A hospital corpsman with Alpha Battery, 1st Battalion, 12th Marines, demonstrates how to properly apply a tourniquet during a casualty evacuation drill in the Hijudai Maneuver Area, Japan. Photo by Lance Cpl. Christian J. Robertson
By. Michael Galarneau
The concept of medical planning is not new. Throughout the Civil War, Clara Barton collected and delivered wagon loads of bandages and other medical supplies to U.S. Army doctors caring for wounded Union soldiers. Barton, a trailblazer in combat care, also tended to the wounded on battlefields and prepared them for evacuation.
By World War II, most medical planning was done using field manuals, which depended on “rules of thumb” and lookup tables to predict casualties. This process was an improvement on earlier methods and relied on mathematical formulae to predict casualty counts based on the population at risk, offensive/defensive posture, and a planner’s estimate of an appropriate casualty rate based on the anticipated operation.
There were many problems with planning this way. Results were inconsistent and couldn’t always be replicated, which meant that two separate planners could (and frequently did) obtain widely different estimates on the number of casualties. In addition, this methodology wasn’t transparent—it hindered planners’ ability to communicate with others about how they arrived at their estimates, and the lack of documentation prevented consistent reconstruction of the estimation process.
Aside from these drawbacks, there was one other problem: this method of medical planning only took into account the estimated number of casualties and didn’t include an estimate of the resources that would be required to care for those casualties. Until recently, this was how medical planners prepared for war.
Modernizing Methods for Medical Planning
As military warfare has evolved, often at a rapid pace, the need to more accurately determine what medical resources and personnel are needed has become critical. The right medical care at the right time and place is the difference between life and death.
Fortunately for modern warfighters, today’s military medical planners don’t have to rely on techniques from World War II. Data scientists at the Naval Health Research Center (NHRC) have developed a set of computer-based tools, using science and empirical data, to help planners maximize survivability and health outcomes for combat-injured service members.
The Medical Planner’s Toolkit (MPTk) and the Joint Medical Planning Tool (JMPT) provide repeatable, documented, empirical, science-based methods to predict the likelihood of injuries and illnesses; create casualty estimates; simulate routing and treatment times; estimate required equipment, supplies, personnel, and transportation assets; conduct medical systems analysis; and assess operational risk.
The MPTk not only provides daily estimates of the number of casualties across the range of military operations, but also the types of injuries and illnesses that can be expected based on the mission. Knowing whether to anticipate blast injuries, chemical burns, or vector-borne illness enables medical personnel to provide the right level of care and treatment, ensuring the best health outcomes for afflicted service members. It also allows medical planners to calculate the number of operating rooms, intensive care unit beds, medical/surgical ward beds, blood products, surgeons, nurses, hospital corpsmen, and other medical supplies and resources necessary to provide optimal patient care and effectively manage the medical workload.
The JMPT combines all the information about casualty streams and resources from the MPTk to examine the trade-offs in distance between military treatment facilities, the types and roles of these facilities, the number and specialties of medical personnel, and the availability of transportation assets. This ensures that medical planners can determine the best course of action in an evolving warfighting environment to meet the needs of wounded and ill service members, giving them their best chance of survival while optimizing their long-term health outcomes.
The Power of Data
So how do these tools work? How have NHRC’s researchers been able to achieve what medical planners throughout history have struggled to achieve? It’s all about harnessing the power of data.
The term “big data” may be new, but the concept is not. For more than 37 years, researchers at NHRC have been doing a lot with data. Before there was JMPT and MPTk, there was the Expeditionary Medical Encounter Database (EMED).
NHRC researchers developed EMED to improve medical mission readiness by providing researchers and medical planners with accurate injury and clinical treatment data for casualties from point of injury to definitive care and rehabilitation. As Navy and Department of Defense requirements evolved, EMED evolved as a high-quality database to support research on several topics, including: injury prevention and mitigation, personal protective equipment evaluation, quality of life outcomes, clinical practice guidelines, and determination of theater medical requirements.
