LOGISTICAL CONSIDERATIONS

Packing for ARSC missions can be framed usefully by the Ruck-Truck-House model developed by SOF medics,82 which is a modular approach to mission planning based on cube and weight constraints. As building blocks, each phase of this supply model builds upon itself, with Ruck capabilities intrinsic to Truck, and Truck capabilities intrinsic to House. The term Ruck-Truck-House refers to the cube and weight of the mission equipment and not necessarily to the mobility platform. For example, ‘Ruck’ missions may be performed from a truck, and ‘Truck’ missions are often conducted via rotary wing platforms.

Specific team member composition of each team is based on multiple variables, and specific staffing recommendations are outside the scope of this practice guideline. Generally, ARSC teams should be prepared to scale their team size according to mission requirements dictated by the Operational Command. A Ruck team may be the smallest number of personnel of any given ARSC team that still provides a minimal, functional capability, while a House team may be the maximum number of personnel with maximal capability. Limitations of scaled teams must be clearly articulated to the Operational Command in order to accurately communicate inherent risk.

RUCK

The Ruck model is the most mobile pack out, as supplies and equipment are limited to what can be carried on each team member’s back. It is well understood, that this is not the ideal environment for surgical care; however, mission requirements occasionally dictate this capability. When it comes to surgical intervention, or no intervention and likely casualty death, this substandard option becomes a mission requirement. Due to its inherent limitations on resources, the Ruck model requires the highest levels of clinical skill, tactical proficiency, and teamwork, and personnel must be highly trained in all above areas for mission success. Medical planners and the surgeon must clearly communicate the clinical and other limitations to mission planners and the supported Operational Command in order to conduct appropriate risk mitigation. The Ruck model fits onto most transportation platforms. Although emergency surgery may be performed with this model, it is generally capable of providing temporary support for only one critical patient with no capacity to hold critically ill patients for any length of time. Blood products are extremely limited and the lack of power and electricity prevents use of blood storage and cooling, blood warming, and electronic patient warming devices. As a result of these limitations, rapid patient evacuation to the next level of care is vital and urgent resupply must occur in order to continue the mission. Alternatively, the plan may include performance of en route care and return to base upon mission completion. Additionally, communications are limited to personal radios and team security must be provided by the supported unit during clinical care.

TRUCK

The Truck model is also very mobile, capable of set up or collapse within minutes, and can be transported to a fixed location. Although this model may have greater capability than the Ruck model, its limitations must be carefully considered and communicated to planners and commanders in order not to fail expectations placed upon it. It includes each team members’ ruck and as many additional supplies and equipment that can fit onto the mission’s mobility platforms, depending on the mission need. This model may be able to treat and sustain more patients but is also limited by power and electricity, blood storage, and fluid volume. Although supplies are increased, it is still dependent upon a rapid evacuation and resupply chain if heavy casualties are encountered or it is intended to perform a static mission.

HOUSE

The House model is far less mobile, as it refers to a fixed location where the full equipment loadout of an ARSC team can be established and is only feasible to be maintained at a team house, firebase, or other mission support site. This model provides the highest level of care organic to the team and has a greater patient capacity. Continuous operations may be sustainable with casualty evacuation and resupply of blood and other Class VIII. Additional requirements for full operational capability include power and electricity for blood cooling and storage, blood warming and infusion, patient warming, water for steam sterilization and hygiene, and other requirements. Open communication of requirements, capabilities and limitations to planners and commanders will enable mission success.

In all three models, challenges are magnified with supply and resupply limitations, blood availability, and prolonged hold time, transport time to next level of care, personnel available to help, and more. It is understood that this is not the ideal environment to care for surgical patients and that certain severe injuries will not be survivable. As emphasized above, the limited capabilities of these teams have to be understood by mission planners and operational commanders. Clinical experts including the senior surgeon should be involved in medical planning of mission support in order to ensure that critical supply requirements and limitations are addressed, clearly articulated, and solutions are developed within mission constraints. Involve planners and the Operational Command early and often in mission planning to understand command requirements, mitigate risks, and shape expectations for success. See Appendix A for sample packing lists for each model.

Many mission variables impact what is ultimately packed into the finite cube and weight requirements for each model. See Table 2 below for some of the variables to consider when planning for logistical support of ARSC missions.

