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Introduction to Military Medicine

Introduction to Military Medicine. History of Afghan Medicine. Afghan medicine has a long distinguished history German-Turkish influence prior to 1970’s Then Russian system 1970’s to 1990’s Under Taliban rule 1996 to 2001 almost complete dissolution of the health care system

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Introduction to Military Medicine

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  1. Introduction to Military Medicine

  2. History of Afghan Medicine • Afghan medicine has a long distinguished history • German-Turkish influence prior to 1970’s • Then Russian system 1970’s to 1990’s • Under Taliban rule 1996 to 2001 almost complete dissolution of the health care system • Healthcare delivery mainly by N.G.O.’s after 2001 • U.S. system influence since 2001, particularly with the Afghan National Security Forces (A.N.S.F.) comprised of the Army National Army (A.N.A.) & Afghan National Police (A.N.P.) • Present focus on training programs

  3. The National Military Hospital, and other ANA Facilities in the Kabul Area The 400 Bed National Military Hospital and a series of six clinics requires clinical and administrativementors for all aspects of health care, to include a poly clinic, infectious disease clinic, and hospital annex located on the hospital grounds, the Kabul Military Training Center, the Pol-e-Charkhi, Darulaman, and Jalalabad Garrison Clinics, the Military Examination and Processing Center (MEPS), and the Air Corps Clinic. See next slide for current mentor manning and requirements. Eshkashem Konduz Mazar-eSharif Baghlan Sar-e Pol Samangan Pol-e Khomri Meymaneh Kabul National Military Hospital KMTC Clinic Darulaman Clinic Pol-e-Charkhi Clinic Air Corps Clinic Kabul KONAR FARYAB Charikar Bagram PARVAN Bamian Jalalabad Herat Gardez Baraki Shindand Ghazni Baghran Deh Rawod Orgun-e Farah FARAH Shkin Qalat Kandahar Geresk Lashkargah Zaranj Spin Boldak NIMRUZ

  4. ANSF Medical Facilities Mazar-e Sharif 209th Corps 50-bed Regional Hospital F - Civ-Mil Collaborative Hospital, Rehab Center; Allied Health Professions Training Institute Regional Depot Additional Kabul Medical Facilities POLY Clinic Annex Hospital Eshkashem Konduz Mazar-eSharif Baghlan Sar-e Pol Samangan Kabul - 201st Corps OTSG/Medical Command HQ 400-Bed Nat’l Military Hospital **National Depot** ANP Clinic Pol-e Khomri Meymaneh Kabul KONAR FARYAB Charikar Bagram PARVAN Bamian Jalalabad GARDEZ 203st Corps 50-Bed Regional Hospital F - 50-bed Expansion Regional Depot Herat Gardez Baraki Khowst Shindand Ghazni Baghran Deh Rawod Herat 207th Corps 50-Bed Regional Hospital F - 50-bed Expansion Regional Depot Orgun-e Farah FARAH Shkin Qalat Kandahar Geresk Lashkargah F = Future Future ANA Garrison Clinics KANDAHAR 205th Corps 50-bed Regional Hospital F - 50-bed Expansion Regional Depot Zaranj Spin Boldak NIMRUZ

  5. Afghan National Police Facilities in the Kabul Area Mentors are required for the Afghan National Police Clinic, Kabul Police Training Center (RTC), Police Academy, and Regional Headquarterswhich supports police trainees and their beneficiaries. Mentors are needed for all aspects of clinic administration and operations. Eshkashem Konduz Mazar-eSharif Baghlan Sar-e Pol Samangan Pol-e Khomri Meymaneh Kabul ANP RTC Clinic and Regional HQs Kabul KONAR FARYAB Charikar Bagram PARVAN Bamian Jalalabad Herat Gardez Baraki Shindand Ghazni Baghran Deh Rawod Orgun-e Farah FARAH Shkin Qalat Kandahar Geresk Lashkargah Zaranj Spin Boldak NIMRUZ

