Introduction

Over the past decade, the range of missions a brigade commander has found himself planning and executing has transcended traditional combat operations. "Winning battles and engagements is important, but alone is insufficient. Shaping the civil situation is just as important to success."¹ With increasing frequency, the Department of Defense (DOD), with or without interagency collaboration, is supporting activities outside the United States "to relieve or reduce human suffering, disease, hunger or privation."² Consequently, the combatant commander is required to be knowledgeable of, develop, plan, and execute humanitarian operations.³

A significant number of combatant commanders may lack sufficient understanding of the capabilities of professional medical staff, resulting in their inefficient application. The focus of this article is on the planning considerations with the resources that are organic to the armor, infantry, and Stryker brigade combat teams (BCTs). The intended audience of this article is the brigade-level staff and the brigade commander.

Professional Health Care Staff of the Brigade Combat Team

In the planning stages of a humanitarian mission, the critical assessment is a detailed inventory of the medical staff and medical equipment. The brigade surgeon or brigade physician assistant (PA) can provide this data and further clarify the skill set of each health care professional as questions arise. This inventory must go beyond labeling every emergency medical technician (Medic, 68W), medical service corps officer, medical specialty corps officer, and mental health professional as "doc."

Certifications

An emergency medical technician-paramedic (EMT-P) has the credentials to provide advanced cardiac life support and pediatric advanced life support.⁴ In contrast, an EMT-Basic (EMT-B) provides basic life support.⁵ Are the medics in your organization credentialed as EMT-B or are they credentialed as EMT-P? The capability of an EMT-P compared to that of an EMT-B is vast. In the planning of ground or air evacuations for civilians in a humanitarian assistance mission, the EMT-P skills are suited to handle the complications of a critical care or cardiac patient in transport without requiring the presence of a physician.

At battalion and brigade levels, the physicians assigned are usually pediatricians, internists (internal medicine), primary care PAs, and family medicine physicians. It is equally important to define the skill set of the physicians, PAs, and nurse practitioners. It is a mission-essential task to provide an adequate number of female staff members for all humanitarian operations and to never hide the fact or mislead anyone that the team is composed of or has military members.

The gender identification of the health care staff is important. If the humanitarian mission directs providing a medical consultation service by the professional medical staff, the brigade staff can create a viable plan with this information. The medical staff's credentials dictate the type of medical care and services it can provide. A pediatrician's consultations should be limited to the age of 18 and under. In contrast, an internal medicine physician's consultation should exclude the pediatric patients. An internal medicine physician's expertise and scope of practice are focused on the adult population (18 years and older).

Physician Assistants

The PA is the backbone of the medical efforts at battalion and brigade levels. In garrison, the infantry, armor, or Stryker BCT's modified table of organization and equipment (MTOE) routinely authorizes one physician (brigade surgeon), with the remainder of the authorizations filled by PAs. The PA provides the bulk of the momentum for the medical sustainers in garrison, encompassing medical readiness, medical training, and patient care for the military-age population.

The commander must take notice that this health professional is an expert at taking care of the military-age population. The utilization of a PA to provide care to a pediatric population for a humanitarian mission may place this health professional outside his scope of practice. It is common for the U.S. Army Medical Department (AMEDD) to credential a PA to treat and evaluate patients only from the age of two and higher.⁶ In contrast, a properly credentialed nurse practitioner can evaluate and treat patients under the age of two, perform well-baby evaluations, and treat adults.⁷

Professional Filler System

As a BCT deploys, the AMEDD fills the authorized Professional Filler System (PROFIS) positions of the MTOE. Historically, PROFIS personnel are subject to change. Customarily, the AMEDD tasks primary care providers, normally comprised of family medicine, internal medicine, pediatrics, or emergency medicine. Occasionally, due to a shortage of primary care providers or the frequency of deployments, a specialist is assigned. It is important to understand that these specialized medical professionals, often comprised of cardiologists, urologists, and gastrointestinal specialists, bring an additional source of consultative capability to the BCT. However, they can be limited in their ability to provide treatment due to the fielded medical equipment sets (MES) and medications doctrinally available at the brigade support medical company and at medical platoons.

