Adapting Foreign Disaster Medicine to Future Wartime
Lessons learned during the Hurricane Dorian relief effort in a non-threat environment can be adapted to the Indo-Pacific area of operations for potential wartime operations. Given the recent hurricane relief effort, it could be argued that medical crews are not ready to operate remotely in a hostile environment from an island base with limited communications, fuel, command and control, and information on casualties.
By HMC Wayne N. Papalski, CAPT Ben Walrath MD, AWSCM Shane Gibbs, MSG Mike Remley, SGT Ricky Deitzel, HM1 Ryan Honnoll, and LCDR Paul Roszko, ER Phys, WRNMMC
From Combat & Casualty Care, Spring 2020
In early September 2019, the category five Hurricane Dorian stalled over the northern Bahamas for two days, marking a spot in history as the most destructive storm to wreak havoc on the island chain. The U.S. Navy was tasked to provide humanitarian relief effort via Helicopter Sea Combat (HSC) and Helicopter Mine Countermeasure (HM) Squadrons comprised from the Helicopter Sea Combat Wing Atlantic (HSCWL). The response from the HSCWL support to the Bahamas resulted in:
- Eight SAR/TACEVAC mission with 108 survivors treated/recovered and transported
- 417 passenger transports
- 29,000 pounds of food and water delivered
- 203,850 pounds of cargo
Although the Foreign Disaster Relief (FDR) response was extremely successful, this was the first time in U.S. naval history that a mission was completed in an outside the continental U.S. (OCONUS) relief effort that started and ended each day from a continental U.S. (CONUS) base. That dynamic environment caused critical medical, logistical, communication, and human factor concerns that can be adapted to the future peer-to-peer wartime environment. While traditionally commands rise to challenges and turn “water into wine”, these already problematic caps on the ability to just show up to the fight ready put our fighting forces at risk.
HSCWL began flying missions within nine hours of their arrival to Homestead by transiting the 197 miles to Nassau, Bahamas. That transit time took approximately an hour and twenty minutes each way depending on weather and winds. Initial reports to crews flying were that the only fuel source was Nassau International Airport, at the Odyssey Fixed-Base Operator (FBO). This FBO is also where the United States Agency for International Development (USAID) and Virginia Task Force 1 (VA-TF1) teams were being based out of to support all initial relief.
The first crews landing at Nassau were met with no immediate command and control tasking for the HSCWL assets to support. There were multiple USAID and VA-TF1 assets that had been sitting on the FBO for days needing flights to the Marsh Harbor and Freeport areas in the Bahamas. Their initial missions were to be the first set of US government surveyors to assess the damage in those areas. During the confusion of getting mission tasking together on these first days of flying, the FBO was overwhelmed with all forms of rotary and fixed wing traffic. The average wait time for a fuel truck that day was over an hour, causing crews to hand walk the fuel truck attendant to their aircraft to be fueled up.
Fueling during the entire first three days of operations became the main focal point of planning all missions to properly operate in the vast island chain environment. Distance and limited fuel was one of the major threats posed to crews during the entire relief effort. All operations had to plan for fuel in Nassau due to the there being no fuel in any of the islands’ normally functioning FBO’s. This caused operations to be extremely conservative due to majority of the transit being of great distance and overwater.
Following initial tasking and mission planning for fuel came attempts to leave Nassau. Nassau was the only controlled airspace in the Bahamas the first few days after the storm hit, with all relief effort landing and taking off from there. There was limited ramp space on the FBO, crowds of aircraft waiting to taxi, extremely long wait times to receive identification codes to take off, and the threat of transiting traffic once immediately airborne. There were all forms of aircraft support from the Department of Defense, Homeland Security, other government agencies, Foreign government agencies, non-profit, for profit, and good Samaritan fixed and rotary wing support. The term “aerial Cajun Navy” was coined as lesson learned from the string of help in the form of boats from Hurricane Harvey.
Once finally off deck from Nassau, missions revolved around working with USAID and VA-TF1 to assess the heavily damaged areas. Within minutes of flying the first missions in the objective areas, crews found themselves: landing to assess crowds waving the helicopter down; inserting USAID into certain areas to assess tasking they received prior; or evacuating patients being turned over to HSC crews. Prior to the first tactical evacuation (TACEVAC) mission, all patients were to be transported to Nassau to the FBO, to be triaged at a makeshift collection point. This was relayed to crews by Liaison Officers (LNO) in Nassau. A lot of this was to control undocumented populous coming from the islands. However, communications became a critical issue early on in trying to execute any and all TACEVAC missions.
There was little service to communicate in the transits to and from Nassau. Once in the majority of the objective areas, communications were limited to anywhere that may have had an undamaged cell tower or if communications with a designated relay aircraft worked. The majority of the communications came from using a commercial off the shelf (COTS) unclassified applications, such as “Whats App”. All command mission tasking and updates were made via “What’s App” and logged by a Squadron Duty Officer (SDO) back at the deployed unit center (DUC). The majority tasking for TACEVAC missions was impromptu, causing deviations in fuel planning to take place in order to determine if the crew had the fuel to successfully take the mission.
The tasking for search and rescue (SAR) and TACEVAC missions came by chance for crews. With the extremely limited communications, crews were often conducting other designated missions and found themselves getting mid-mission tasking to rescue or pick up a patient/survivor. This came either via “What’s App”, tasking by parties on the ground in the objective area, landing at certain survey sites, or social media. The Coast Guard was screening and fielding all media aspects to render aid, however, there were few instances of aid workers on the ground showing coordinates to crews of where people were stuck after they saw it online. This accounted for recovery of 30+ stranded survivors who had been left with no food or water on remote outer islands, days after the storm hit.