Table 2: Variables to consider when planning logistical support for ARSC missions

#### Variables to consider when planning logistical support for ARSC missions

ARSC team composition

· Number and type of medical personnel on the ARSC team

· Team members’ specialties, experiences, capabilities, preferences

Patient variables

· Types of patients (friendly combatants, enemy, civilian, pediatric, geriatric, MWDs)

Mission

· Operational Command intent

· Security situation (i.e. expected tactical risk to medical personnel)

· Length of mission

· Number of expected casualties, number of troops at risk

· Communication capabilities of medics and next levels of care

· Space available for equipment

· Max/min equipment weight requirements

· Security element for the ARSC team

· Task force composition (joint, combined) and service, state or national caveats

· Team sustainment requirements

Evacuation

· Capability, time, distance from forward medics

· Capability of the evacuation platform (CASEVAC vs MEDEVAC vs CCATT)

· Capability, time, distance to next level of care

Environmental

· AO-specific medical concerns

· Night vs day operations

· Cold vs hot environments

· Indoors vs outdoors

· Physical and human terrain

· Security environment

Resupply

· Emergent and routine time and processes for resupply of blood products and Class VIII

RESUPPLY

Resupply should be categorized as Mission Critical, Mission Essential, and Mission Enhancing for planning and communicating purposes. The category of medical supply or equipment items may change depending on the mission.

- Mission Critical: There is high risk of mission failure without these items.
- Mission Essential: There may still be significant impact but less risk of mission failure if lacking these items.
- Mission Enhancing: There is low risk of mission failure if lacking these items.

The following subsets may require separate and deliberate logistical planning.

- Mission Critical, consumable: there simply are not ways to improvise shortfalls on a few things (i.e. blood products, citrate bags, IV calcium, key anesthetic medications)
- Mission Critical, durable with lifespan: replacement instruments, litters, replacement medical electronics such as ventilators, monitors, ultrasound, Doppler probe, suction, etc.

Frequent high use. May be improvised: laparotomy sponges, TCCC equipment, OR towels and drapes, dressings, flushes, syringes, IV catheters, IV tubing, HPMKs, suture, lines, tubes, pain medications, antibiotics, etc.

A best practice is to plan with the supported unit’s logistical support personnel in order to increase available assets for resupply and shorten the time required to execute. Educate the supported unit on movement requirements and limitations of critical supplies in order to facilitate timely and accurate decisions if a medical representative is not available at the higher level of command. Establish push and pull rapid resupply packages, often called “speed balls,” at the resupply base with focus on medications and expendables rather than durable equipment. Establish and practice supporting procedures in order for resupply to function well, and maintain abundant medical supply stocks for unexpected requirements. Depending on the mission, consider incorporating non-U.S. resupply resources into medical logistics planning including intergovernmental organizations, non-governmental organizations, and host nation facilities and services. Such schemes may optimize coalition or advise, assist, and accompany missions where the population at risk may be primarily host or foreign country nationals.

SPECIFIC LOGISTICAL CONCERNS

Surgical Sets

Traditional Role 2 surgical sets are bulky, difficult to access, and redundant.3,83 Surgeons and surgical technologists should work together to design sets that support their specific mission. In general, hold and evacuation times are directly proportional to the degree of care to be rendered, and subsequently, the amount of equipment required. See Appendix A for packing considerations organized by the Ruck-Truck-House model.

Anesthesia Equipment

Equipment should be mobile and adaptable to a variety of surgical cases. TIVA and regional anesthetic strategies are mobile and light. Additionally, regional anesthetics will decrease requirements for systemic pain medication and lessen the concern for airway compromise and management. The use of regional anesthesia in patients at risk for compartment syndrome is controversial; although the data is sparse, there is no evidence that peripheral nerve blocks delay the diagnosis.84

Nursing Equipment

Nursing equipment is often single use, disposable and requires frequent resupply (i.e. IV catheters, IV tubing, syringes). Careful reuse of nursing items for the same patient will minimize waste. Long term nursing supplies are not necessary since the ARSC teams do not have holding capacity and rely heavily on expeditious transport to the next level of care.

