Jez Eden , LtCdr RN

1. LO2 – Maritime Medical Planning Principles JezEden, LtCdrRN NATO UNCLASSIFIED Releasable to the INTERNET

2. SCOPE • Timelines • Roles • Risk Assessment • Questions NATO UNCLASSIFIED Releasable to the INTERNET

3. Timelines • 70% of battle casualty deaths occur within 5 minutes of wounding • 20% are preventable through immediate application of fairly simple measures • But time is critical • 10-20% will die within 4 hours without surgery • New medical techniques and procedures have reduced battle casualty deaths by 30% NATO UNCLASSIFIED Releasable to the INTERNET

4. Clinical Timelines • 1-2-4 Hour Principle: [JDP 4-03 Med Sp to Ops] • Within 1 hrs = resuscitation and stabilizing treatment • Within 2 hrs = Damage Control Surgery (DCS) • Within 4 hrs = Primary Surgery (PS) NATO UNCLASSIFIED Releasable to the INTERNET

5. Timelines • 10-1-2 Guidelines: [ACO Dir (AD) 83-1 (Edn 2) dated Oct 10] • Within 10 mins = haemorrhage & airway control • Within 1 hr = MEDEVAC assets reach the casualty • Within 2 hrs = casualties requiring surgery, to be in an operating theatre NATO UNCLASSIFIED Releasable to the INTERNET

6. Level • Level 1 • Level 2 • Level 3 • Level 4 • Level 5 NATO UNCLASSIFIED Releasable to the INTERNET

7. Role 1 • Maritime Medical planning Guidance: • Nationally Mandated Minimum Medical Requirements (NMMMR): • Primary care, Triage, First Aid, Pre Hospital Emergency Care, Evacuation • Personnel – Personnel qualified to the minimum IMO trg level and dedicated personnel to provide care who are current in advanced first aid or medical trg at an agreed level. • It should be possible to provide limited medical treatment, under the guidance of an authorised healthcare professional NATO UNCLASSIFIED Releasable to the INTERNET

8. Level 2 • MMPG refers to Level 2 as level 1 but would normally include the addition ships Dr • Provide a greater range of diagnoses, with greater confidence and accuracy as well as treating common medical conditions with an increased range of treatment options • The hull should have an authorised independent health practitioner • Should be able to provide triage in MASCAL situations, along with advanced airway access, access for fluid resuscitation and non surgical haemorrhage control NATO UNCLASSIFIED Releasable to the INTERNET

9. Level 3 • MMPG refers to level 3 as; As level 2 but with access to specialist doctor led resuscitation and damage control surgery within clinical timelines • Maritime equivalent to Role 2 Light Manoeuvre. It is the lowest level where surgery is provided. The minimum level of surgery provided is damage control surgery. • Personnel – Should include one surgeon, one anaesthesia provider and two operating theatre staff. Additional medical staff to fulfill the nursing, laboratory and imaging capabilities • Evacuation – Provide for in transit care of a ventilated patient. NATO UNCLASSIFIED Releasable to the INTERNET

10. Level 4 • MMPG refers to level 4 as; As level 3 but with access to primary surgery within clinical timelines. Might include 2 x operating tables (OT), 2 surgical teams (ST), 4 x ITU beds, X Ray, Lab, blood bank • Maritime equivalent to Role 2 Enhanced. Should be able to maintain its capability and remain within a TF in the presence of a flow of casualties • Ability to hold one ventilated patient for up to 48 hrs and able to regenerate surgical capability without compromising the mission • Evacuation–Provide in transit care of a ventilated patient without compromising the capabilities of the MTF NATO UNCLASSIFIED Releasable to the INTERNET

11. Level 5 • MMPG refers to Level 5 as; As level 4 but with access to specialist surgery within clinical timelines. Mission tailored. May include 4 x OT, 4 x ST 8 x ITU beds, CT scanner, O2 production, PECC dedicated medevac capability. This is the maritime equivalent to Role 3 • The hull shall be a designated MTF platform designed to receive and hold casualties without compromising the mission. May be a dedicated hospital ship • Sustainability – Ability to hold patients for 7 -10 days or until evacuation to the APOD can be achieved. • Designated medevac teams NATO UNCLASSIFIED Releasable to the INTERNET

12. Scheme of Manoeuvre Level 5 Level 2 Level 4 Level 3 NATO UNCLASSIFIED Releasable to the INTERNET

13. Risk Assessment • Early in the development of any plan medical planners should draw together all relevant information in order to conduct a risk based evaluation of key factors • An initial broad based assessment of the medical capability required within the deploying force needs to be made. This will be fine tuned as the planning process develops • If sufficient medical capability is not available or the medical plan cannot meet doctrinal clinical timelines then this risk must be highlighted to the Operational commander NATO UNCLASSIFIED Releasable to the INTERNET

14. Risk Assessment • Early in the development of any plan medical planners should draw together all relevant information in order to conduct a risk based evaluation of key factors • An initial broad based assessment of the medical capability required within the deploying force needs to be made. This will be fine tuned as the planning process develops • If sufficient medical capability is not available or the medical plan cannot meet doctrinal clinical timelines then this risk must be highlighted to the Operational commander NATO UNCLASSIFIED Releasable to the INTERNET

15. Risk Assessment • Overall risk score is based on 3 factors: • The operation to be undertaken • The relative size of the formation (PAR) • The region in which it is to operate NATO UNCLASSIFIED Releasable to the INTERNET

16. Risk Assessment NATO UNCLASSIFIED Releasable to the INTERNET

17. Risk Assessment NATO UNCLASSIFIED Releasable to the INTERNET

18. Risk Assessment

19. Risk Assessment • Score 1 – (Level 1) • Score 2 – 3 – (Level 2) • Score 4-6 – (Level 3) • Score 8-12–(Level 4) • Score 16 – (Level 5) NATO UNCLASSIFIED Releasable to the INTERNET

20. Conclusion The only certain result of your plan will be casualties - mainly the enemy's if it's a good plan, yours if it is not.  Either way, foremost in your supporting plans must be your medical plan. Brigadier Rupert Smith Deputy Commandant Army Staff College 1990