L9 - Conduct a Medical Estimate / Casualty Estimate

1. L9 - Conduct a Medical Estimate / Casualty Estimate Agnar Tveten, Cdr, MSc. NOR Navy, Director Radio Medico Norway (NOR TMAS) NATO UNCLASSIFIED Releasable to the INTERNET

2. Agenda • What is risk • The risk matrix • How do we deal with risk • Maritime medical risks • Naval risks and the matrix • Leveling the medical capabilleties NATO UNCLASSIFIED Releasable to the INTERNET

3. WG on casualty estimation • The old MMPG made for Navy on Navy, blue water battles. • Static model. No guidance for different levels in fighting intensity. • No guidance for asymmetric warfare, different types of naval operations or diversity in operational risk. • The old MMPG • Challenges with new guidelines • Solution

4. WG on casualty estimation • New evidence based model? • Historical data outdated due to new operational challenges and improvements in medicine. • Empirical questionable due to very few new data. • The need for a dynamic model that can apply to different types of operations, different sized naval parties and changes in fighting intensity. • The old MMPG • Challenges with new guidelines • Solution

5. WG on casualty estimation • What do NATO navies actually do, when planning for a new mission? • Assessing risk based on size of party, proximity to modern healthcare, and operational risk derived from type of operation and opponents capabilities and will. • The old MMPG • Challenges with new guidelines • Solution

6. WG on casualty estimation • The solution: a risk matrix giving naval planners guidance in how to assess different risk factors, and provide guidance on medical facilities needed according to level of risk. • Does not give an exact demand for surgical teams or beds, but capabilities needed, and indication of capacity. • The old MMPG • Challenges with new guidelines • Solution

7. WG on casualty estimation • Applicable to most scenarios. • Necessary with skilled medical planners to get more detailed output. • One axis taking into account size of party and proximity to NATO permanent medical treatment facilities. • The old MMPG • Challenges with new guidelines • Solution

8. WG on casualty estimation • One axis taking into count operational risk due to type of mission and opposing capabilities. • The output gives a score that indicates what level of care will be needed. • The skilled medical planner can give different ratings to different operations or adjust the levels for an operation. • The old MMPG • Challenges with new guidelines • Solution

9. Example from the matrix on risk score in low intensity naval warfare operations

10. Level descriptions according to score • Level 1 (Score 1) • Nationally mandated minimum medical requirements for that platform to provide primary care, triage, first aid, pre-hospital emergency care, evacuation. This will encompass minimum IMO standards and comply with relevant STANAGS. Role 1 care. • Level 2 (Score 2-3) • As Level 1 but would normally include addition of a ships doctor. Role 1 care. • Level 3 (Score 4-6) • As level 2 but with access to specialist doctor-led resuscitation and damage control surgery within clinical timelines; If embarked might include one surgical team and one operating table, basic laboratory and imaging capability, limited intensive care and a small holding capacity. This is the maritime equivalent to Role 2 Light Manoeuvre. • Level 4 (Score 8-12) • As level 3 but with access to primary surgery within clinical timelines; If embarked might typically include up to two operating tables, two surgical teams, four intensive care beds, diagnostic capacity including x-ray, basic lab, blood-bank, pharmacy, sterilization capacity, dentistry, a moderate holding capacity for nursed patients and access to specialist medevac capability. This is the maritime equivalent to Role 2 Enhanced. • Level 5 (Score 16) • As level 4 but with access to specialist surgery within clinical timelines; Mission tailored but typically might include up to four operating tables, four surgical teams, eight intensive care beds, diagnostic capacity including Computerised Tomography (CT) scanner, oxygen production capacity, PECC, dedicated medevac capability, and a larger holding capacity for nursed patients. This is the maritime equivalent to Role 3.

11. WG on levels • The Role system • Challenges with new levels • Solution • Not relating to the actually capacities • Not defined by the factors that differs the medical care on board ships • Inaccurate (useless) for operational purposes

12. WG on levels • The Role system • Challenges with new levels • Solution • Minimum requirements not guidelines • Detailing level • Emergency care versus General Practice • Personnel qualifications • Special capabilities like pressure chamber

13. WG on levels • The Role system • Challenges with new levels • Solution • Defined by 7 criteria • Some capabilities not linked to level (minimum requirements) • Reference table

14. Level 3 • The MMPG refers to level 3 as; As level 2 but with access to specialist doctor-led resuscitation and damage control surgery within clinical timelines; if embarked might include one surgical team and one operating table, basic laboratory and imaging capability, limited intensive care and a small holding capacity. This is the maritime equivalent to Role 2 Light Manoeuvre. • Level three is the lowest level where surgery is provided. The minimum level of surgery provided is damage control surgery; this is defined in AMed P-13A. At level three you will also find basic laboratory and imaging capability, intensive care and limited holding capacity. • Organisation and Medical Staff: • Personnel: One surgical team sufficient to provide damage control surgery; this should include one surgeon, one anaesthesia provider and two operating theatre staff. There should also be medical staff to fulfill the nursing, laboratory and imaging capabilities. Health professionals should also be available to provide MEDEVAC within the littoral, though this may compromise the capability of the MTF. A dental capability may be included in the MTF. • Platform Characteristics: The hull shall have an area designated for use as a surgical area. • Sustainability: Medical support capability will be able to hold post-operative patients within the theatre holding policy. • Primary healthcare and clinical investigation: • The basic laboratory capability should be able to provide simple blood measures including: cross-match, haemoglobin, electrolytes and basic transfusion facilities. Basic imaging should include x-ray and ultrasound capabilities. • Secondary Healthcare and Hospitalisation: • It should be possible to provide a dedicated medical ward with specialist nursing care and the provision of intensive care if required. The MTF shall be able to hold a ventilated for up to 6 hours after the provision of damage control surgery.  • Evacuation: • The MTF should be able to provide for the in-transit care of a ventilated patient and the platform should have a helicopter landing pad sufficient for such RW assets as are used to move such ventilated patients. • Minimum Medical Assets: • It is anticipated that the MTF should have access to blood products (in accordance with STANAG 2408) and sterilisation facilities if practicable.

16. Questions… Agnar Tveten, Cdr, NOR Navy, MSc. Director of Radio Medico Norway (NOR TMAS) Email: agnar@tveten.org NATO UNCLASSIFIED Releasable to the INTERNET