  6. Regional ANP Medical Administrative Centers ANP Regional Headquarters of 15 personnel require medical administration mentors who will provide administrative oversight of healthcare for ANP officers and beneficiaries. Tasks will include medical readiness, civilian contract management, patient movement coordination, and rehabilitation and return to duty issues. Mazar-e Sharif ANP Regional HQs Eshkashem Mazar-eSharif Herat ANP Regional HQs Baghlan Sar-e Pol Samangan Pol-e Khomri Meymaneh Kabul KONAR FARYAB Charikar Bagram PARVAN Herat Gardez Baraki Shindand Ghazni Baghran Deh Rawod Orgun-e Farah FARAH Shkin GARDEZ ANP Regional HQs Qalat Kandahar Geresk Lashkargah Zaranj KANDAHAR ANP Regional HQs Spin Boldak NIMRUZ

  7. Regional ANP Clinical Mentors Afghan National Police (ANP) Regional Training Centers (RTC) of 7-10 medical personnel require clinical mentors. RTCs support police trainees and their beneficiaries in the below listed areas, providing basic outpatient medical services. Afghan National Army Regional Hospitals located in Kabul, Gardez, Kandahar, Herat, and Mazar-e Sharif provide back-up inpatient and referral services to each of these RTCs. Mazar-e Sharif ANP RTC 7 Personnel Clinic Kunduz ANP RTC 10 Personnel Clinic Eshkashem Kunduz Mazar-eSharif Herat ANP RTC 7 Personnel Clinic Baghlan Sar-e Pol Samangan Bamyan ANP RTC 10 Personnel Clinic Pol-e Khomri Meymaneh Kabul KONAR FARYAB JBAD Charikar Bagram PARVAN Bamyan Jalalabad ANP RTC 10 Personnel Clinic Herat Jalalabad Khost Gardez Baraki Khost ANP RTC 7 Personnel Clinic Shindand Ghazni Baghran Deh Rawod Orgun-e Farah FARAH Shkin GARDEZ ANP RTC 7 Personnel Clinic Qalat Kandahar Geresk Lashkargah Zaranj KANDAHAR ANP RTC 7 personnel Clinic Spin Boldak NIMRUZ

  8. ANP Medical Manpower DistributionAdministrative Positions – 106 personnel Balkh Regional HQ 15 personnel Kabul Herat Regional HQ 15 personnel Khost Regional HQ 15 personnel Kabul 3 Kabul OTSG 31 personnel Kandahar Regional HQ 15 personnel Kabul Regional HQ 15 personnel

  9. ANP Medical Manpower DistributionCombat Medics – 60 personnel Balkh, Kunduz, Takhar 12 personnel Kabul, Nangahar 15 personnel Herat 9 personnel Khost, Paktika 9 personnel Kandahar, Nimruz 15 personnel Combat Medics:- Embedded with Border Police- Equipped with tactical ambulances

  10. STAGES OF CARE:3 Distinct Phases • Care Under Fire • Tactical Field Care • Combat Casualty Evacuation Care

  11. ANA Echelon System • 1st Echelon: Self-Aid and Buddy Care (soldiers, combat medics) First aid, airway, hemorrhage control, field dressings, IV fluids, analgesia • 2nd Echelon: Kandak Aid Station (combat medics,Docs) minor surgery or stabilization for further transport (ATLS or resuscitative-salvage surgery)

  12. ANA Echelon Scheme (cont) • 3rd Echelon: TMC ,forward facility Facility capable of ATLS resuscitation, resuscitative surgery (salvage surgery) & minimal reconstructive surgery • 4th Echelon: Regional Hospital Hospital equipped for definitive care; rehab only if within certain predetermined time • 5th Echelon: National Military Hospital Kabul Reconstructive and rehabilitative

  13. PREVENTABLE CAUSES OF COMBAT DEATH • 60% Hemorrhage from extremity wounds • 33% Tension pneumothorax • 6% Airway obstruction, e.g., maxillofacial trauma

  14. Factors influencing combat casualty care • Enemy Fire • Medical Equipment Limitations • Widely Variable Evacuation Time

  15. Care Under Fire • “Care under fire” is the care rendered by the medic or first responder at the scene of the injury while still under effective hostile fire • Available medical equipment is limited to that carried by the medic or first responder in his aid bag

  16. Care Under Fire • “The best medicine on any battlefield is fire superiority” • Medical personnel’s firepower may be essential in obtaining tactical fire superiority • Attention to suppression of hostile fire will minimize the risk of additional injuries or casualties

