When medical support in theater is not enough
By Kraig Johnson
From Stability Operations: Volume 8 Number 1
As of February 2012, in Afghanistan, there were over 110,000 civilian contractors, compared to approximately 90,000 US military service members, according to the Department of Defense. These civilian contractors provide many services including security, base life support (BLS), maintenance of vehicles, interpreters, and dining facilities. While the military medical components do provide life, limb and eyesight (LLE) medical care, the majority of the primary care medicine falls on the contractor.
With the limited medical resources in theater and the number of employees from different countries and various levels of routine medical care provided by their host countries, the need for employees to be transported out of theater for definitive care and evaluation poses a challenge to any contractor.
According to the Labor Department’s statistics, 1,777 American contractors in Afghanistan were injured or wounded seriously enough to miss more than four days of work in 2011 (NYT). This number alone shows the basic impact of providing services in an environment such as Afghanistan.
There are 3 types of movement that routinely occur in theater for medical purposes. They are:
Patient Movement, in theater, where an employee suffers an injury or illness that requires him/her to be moved to a facility (military or contractor operated) that has more extensive diagnostics (radiology, laboratory, etc.) or higher trained medical professionals (Physicians, PA’s, etc.). An example of this would be an employee is injured at a smaller FOB and is transported to a larger FOB or base for care.
Patient Movement, out of theater, where an employee suffers an injury or illness that is beyond the scope of medical services provided in theater but is not serious enough to require utilization of the emergency medevac system. An example of this would be an employee with an orthopedic injury requiring rehabilitation or surgery.
Medevac, where an employee suffers an injury or illness that is severe enough that either the military medical personnel or the contractor civilian medical provider initiates the emergency medevac system. Examples could be an employee suffers traumatic injuries from hostile fire or has a heart attack
Most of the movements occur through coordination of care between both civilian and military medical assets. Except for the instance of an activation of the emergency medevac system of the military, most all other movements are coordinated through the contractor medical provider (Onsite OHS, for example), and the prime contractor’s insurance provider.
As the medical condition is discussed with all pertinent parties (contractor medical provider, prime contractor management, prime contractor insurance provider, and civilian medical transport agency), the appropriate level of patient care is discussed and agreed upon by the providers. In the period from 2009-current, there have been very few instances that the author can recall where there has been a difference on medical opinion on the level of care to be provided to an employee who was being transferred out of theater (this will be discussed further in the Lessons Learned section).
The overall coordination needed to provide a successful medical transport from an austere environment such as Afghanistan, to tertiary medical care facilities throughout the world is a difficult task to say the least. Keep in mind that over half of the contractor employees in Afghanistan are non-US citizens. These employees come from countries such as India, Nepal and Kenya. This significantly plays into the planning and coordination of a medical movement in that there are varying levels of care provided. For example, what a US citizen might consider a lower standard of medical facility in the United States may actually be a high level of medical care in another country. This is where the communication and coordination proves to be vitally important.
The open lines of communication (see figure 1) ensure that all information is shared with the necessary parties. The entire process from the time of injury/illness to arrival at the tertiary care facility can vary tremendously. Factors that can impact overall time required to move an employee include, but are not limited to the following:
The overall medical condition, as the seriousness of a condition can dictate speed and urgency of medical transport. This sometimes causes an event that may have started as a basic movement to an event that escalates to the necessity to activate the emergency medevac system.
The geographical location of employee, as this impacts how quickly an employee can get to a definitive level of care. This also is driven by type of movement assets available (ground, rotary wing, or fixed wing).
The nationality of the employee, as some nationalities have difficulties obtaining entry visas for certain countries, even if they are on an air ambulance.
Administrative issues, since any movement in theater, or especially out of theater, requires a number of administrative tasks that need to be completed prior to the employee going anywhere. These include but are not limited to: copies of LOA in hand, passport, medical records, and contact information for the facility the employee is going to, liaison information, embassy information. These issues are routinely handled by the Contractors HR department in coordination with in-theater project management and medical provider personnel.
While providing medical services in various austere locations, Onsite OHS has assisted/initiated over 700 medical evacuations/patient movements. These have consisted of routine cases such as chronic orthopedic issues, to immediate medical responses, to hostile actions.
The OHS model for medical evacuation and movement has worked, for the most part, as efficiently as expected. The pitfalls appear when there is miscommunication, or when mission priorities change the outlook for a medical evacuation/movement. Depending on the particular location, some prime contractors still rely heavily on un-owned air assets such as the military or other contractors, and with that, the movement of the patient may be at the discretion of mission commanders or other contractors.
Overall, our experience has been that the interaction with all parties (prime contractors, Insurance providers, military medical assets, and tertiary care facilities) has been exemplary. When it comes to medical issues, everyone usually is able to fully understand the urgency and need for an employee to get to a higher level of care.
Some lessons learned prove to be simple yet vital in the success of medical movements/evacuations:
Engage all applicable parties BEFORE the need arises by making early initial contact with the contractor’s DBA/Insurance providers, asking the names and contact numbers of the air ambulance providers that are used, and making initial contact with them, meeting with the highest level of military medical authority at the FOB(s) or location(s) you will be operating, building a strong working relationship with contractor HR/personnel management, and coordinating closely with contractor site management to clearly define the roles that are to be played and discuss any issues that may arise.
Prevent complacency by not letting the lack of using the medical evacuation/movement processes allow it to become outdated and flawed. Routinely follow up with all parties at regular intervals to allow for better coordination and communication when the need arises. Schedule a debriefing with site management and contractor insurance provider after a medical movement to discuss what could be done differently, the positives, and the negatives. Make sure to update policies and procedures as missions change (base expands or contracts, decreased number of contractor employees, loss of assets, etc.) and maintain a updated list of available resources, both civilian and military, and reciprocate that information with them.
Maintain patient advocacy by understanding that this is a stressful event for an employee. Think of what can be done to minimize that stress and ensure that the employee gets the most prudent medical care in the shortest amount of time possible. This includes being the go-between with the insurance company, civilian air ambulance provider, or military asset. Relay any concerns you have as early as possible and seek resolution as soon as possible.
Follow up by ensuring that you maintain communication and status reports from the time the medical movement is initiated until the employee arrives at their final Medical treatment facility. This will allow you to update your client, site management and other personnel as needed. This also allows you to fully close out any recordkeeping or patient records that need to be updated.
Kraig Johnson has over 20 years in the Medical Program Management Field and is currently the Director of Operations for Onsite OHS. Contact Kraig at Kraig.Johnson@onsiteohs.com.