Medical supplies and logistics for critically sick patients became another serious issue. Due to the little to no communication on the tasking of patient type, crews often arrived on scene with no incoming report on the patient. There were two missions where HSC commands had to turn the TACEVAC mission down because they did not have the proper gear to safely care for the patient. While a casualty evacuation (CASEVAC) asset can accept the risk, search and rescue medical technicians (SMTs) attached to HSC commands shall deliver advanced life support (ALS) care as per the OPNAVINST 3130.6e. There have been well-documented issues related to supply problems for SMTs Level B kits, resulting in an inability to meet the ALS mission set dictated by doctrine. Both of the turned-down missions were for sick medical patients that required sedation, ventilator management, and a capable ALS-level provider to care for them during the lily-padding of Island Transport back to Nassau. Both missions were turned down at the patient bedside or in the presence of the patient’s provider. Accepting either patient would have knowingly put them in harm’s way, given the lack of proper gear and medications to care for them during a long transit with limited fuel. Further complicating matters was the fact that both critical patients were left in a resource-limited environment with few medical supplies and no alternative evacuation asset immediately available to complete the mission. Crews learned the next day while dropping off aid supplies that one of the patients unfortunately succumbed to their illness.
Additional mission concerns were the possibility of unknown patient transport requests. Routine cargo transport missions turned into USAID or VA-TF1 members rushing the HSC crews with a sick patient to be urgently transported back to Nassau. A similar pop-up tasking came from VA-TF1 leadership in certain sites, reporting that there were severely dehydrated survivors on certain islands and crews would break tasking if fuel was available to perform the rescue. While normally an easy undertaking, the island hopping, limited fuel, and requirement to bring all patients back to a single staging area overwhelmed by aircraft posed risk to rotary wing crews.
Medical providers in any disaster relief scenario anticipate treating large numbers of casualties with poly-trauma or medical patients requiring critical care medicine. While those patients did pop up on a few missions, the majority of the patients treated by the crews were suffering from chronic conditions with no treatment available. There were a number of rescues for patients out of food and water resulting in severe dehydration. The bulk of all critical patients transported were sick due to the sudden inability of local healthcare resources to manage chronic illnesses. The lack of infrastructure and extremely limited health care required crews to manage exacerbations of chronic obstructive pulmonary disease (COPD), asthma, heart failure, and diabetes, hypertensive emergencies, and complications of missed dialysis sessions.
While in the middle of operations, a crew was tasked with going with a USAID survey team to a small island north of Freeport called Grand Cay Island. This was five days after the storm had passed. The USAID team asked to have a SMT from the aircraft remain on station with them due to the unknown amount of time the survey team needed to be on station. The SMT established contact with councilman via the USAID personnel to evaluate if there were any emergent medical needs. Grand Cay was a larger remote population with a small clinic on the island. Prior to the storm, the staff from the clinic departed to evacuate and had not returned.
While the clinic structure was left unharmed, there was a large amount of internal flooding due to leaks in the ceiling. With help from the local community, the SMT helped clean up a treatment area and assessed the condition of the clinic’s supplies.
After aiding in the clinic clean up, there was a gathering of community members outside the clinic to be evaluated. Normally, the clinic was open for the community to get their regular medical needs. Due to the storm though, some chronic medical conditions had been left unmanaged. The SMT evaluated over 35 patients that had been advised a “medical provider” was around the clinic. The primary medical skillset of SMTs is point of injury medical and trauma illness/injury and the enroute care of emergent acute and chronic medical conditions. Out of 35 patients, six required actual clinical procedures ranging from multiple sutures, diabetic evaluations, tooth removal, and a high-risk pregnancy. The lack of medical infrastructure in the entire area of operations (AOR) crippled the ability to provide proper care for patients. Even if the patient was evacuated to Nassau, their operating capacity was overwhelmed within days of the storm hitting (Nassau, although being the capital of the Bahamas, was one of the smallest islands affected by the storm).
Lessons Learned from the Tyranny of Time and Distance
While there was no direct threat during Hurricane Dorian, not having a naval vessel near the AOR made remote operations, communications, and control aspects even more difficult. Relief crews were constantly left in periods of no communications, which in a threat environment could directly impact mission effectiveness and safety. Fuel considerations in this environment are equally as important. The single source for fuel in these operations is an exploitable weakness during wartime. Disrupting this would hinder operations considerably. Additionally, other Services have inflight refueling as an option for their rotary wing assets. The Navy currently does not have this refueling option for the MH-60 model helicopters. Having that capability would be a mission enhancement that can increase force support and lethality in wartime operations.
In the wake of a potential mass casualty or combat operations in the amphibious/maritime environment, the inability to get on scene quickly continues to stretch medicine beyond the “Golden Hour” response. The added factor of remote operations, fueling, and communications concerns creates chaos as crews try to gain tactical understanding of what type of mission tasker they could be responding to. Delayed response to a mass casualty or combat operation mimics the scenes from the recent Hurricane Relief where the majority of patients were over 48 hours from the onset of their injury/illness. Not all patients were poly-trauma and many medical illnesses were worsened by deteriorating environmental conditions, leading to dehydration, sepsis, malnourishment, heat injuries, etc…
The most important part of the initial response is being mission ready. Currently, the well documented problem within the HSC community is the force health protection and TACEVAC response not being mission ready. Crippled with no funding, commands are failing to meet the doctrine of being advanced life support capable. Not having medical supplies such as appropriate monitors, point of injury consumables, ventilators, and required medications to treat casualties will continue to put lives at risk, now and for the next fight!