Medical Equipment Sets of the Brigade Combat Team and Their Limitations

In determining the type of health care that organic personnel can render in a BCT, the commander must be cognizant of the medical staff's professional training and the unit's MES. A pediatrician is an expert in treating and evaluating the entire child-age population of any refugee or internally displaced persons (IDPs) camp, but has significant constraints that the planning staff must overcome. All the primary care providers,⁸ specialists, and medics are constrained by MES fielded by the AMEDD. The MES of the medical units in a BCT were developed and fielded for a population age of 18 and older - not for pediatric patients. The medications in the MES are not in a formulation that allows administering the proper dose to children based on weight. The medications in the MES are for an adult population that is generally free of chronic diseases. The diagnostic medical equipment sets are for adult patients. In order to provide care to the pediatric population, the health care professionals would require that a pediatric MES be fielded or would need to have the ability to purchase the required set.

Funding for Consumable Class VIII Items

It is not within the scope of this article to discuss the intricacies of Class VIII funding. Suffice it to say that to acquire these MES and pediatric medications, they will need to be requisitioned and resourced using an approved funding source. Using consumable Class VIII supplies from normal funding sources that are intended for the BCT's military members can cause a legal problem for the chain of command if they are diverted to support a humanitarian mission. Seek legal counsel prior to approving consumption of military medical supplies for humanitarian purposes.

Preventing Disease by Providing Potable Water

Regardless of the capabilities the professional medical staff can provide in the support of humanitarian assistance missions, the resources will unquestionably fall short of the requirement. Thus, commanders should focus their attention on creating the greatest effect to minimize suffering. The single most important commodity any organization supporting refugee camps or IDPs can provide is potable water.⁹ Providing clean water for human consumption and sanitation purposes will reduce the risk and rates of infectious diseases that typically plague camp populations.¹⁰ The implementation of good hygiene procedures, like hand washing with clean water, will have a dramatic effect on the spread of disease.¹¹

Figure 8-1. The very young and elderly have a higher mortality and morbidity rate from the consumption of nonpotable water. (Photo by JTFB Combat Camera, 2009)

As described by the World Health Organization (WHO), "The quality of drinking water is a powerful environmental determinant of health. Assurance of drinking-water safety is a foundation for the prevention and control of waterborne diseases."¹² "Lack of drinking water and sanitation kills about 4,500 children a day and sentences their siblings, parents, and neighbors to sickness, squalor, and enduring poverty. Improvements bring immediate and lasting benefits in health, dignity, education, productivity, and income generation."¹³ The military commander has the capability to have a significant impact in this arena of essential services with the BCT's organic equipment, preventive medicine expertise, and distribution capability. The water purification equipment of the BCT must deploy with the unit.

Preventing Disease Outbreaks Through an Immunization Program

Like providing potable water, implementing a vaccination campaign for a displaced persons camp or a refugee camp will decrease human morbidity or mortality. "It is one of the most important public health interventions," according to the WHO.¹⁴ "Vaccines are a cost-effective method of further reducing human suffering and death."¹⁵ It is not a question of eliminating diseases spread by poor sanitation, but rather a matter of putting practices in place that limit their spread. Vaccinations against Hepatitis A, Hepatitis B, and diarrheal diseases are a cost effective method to curb the spread.¹⁶

The command's determination of which vaccines to administer should be based on the diseases endemic in the area and the WHO's recommendations. The commander can effectively utilize Commander's Emergency Response Program (CERP) funds in this endeavor. Immunizing individuals residing in displaced persons camps or refugee camps creates a refrigeration requirement for the transport and storage of the vaccines. In any immunization campaign, an adverse vaccine event will most likely occur. The commander must ensure appropriate personnel are available on site to manage this occurrence and have a prescribed plan for transportation, hospitalization, and acute follow-up.¹⁷ Army Regulation (AR) 40-562, Immunizations and Chemoprophylaxis, details the minimal requirements for the U.S. Army.

Proper Disposal of Medical Waste

Medical operations generate waste that must be disposed of using proper medical waste disposal procedures. "Waste generated by health care activities includes a broad range of materials, from used needles and syringes" used in immunization campaigns, "soiled dressings, diagnostics samples, medical devices, pharmaceuticals..."¹⁸ "Poor management of health care waste potentially exposes health care workers, waste handlers, patients, and the community at large to infection, toxic effects, injuries, and risk polluting the environment."¹⁹

Improper waste disposal will create a sensational media story when identified by any reporter and negate the positive effects of the humanitarian mission. Waste generated by military forces must be disposed of properly.²⁰ Detailed guidance is located in the Medical Command Regulation 40-3, Management of Regulated Medical Waste. Safeguarding medical waste is just as important as properly disposing of it. An individual or group rummaging through medical waste can become a medical casualty, generate an infectious disease outbreak, and/or inadvertently distribute or utilize objects that can spread disease directly or indirectly.

