Enabling Integral Health in the Littoral Environment

Our home is girt by sea, a phrase sung from every primary school hall and sports stadium from 19 April 1984. This phrase and its implications have been missing in Army doctrine for quite some time. The Middle East Area of Operations (MEAO) period of our history slanted our tactical thinking. Our training often details a threat assessment of Area of Operations (AO) dominance, assuming and providing assuredness through multi-domain superiority. The Defence Strategic Review (DSR) has assessed and realigned to threats in our region. The need to be ready for a Large Scale Combat Operation (LSCO) of an amphibious nature becomes obvious. A key planning consideration for any operation or tactical action is health. If overlooked or under planned it can lead to loss of momentum, costing lives and tempo. At battlegroup (BG) level or lower, considerations for health remain largely in the integral to close levels of health support. It is within this integral space we will address key areas for improvement in support of littoral planning. 

The Problem

Uncontrolled haemorrhage remains the leading cause of preventable death in combat operations (Eastridge et al 2012). Point of injury care remains the greatest factor in survivability of casualties. It is a fair assumption to make that enhancing the ability of clinicians to provide this care will lead to better outcomes. The current health support for an Amphibious Task Force (ATF) relies on the Maritime Role 2 Enhanced (MR2E). It remains within Aeromedical Evacuation (AME) until the land-based R2 establishes. The interim period is covered by land or sea-based Role 1s (R1) with integral medical support. These close health assets reposition as required to support the ATF. This planning and almost ‘standard’ layout enables the timings of 10-1-2 as demanded by the Joint Trauma System. With early Casualty Evacuation (CASEVAC) now no longer being a surety and 76% of combatants killed in action dying prior to reaching a medical facility, we as an organisation, must look to enable and support prolonged field care (Cap et al 2015). This requirement is then further amplified in the littoral AO, likely consisting of multiple force elements and lines of effort, with significant and complex environmentally-driven dispersion factors affecting lines of communication. The ‘golden hour’ standard will likely devolve into a 72h – 96h holding policy (Philpott 2020), already earning the title ‘Brass 96’ from the United States Marine Corps. This will further force a shift in command decisions, logistic planning, and training methodology to support these integral health assets.

Command and Risk

The first, and most brutal concept to contend with is reverse triage. Within the MEAO, triage practices dedicated the greatest number of resources to the most critical patients, as you would expect in a well-resourced and secure AO. The considerations for treatment shift to a bi-directional model in the face of consistent overwhelming casualties, prolonged field care, and the need to return personnel to duty in support of LSCO (April et al 2022). It is a significant ethical issue, (Wissemann 2023) in that it requires clinicians to treat casualties who may be treatable, as expectant to maximise their resources for other more survivable casualties who will be able to return to duty swifter. The decision to exercise this utilitarian concept will lie with senior manoeuvre commanders, with support from health staff, who must take a militaristic stance to support the operation. This concept applies to all future theatres of war involving a LSCO. The effects will cascade through health planning, through the front-heavy logistic efforts required and limited ability for medical evacuation from R1s. In turn, amplified again by larger, contested and dispersed battlespaces of the littoral nature. 

Supply and Sustainment

With reverse triage established, the second difficulty encountered in the integral space for prolonged field care is supply of medical consumables (MEDCONs). In a dispersed, complex AO with enemy threats, the limited opportunities for resupply must be able to maintain momentum of the ATF elements. Of the supplies, 2 Bde has identified that the use of whole blood transfusions and the ability to carry these stores in the integral space is critical to increasing survivorship of battle casualties (McWhirter et al 2024). This capability must become standard, with integral and close CSS elements primed to enable this supply through forward-held stock, and an established Emergency Donor Panel to enable activation of Walking Blood Banks (Day et al 2020). Army must review delivery systems for MEDCONs, as integral assets have limited capacity to hold stores. In a dispersed, littoral environment, the Army should look to rush a drop-by-drone capability (Lammers et al 2023), enabling rapid resupply that can adjust to the threat picture. Drones enable a cost-effective, timely and efficient method of resupply, by air or by sea, in island chains. These lines of supply must remain fluid and be capable of surging support to sites of MASCAS to support the provision of prolonged field care.