  17. Care Under Fire • Personnel may need to assist in returning fire instead of stopping to care for casualties • Wounded soldiers who are unable to fight should lay flat and motionless if no cover is available or move as quickly as possible to any nearby cover

  18. Care Under Fire • Hemorrhage from extremities is the 1st leading cause of preventable combat deaths • Prompt use of tourniquets to stop the bleeding may be life-saving in this phase

  19. Care Under Fire • All soldiers engaged in combat missions should have a suitable tourniquet readily available at a standard location on their battle gear and be trained in its use • Various types of tourniquets exist

  20. Combat Application Tourniquet (CAT) WINDLASS OMNI TAPE BAND WINDLASS STRAP

  21. Tourniquets

  22. A survivable airway problem

  23. Summary • “If during the next war you could do only two things, 1) place a tourniquet and 2) treat a tension pneumothorax, then you can probably save between 70 and 90 percent of all the preventable deaths on the battlefield.” -COL Ron Bellamy

  24. Tactical Field Care

  25. Officers in the Field must consider the mission!! • The three goals of Tactical Combat Casualty Care (TCCC) are: • Save preventable deaths • Prevent additional casualties • Complete the mission

  26. KEY POINTS • Return fire as directed or required • If able, the casualty(s) should also return fire • Try to keep from being shot • Try to keep the casualty from sustaining additional wounds • Airway management is best deferred until the Tactical Field Care phase • Stop any life threatening hemorrhage with a tourniquet • Reassure the casualty

  27. Evacuation

  28. Combat Casualty Evacuation Care • “Combat Casualty Evacuation Care” is the care rendered once the casualty has been picked up by evacuation vehicles • Additional medical personnel and equipment may have been pre-staged and available at this stage of casualty management

  29. Casevac Care • At some point in the operation the casualty will be evacuated • Time to evacuation may be quite variable from minutes to hours • The medic may be among the casualties or otherwise debilitated • A MASCAL may exceed the capabilities of the medic

  30. Patient Access to Emergency Care in Afghanistan • Not good for most Afghans • Kabul has 10 hospitals providing care, but civilians do not have access to the National Military Hospital • New regional military hospitals in Mazar-e-Sharif, Heart, Gardez, and Kandahar • Many clinics built by U.S. A.I.D. are nonfunctional or unstaffed

  31. The Emergency Medical Transportation System in Afghanistan • U.S. and the International Security Assistance Force (I.S.A.F.) have ground & air ambulances, but just for I.S.A.F. troops • Kabul has 13 ambulances run by Norway N.G.O. • 700 ambulances & 2 helicopters purchased by U.S. military in March 2007 for A.N.S.F. combat casualty evacuation • Very poor roads in much of the country make ambulance access and transfers difficult • Concept of referral system is being built

  32. Challenges • Basic infrastructure not in place • Lack of depth in management and from MOPH and NGO’s • “Kabul centric” delegation of resources • Lack of data describing health status, and health care assets

  33. Challenges • Inaccessibility (geography, climate) • Security • Balancing tertiary care and primary services • Donor/partner coordination and collaboration

  34. Combined Security Transition Command - Afghanistan Afghan Health Sector • Destroyed by 30 years of occupation and war • Health demographics reflect an emerging health care system • Maternal Mortality Rate: 19/1000 • Infant Mortality Rate: 160/1000 • Under 5 Mortality Rate: close to 20% • Life expectancy: 43 years • Literacy: Male 40%, female 15 % • Access to safe water: Urban – 80%, Rural – 20%

  35. Funding of Medicine in Afghanistan • Afghan constitution guarantees free “Basic Package of Health Services” to all citizens • Virtually all current funding is from U.S. military (for A.N.S.F. facilities) and from N.G.O.’s • Afghan Ministry of Public Health (MoPH) has new sources of income • CURE Hospital in Kabul is fee for service (sliding scale $)

  36. Health Facilities • Facilities implementing the Basic Package of Health Services • 25 health facilities per province • 15 Basic Health Units • 7 Comprehensive Health Centers • 3 District Hospital Outpatient Departments Basic Health Unit, Wardak

  37. Types of Basic Health Facilities Health Post Basic Health Center Comprehensive Health Center District Hospital

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