Utilization of the BCT's Field Sanitation and Preventive Medicine Teams

The brigade support medical company has subject matter experts on field sanitation and preventive medicine.²¹ In addition, per U.S. Army doctrine, at the company level there are at least two Soldiers trained in unit and field sanitation.²² Brigade, battalion, and company commanders can utilize these individuals to conduct camp assessments in support of humanitarian operations.

The field sanitation and preventive medicine teams provide valuable assessments in creating and monitoring IDP camps or refugee camps. This assessment should identify the potable water requirements, the quantity and location of latrine facilities, and human waste disposal requirements. The field sanitation team will also be able to develop a food safety inspection program as well as insect and rodent control measures. These duties are identical to the functions they provide to their parent organization, and minimal additional funding and support is required. Field sanitation is another area in which the commander's utilization of CERP funds will proportionally relieve human suffering.²³

Managing Expectations, Operating, and Supporting Health Care Clinics

In planning ad hoc clinics or contributing to the support of the health clinics in an IDP or refugee camp, it is important that medical units become the supported element. It is not unusual for hundreds of IDPs or refugees to seek medical care on a single day.

Augmentation for crowd control is a requirement. If the medical staff is part of the crowd control force, it cannot focus its attention on providing medical care. Crowd control includes the flow of patients into the patient care areas, establishing security and a plan to deal with disruptions, plus a carefully executed plan for departure at the conclusion of the day's activities.²⁴ Individuals waiting in line will get upset or initiate a riot when a humanitarian clinic closes or if they believe they cannot be seen before the clinic closes.²⁵ Managing expectations is also important. A triage system must be put into place, and the focus should be on acute illness and, if the resources are available, some chronic care.

An individual who shows up for a second opinion for a cancer diagnosis or treatment will be disappointed. A process to screen these folks before they enter the clinic will allow the health care providers to concentrate their limited time on the medical issues they can treat. A method is to have a staff member screen each person in order to direct them to the patient care area or issue a supply of vitamins and conclude their visit. The medical element of Joint Task Force Bravo, based at Soto Cano Airbase, successfully uses this methodology. This organization has years of experience in conducting medical missions consisting of health clinics in the remote areas of Central and South America.

Figure 8-2. In 2009, El Salvador experienced torrential rains that resulted in flash floods and mudslides. Joint Task Force Bravo (SOUTHCOM) responded to the natural disaster by delivering humanitarian aid and conducting ad hoc clinics. On an average day the health care professionals provided medical care to more than 500 people. The staff comprised members of the DOD, nongovernmental organizations (NGOs), and the host nation.

Often, the host nation population travels for hours to seek the medical care provided as a joint venture with host nation professionals, NGOs, and interagency partners. A member of the humanitarian team starts with a lecture on preventive medicine and sanitation. Children are given a single dose of anti-helminthic (de-worming) medication due to the ubiquitous infestation of the population. Each person requesting a consultation with a provider is screened by an allied health professional in order to direct them to the patient care area or is informed that the services requested are beyond the scope of the care provided and are issued a supply of vitamins. This methodology generates the feeling that everybody received something for their visit, whether they saw a physician or not.

Providing Quality and Culturally Aware Medical Care

The situational understanding and awareness of the IDPs and refugees goes beyond their immediate predicament. It is important to understand the varied cultures that exist in the population and their respective language. It may not be appropriate for a male physician to interview and evaluate a female patient without a female chaperone. Similarly, it may not be appropriate to use a male translator for a female patient consultation. Members of the humanitarian mission who speak the language are invaluable. The use of an interpreter increases the time requirement per patient and adds an additional element that can lead to a medical error. It is not always possible to have a native speaking health professional or native- speaking translator who has a mastery of medical terminology. Despite the focus to get the most patients seen, the ultimate benchmark should be on the quality of care, minimizing the number of medical errors and adverse events. This understanding must be incorporated into the commander's intent.

Summary

This article provides members of the BCT planning staff and brigade commander a starting point for humanitarian missions for IDPs camps and refugee camps. By directing the limited and valuable resources organic to a BCT, the BCT commander can have a positive effect on winning the hearts and minds of the population by reducing the level of human suffering.

Endnotes

1. An internal medicine physician traditionally focuses his or her scope of practice to an adolescent-age (18 years) population and higher. http://www.certificationmatters.org/abms-member-boards/internal-medicine.aspx. Accessed 8 May 2012.