Equipment

The Australian Army does not currently hold any significant level of medical equipment or conduct medical-specific training in support of sustaining a BG-level amphibious operation. Whilst recognising this issue is not limited to medical concepts, swift steps are needed to deliver small boat platforms capable of sustaining a resuscitative capability. This will incur an inherent training liability to support the use of CASEVAC platforms capable of maintaining patient care in the littoral environment. However, 1 and 4 HB support amphibious training events and exercises lack the capability and formalised training to support an event of any scale. This training liability is not within the scope of discussion for this article, as it is likely an Army-wide issue that will entail a significant shift in lines of effort in support of the DSR.

Personnel 

With casualty processing, supply issues, and equipment deficiencies identified, the crux of this assessment is forthcoming and – as in all things Army – the answer is soldiers. The Medical Technician (MT) needs to be enabled to display professional mastery. This must be steeled through expansive and challenging training, to respond in such a dynamic and threatening region. As the training stands, MTs have a lesser scope of practice, or authority to provide treatments, then a civilian paramedic. They do not currently have the policy-enabled ability or formal training to provide treatments required in a prolonged field care environment, even before addressing the above issues. The impact of this lack of trust snowballs with a significant number of available treatments requiring Medical Officer (MO) review or permission. Again, this is a system building off a reliance on consistent comms, minimal casualties, and resource rich environments. Whilst well suited to the MEAO or civil aid activities, it will disintegrate in the face of LSCO in littoral AOs. MTs need more thorough training, permissions, and autonomy to operate in the dispersed, threatening, and unstable environments of our near future.

Conclusion

Any amphibious operation requires adaptability and a heavy dose of mission command for a successful outcome. It is in essence these two aspects that must be reflected upon by decision makers to enable the integral health assets supporting the warfighters. We must look to support the development of clinicians with a view to the near region and its littoral composition, compounded by the uncertainty this environment will entail. Even with commander decisions, logistic supply and suitable equipment, our greatest weakness remains the autonomy and clinical scope of an MT. This individual, where every decision made has a magnified effect upon a patient’s survivability, is bereft of trust from a clinical-policy perspective, enhanced by an ingrained over-reliance on MO supervision. It is up to us as an organisation to enable our soldiers in their roles, through improved training opportunities and supporting professional mastery, to deliver healthcare in a non-permissive, dispersed, and unstable theatre.

References

April, M.D., Bridwell, R.E., Jones, J., Oliver, J., Long, B. and Schauer, S.G., 2022. Descriptive Analysis of Casualties Rapidly Returned to the Fight after Injury: Reverse Triage Implications for Large Scale Combat Operations. Medical Journal, US Army Medical Center of Excellence (MEDCoE).

Cap, A.P., Pidcoke, H.F., DePasquale, M., Rappold, J.F., Glassberg, E., Eliassen, H.S., Bjerkvig, C.K., Fosse, T.K., Kane, S., Thompson, P. and Sikorski, R., 2015. Blood far forward: time to get moving!. Journal of Trauma and Acute Care Surgery, 78(6), pp.S2-S6.

Day, W.G., Cooper, E., Phung, K., Miller, B., DuBose, J. and Lin, A.H., 2020. Prolonged stabilization during a mass casualty incident at sea in the era of distributed maritime operations. Military medicine, 185(11-12), pp.2192-2197.

Eastridge, B.J., Mabry, R.L., Seguin, P., Cantrell, J., Tops, T., Uribe, P., Mallett, O., Zubko, T., Oetjen-Gerdes, L., Rasmussen, T.E. and Butler, F.K., 2012. Death on the battlefield (2001–2011): implications for the future of combat casualty care. Journal of trauma and acute care surgery, 73(6), pp.S431-S437.

Lammers, D.T., Williams, J.M., Conner, J.R., Baird, E., Rokayak, O., McClellan, J.M., Bingham, J.R., Betzold, R. and Eckert, M.J., 2023. Airborne! UAV delivery of blood products and medical logistics for combat zones. Transfusion, 63, pp.S96-S104.

McWhirter, K.K., April, M.D., Fisher, A.D., Wright, F.L., Rizzo, J.A., Corley, J.B., Getz, T.M. and Schauer, S.G., 2024. Blood consumption in the Role 2 setting: A Department of Defense Trauma Registry analysis. Transfusion.

Philpott, J.C., 2020. Improving Patient Outcomes. Surviving in a contested and distributed operations environment. Marine Corps gazette, pp. 44-47

Wissman, M., 2023. War on the Rocks: Large-Scale Combat Operations will bring new medical ethics challenges., accessed 17 April 2024.