. This report briefly describes the scenarios, structure, and processes of the workshops. However, its main purpose is to summarize their results. Workshop output included the responses by teams of subject matter experts to a series of questions and issues raised by the workshops. In most cases, several workshops addressed the same issues and questions, albeit from the different perspectives imposed by the specific scenario. Output also included the broader implications of the workshops. Some of these pertain to the HSS system; others transcend that system and apply to the Army as a whole.

How the Report Is Organized

The next chapter describes the five workshops. The one following that presents the subject matter expert perspectives from the workshops on the issues and questions they addressed. The final chapter describes the broader implications of the workshops. Appendix A contains a list of the subject matter experts. Appendix B lists the advanced medical technologies that the scenario uses.

Chapter Two

The Workshops

The AMEDD and RAND completed five individual workshops. ATWs I-III were conducted in April, August, and November of 2002, respectively. ATW IV occurred in February 2004, and ATV V took place in May 2004. The general structure of the workshops was the same. Each involved a combat scenario lasting between 8 and 100 hours and teams of subject matter experts whose areas of expertise spanned the functional areas critical to an analysis of combat casualty care issues. The simulations used varied across the workshops, but the general procedure was to assess the number and types of casualties that were incurred during the simulated combat and to track those casualties through the HSS system. Each workshop addressed a number of issues and questions. Many of these overlapped several workshops, but some issues were examined in solitary workshops.

The following were the broad purposes of all the workshops:

Identify gaps between AMEDD Future Force HSS system concepts and combat casualty care requirements generated from simulations sponsored by the U.S. Army Training and Doctrine Command (TRADOC) Analysis Center (TRAC).

Identify potential solutions and alternatives for further analysis.

Provide the AMEDD analytic support for programmatic decisions.

Assess the medical risks and the potential to mitigate them.

Although all workshops had the same overarching objectives, each had different specific objectives. The workshops also employed different HSS structures, different simulation tools, and focused on different echelons. Table 2.1 compares the workshops across several dimensions.

ATWs I and II

The first three workshops were considered baseline efforts in the sense that they validated the methodology, procedures, and composition of the teams of subject matter experts. The judgment of the workshop participants was that the methodology and procedures were valid. While baseline, they also provided some insight into HSS system capabilities. Three small teams of subject matter experts each containing ten members supported these workshops. The subject matter experts were mostly officers and noncommissioned officers of the AMEDD, and their skills included aerial evacuation, medical doctrine, ground evacuation, anesthesiology, combat medic, medical technology, trauma, and general surgery. A list of these experts appears in Appendix A. The scenario for the first two workshops involved a Unit of Action (UA) battalion operating in 2015 as part of a brigade involved in a shaping operation that lasted eight hours. The teams independently considered each casualty as he moved through the HSS system, determining what type of treatment and evacuation were required and what could be provided given the assets available in the scenario. The specific objectives were as follows:

Design an analytic architecture to evaluate HSS system concepts by assessing AMEDD issues.

Identify gaps between Army and AMEDD concepts and capabilities and HSS requirements derived from Future Force operational scenarios.

Begin to identify and assess alternative HSS system concepts.

HSS System Employed in Workshops

Generally, the HSS structure used in the workshops was the one designed for units similar to those used in the scenario, except for ATWs I-III, where the structure was relatively generous given the size of the unit. The workshop employed a three-tier HSS system: first responders, a single UA's medical assets, and elements of division-level assets.

The first responder was either a combat medic (Military Occupational Skill 91W), a combat lifesaver, or the individual solider. A combat medic has skills similar to those of an emergency medical technician found on civilian ambulances. Combat medic skills focus on emergency care such as restoring breathing, stopping bleeding and shock, and evacuation. A combat lifesaver is a combat soldier who has received some additional medical training. Individual soldiers also receive training in self-aid.

The UA battalion headquarters had 14 evacuation vehicles, 12 of which were attached to maneuver companies (two each) and two attached to the Reconnaissance, Surveillance, and Target Acquisition squadron. The brigade headquarters had a medical company (20 minimal care beds) and aerial evacuation provided by a forward support medevac team (three UH-60L helicopters). The Forward Surgical Team (FST) is a light medical unit that deploys operating room capabilities forward in the battle area to save the lives of those whose injuries are so serious that they would not live to reach a rear area hospital. It can staff two operating tables. Medical personnel include four surgeons; eight nurses with critical care, anesthesiology, operating room, medical surgical, and practical nursing skills; and six enlisted personnel involved in patient care. The FST can handle about 10 patients per day or 30 in 72 hours (U.S. Department of the Army, 1997, pp. 2-1-2-7). After that time, the supplies and personnel are both exhausted. Furthermore, any soldier treated at the FST will likely also require treatment at the next higher medical echelon. By doctrine, an FST typically supports a combat brigade.