2. Depending on the core training of the PA and/or additional training beyond the core curriculum a PA can specialize in pediatrics, orthopedics, emergency medicine... expanding their capability. It is a common practice for PAs in the AMEDD not to request credentials to treat and evaluate children under the age of two. Physician Assistant's Scope of Practice; Professional Issues, Issue Brief, published by the American Academy of Physician Assistants, October 2011. Available for review at this link. Accessed 8 May 2012.

3. Unlike PAs, nurse practitioners can be credentialed to work independently and traditionally have no pediatric limitations in their scope of practice unless they specialize. Scope of Practice for Nurse Practitioners, published by the American Academy of Nurse Practitioners, Revised 2010 Edition. Available for review at http://www.aanp.org/NR/rdonlyres/FCA07860-3DA1-46F9-80E6-E93A0972FB0D/0/2010ScopeOfPractice.pdf. Accessed 8 May 2012.

4. Paramedic, Requirements for National EMS Certification, brochure. Available for review at www.nremt.org or https://www.nremt.org/nremt/downloads/Paramedic_Brochure.pdf. Accessed 8 May 2012.

5. EMT-Basic, Requirements for National EMS Certification, brochure. Available for review at www.nremt.org or https://www.nremt.org/nremt/downloads/EMT-Basic_Brochure.pdf. Accessed 8 May 2012.

6. Depending on the core training of the PA and/or additional training beyond the core curriculum, a PA can specialize in pediatrics, orthopedics, emergency medicine... expanding their capability. It is a common practice for PAs in the AMEDD not to request credentials to treat and evaluate children under the age of two. Physician Assistant's Scope of Practice; Professional Issues, Issue Brief, published by the American Academy of Physician Assistants, October 2011. Available for review at this link. Accessed 8 May 2012.

7. Unlike PAs, nurse practitioners can be credentialed to work independently and traditionally have no pediatric limitations in their scope of practice unless they specialize. Scope of Practice for Nurse Practitioners published by the American Academy of Nurse Practitioners, Revised 2010 Edition. Available for review at http://www.aanp.org/NR/rdonlyres/FCA07860-3DA1-46F9-80E6-E93A0972FB0D/0/2010ScopeOfPractice.pdf. Accessed 8 May 2012.

8. "Primary care provider" is defined as a physician, nurse practitioner, or PA whose scope of practice is focused on ambulatory care medicine that is not in a specialty field. Examples include: pediatrician, family medicine, and internal medicine.

9. WHO. Water for Life, Making it Happen. Available for review at http://www.who.int/water_sanitation_health/monitoring/jmp2005/en/index.html. Accessed 8 May 2012.

10. Ibid.

11. Ibid.

12. WHO. Water Sanitation Health. http://www.who.int/water_sanitation_health/dwq/en/. Accessed 8 May 2012.

13. WHO. Water for Life, Making it Happen. Available for review at http://www.who.int/water_sanitation_health/monitoring/jmp2005/en/index.html. Accessed 8 May 2012.

14. WHO. Immunization Safety, http://www.who.int/immunization_safety/en/. Accessed 9 May 2012.

15. WHO, Immunization, http://www.who.int/topics/immunization/en/. Accessed 9 May 2012.

16. Ibid.

17. U.S. Department of the Army. AR 40-562, Immunizations and Chemoprophylaxis, Washington, DC: Government Printing Office, 29 September 2006, paragraph 2-9.

18. WHO, Medical Waste, http://www.who.int/topics/medical_waste/en/index.html. Accessed 9 May 2012.

19. Ibid. and WHO, Waste from Health-Care Activities, November 2011, http://www.who.int/mediacentre/factsheets/fs253/en/index.html. Accessed May 2012.

20. U.S. Department of the Army. Medical Command Regulation 40-3, Management of Medical Regulated Waste, 29 April 2008.

21. U.S. Department of the Army, Field Manual (FM) 4-90, Brigade Support Battalion, Washington, DC: Government Printing Office, 31 Aug 2010, page 5-3.

22. U.S. Department of the Army, FM 21-10, Field Hygiene and Sanitation, Washington, DC: Government Printing Office, 2000, page 2-4.

23. It stands to reason; the more money available to implement the facilities and services required, the more the quality of life would improve. The assumption is that the money is being utilized properly and not diverted.

24. U.S. Department of Defense, Joint Publication 3-29, Foreign Humanitarian Assistance, Washington, DC: Government Printing Office, 17 March 2009, page A-7.

25. This is often an informal lesson learned from organizations that conduct humanitarian health clinics in areas with great need. An appropriate amount of security should be present as the clinic closes to ensure the safety of the staff at the clinic and to prevent a riot.