Instrument Sterilization

There are three principal methods to sterilize instruments including autoclave or steam sterilization, exposure to dry heat, and chemical antiseptics. Boiling is regarded as unreliable.85 Mechanical or steam sterilizing devices are large, require high power input, and require several hours to clean, dry, and cool instruments. If sterilization devices are not available on site, instrument sets may be autoclaved or steam sterilized at a base of operations and turned over between missions. Careful planning should be used in packaging instrument sets so that not all instruments are opened and contaminated at once.83 The minimum standard for instrument decontamination is application of enzymatic cleaner followed by disinfection with an antiseptic, which can be achieved with a number of solutions including formaldehyde, glutaraldehyde (Cidex®), or chlorhexidine. Refer to the manufacturer’s standards for time of solution contact and other considerations. In order to preserve resources, certain disposable items such as surgical staplers, clip appliers, or cautery pencils may be disinfected in chemical solution. Cautery grounding pads may be cleaned and reused with germidical wipes; while not ideal, this is the reality of the ARSC environment.

Power Requirements

The medical team must communicate power requirements to the supported element. Medical electronics and blood storage require power. Planning considerations include the size of the generator, voltage output (i.e. 110V vs 220V), maximum ampere load, optimal and maximum wattage operating ranges, type of fuel used, amount of fuel required for the mission, and maintenance plans. Other considerations include the total power required for all electrical equipment, the daily fuel consumption, and the capacity in amperes of the largest available circuit breaker needed to power a heating element or other high energy device. 110V vs 220V power outputs and devices must be carefully matched to provide adequate power to medical equipment and prevent destruction of critical electronic equipment. Be careful to maintain an ample supply of fuses for important electronic equipment. Note that each piece of equipment has unique and specific fuses that are not universal to each other and are prohibitively difficult to find on the local economy in most deployed locations. See Table 3 below for mission critical tasks and equipment that require power.

Medical Waste Disposal

Field hospital medical waste has been estimated to be an average of 1.5 to 3 kg of waste per patient per day.86 ARSC planners should anticipate considerably more waste in the ARSC setting given the critical nature of patients with wartime injuries. Team members should be sensitive to local religious customs when disposing of anatomic waste.86 The World Health Organization (WHO) recommends appropriate disposal of potentially infectious biological waste by either steam sterilization or high temperature incineration.85 Burying waste is an option but consideration should be given to avoid pollution of the environment and water sources.85-86 Establish a safe system to dispose of sharps. The International Committee of Red Cross Manual of Medical Waste Management is an excellent resource and provides specific guidance.86

Table 3: Mission critical tasks and equipment that may require power

#### Mission critical tasks and equipment that may require power

Ruck--

Patient warming-HPMK, ready heats, wool or space blankets

Blood cooling-Person-portable preconditioned coolers

Blood warming-Small battery powered in-line products

Medical electronics-Battery powered portable ventilator, monitors, and ultrasound

Electrical power-Plan for person-portable, battery operated equipment-Lights-Battery operated head lamps (consider equipment that uses standard batteries such as C123, AA, AAA etc. as opposed to nonstandard rechargeable lithium batteries as replacement batteries are more easily acquired)-Communications-Battery powered radios

Personal electronics-Minimal battery power only

Truck--

Patient warming-HPMK, ready heats, wool or space blankets

Blood cooling-Coolers with wet ice for blood or dry ice for plasma, battery powered man portable blood fridges (e.g., HemaCool®)

Blood warming-Recommend Belmont® Rapid Infuser or plasma thawing devices if power capability allows; if unable to support Belmont, utilize in-line device.

Medical electronics (monitors)-Battery power with recharging cords – stress 110V vs 220V awareness

Electrical power-Plan for Generator size 5kW-20kW and associated fuel requirement

Lights-Battery operated head lamps, person-portable free-standing LED spot lights

Communications-Vehicle mounted radio

Personal electronics-Minimal rechargeable

House--

Patient warming-HPMK, ready heats, wool blankets, Bair hugger, consider wall space/area heating units with understanding that these have tremendous power requirement

Blood cooling-Multiple battery powered portable blood fridges (e.g., HemaCool®), ensure backup power source is available should primary power source fail.

Blood warming-Recommend Belmont® Rapid Infuser or plasma thawing devices if power capability allows; if unable to support Belmont, utilize in-line device.

Medical electronics (monitors)In line power, stress 110v vs 220v awareness

Electrical power-Central power vs large generator

Lights-Battery operated head lamps, person-portable free-standing spot lights, wall mounted lights

Communications-Non-classified Internet Protocol (IP) Router Network / Secret Internet Protocol Router Network / WiFi (choice)

Personal electronics-Choice