A full Combat Support Hospital (CSH), typically assigned to echelons above the UA, contains 236 beds: 36 intensive, 140 intermediate, 40 minimal, and 20 neuropsychiatric care (U.S. Department of the Army, 2005, pp. 2-1-2-22). It has two operating room (OR) modules, one surgical and the other orthopedic, which are staffed to provide a total of 96 OR table hours per day. It also allows for attachment of specialty surgical teams. It is an independent organization that includes all hospital services.

The workshops did not use a full-sized CSH. Rather they employed a 44-bed module (24 intensive care beds and 20 intermediate care) that included one surgical OR module. This module provides general surgical services with two OR tables for a total of 36 hours of table time per day. It can do more complex surgeries and has greater specialized capabilities (such as intensive care) than the FST, but its capacity in terms of numbers is about the same. The staff is composed of general surgeons, OR nurses, nurse anesthetists, and OR specialists. In the workshop, the CSH was located at the airport where the troops disembarked.

The only organic medical assistance available at platoon level was highly trained combat lifesavers, i.e., combat soldiers who had additional training in lifesaving techniques. In ATW I, a medic was attached to each platoon, and the UA battalion had two evacuation vehicles for each company-sized unit and three treatment/evacuation vehicles, which were all variants of the Future Combat System vehicle. In ATW II, the UA battalion was reduced to one evacuation vehicle for each company and two treatment/evacuation vehicles. No medics were attached to the platoons. No medical assets were degraded during the operation-i.e., no medics became casualties and no helicopters got shot down; command, control, communications, computer, intelligence, surveillance, and reconnaissance systems worked flawlessly and medical materiel was unrestricted. The medical units used in the workshop were the ones that exist in the Army today.

Overall, the scenario posited a relatively generous medical structure to support the theater and did not hold any parts of that structure at risk. Typically, an FST supports a full brigade, whereas in this scenario only a UA battalion (roughly one-third the size of a brigade-sized UA) was involved in the fight. Normally, a CSH would support an echelon above the brigade, either a division or a Unit of Employment, which typically have three combat brigades or UAs. But since only one UA was involved in the scenario, the full assets of the 44-bed CSH module were available to it. Casualties were sent to whichever facility had available capacity.

How the Workshops Determined Casualties

Each workshop involved a scenario and a simulation. The scenario for ATWs I-III was developed by TRADOC (U.S. Department of the Army, TRAC, 2001). It involved a UA battalion consisting of six combined arms companies operating in an 80-square kilometer area in southwestern Kosovo. The terrain was a mix of complex geography including forests and cities. The scenario called for the UA battalion to attack an enemy brigade in well-established defensive positions in forested terrain as part of a shaping operation. The threat was equipped commensurately with capabilities projected to be available in 2015. The battalion, with its reconnaissance element in the lead, made a 60-kilometer advance while attacking the enemy with long-range fires. Once it reached the enemy's position, the battalion assumed tactical standoff positions and continued to attack threat forces with fires to set the conditions for a close assault. When the destruction criterion was met, five of the six companies assaulted the enemy position to seize, clear, and secure the terrain. The battle lasted eight hours.

The TRAC at Fort Leavenworth used a standard Army simulation, the Interactive Distributed Engineering Evaluation and Analysis Simulation (IDEEAS), to produce a list of all friendly personnel or vehicles struck by enemy fire. IDEEAS is a high-fidelity engineering-level simulation loaded with over 1,700 entities to represent the UA battalion and the opposing threat, a brigade-sized mechanized unit.

The simulation determined which friendly elements were hit and assigned each to one of five categories: catastrophic kill, mobility damage, firepower damage, mobility and firepower damage, and crew kill (i.e., the number killed or disabled is greater than the minimum number of soldiers required to operate a towed vehicle). The simulation also provided the severity of the damage when a friendly element was hit, e.g., a catastrophic and combined firepower and mobility kill yield a 0.2 probability of a crewmember being killed and a 0.5 probability of being wounded. A catastrophic kill of a dismounted soldier yields a 1.0 probability that the soldier is killed.

The AMEDD Center and School (C&S) used a methodical process to determine how many soldiers were wounded as a result of being struck by enemy fire and to assign each one a discrete patient condition for the subject matter expert teams to manage. As described above, the process began with a battle damage assessment category above, as determined by the supporting simulation. The AMEDD C&S then applied a historically derived probability to the dismounted soldier, crew member, or platform occupant to determine if an individual was killed in action (KIA), wounded in action (WIA), or not injured. Once the number of wounded was determined, each casualty was then randomly assigned a patient condition code based on a frequency distribution from the Patient Workload Generator Model used by the AMEDD C&S.


Excerpted from Army Medical Department Transformation by David E. Johnson Gary Cecchine Jerry M. Sollinger Copyright © 2006 by RAND Corporation. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
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