EMED serves as the “data foundation” for JMPT and MPTk. The capability set comprised in these tools was initiated in the mid-1990s, but have steadily evolved to meet changing conditions and new operational constructs. The only constant in their development is that in order to make their calculations, both continue to depend on the high quality data in EMED, which itself is continually updated. MPTk is actually a suite of separate tools (see sidebar).
Medical planners can use MPTk to estimate casualties across a range of military operations, from combat to humanitarian missions, to help determine what supplies, equipment, and personnel are needed to manage casualties and ensure lifesaving medical care is available.
The JMPT supports mission planners by modeling patient flow from point of injury in far-forward environments through to more definitive care. Fully integrated with MPTk, JMPT allows medical planners to:
• Project patient numbers
• Project types of injuries/illnesses
• Simulate patient routing and treatment times
• Determine type of military treatment facilities required to treat patient streams
• Determine how military treatment facility relocation will impact patient treatment
• Determine best use of medical personnel and transportation assets
• Manage patient flow for optimal health outcomes.
The JMPT is used to support a variety of uses from research and medical systems analysis to operational risk assessment and field medical services planning. Together, the JMPT and MPTk are powerful data analytics tools that provide military leaders and medical planners with reliable, science-based information to support medical decision making to minimize injury and illness and save the lives of warfighters.
Making History with Science
For the first time in the history of military medical planning, the tools developed by NHRC have provided a standardized, repeatable process to support medical planning up to and including the combatant command level, allowing mission planners to calculate and quantify risk. Both tools use stochastic, Monte-Carlo techniques (multiple scenario runs), which permit evaluation of possible variance from the average casualty values and thereby provide measurement and quantification of risk associated with alternative courses of action. Both MPTk and JMPT have undergone rigorous verification, validation, and accreditation, and are certified for use across the Department of Defense.
Going forward, researchers at NHRC will continue to upgrade these tools and create new ones to keep up with the rapid evolution of data science and the medical readiness needs of the US armed forces. In the near term, NHRC plans to enhance ability of JMPT and MPTk to calculate casualties caused by chemical, biological, radiation, and nuclear weapon use. The tools also will accommodate calculations of supply and treatment requirements associated with the special needs of these types of patient streams.
To meet the needs of end users, NHRC also is developing web-enabled versions of the tools that will allow faster run times in a distributed environment and can be implemented through cloud computing. Since its earliest days, NHRC has worked to continuously gather, codify, and organize expeditionary medical data in support of the design, development, and deployment of high-quality software based on those data.
The Medical Planner’s Toolkit (MPTk) is a suite of tools that seamlessly integrates four applications into one computer-based workflow. This desktop program provides medical planners with an end-to-end solution for medical support planning across the range of military operations, from combat operations to humanitarian assistance. MPTk consists of the Patient Condition Occurrence Frequency tool, the Casualty Rate Estimation tool, the Expeditionary Medicine Requirements Estimator, and the Estimating Supplies program.
The Patient Condition Occurrence Frequency tool is an application that manages discrete probability distributions. These distributions characterize the probabilities of individual illnesses and injuries. Empirical data show that the number and types of injuries are related to the type of operations that are captured in the data. Accordingly, the tool provides 33 baseline distributions taken from a variety of operational scenarios that span the spectrum from combat missions to disaster relief and humanitarian assistance. Each scenario can be adjusted by users to better fit their planned operations and manage results, all of which can be stored, edited, exported, and imported.
The Casualty Rate Estimation tool provides the capability to emulate a ground operational plan using a 180-day palette to calculate expected battle and noncombat injuries and illnesses during operations. Casualty estimates also can be generated for attacks on ships and fixed facilities, or natural disasters. This tool uses the Patient Condition Occurrence Frequency probability distributions to turn casualty streams into patient streams, providing not only the number of anticipated casualties, but also the number and types of individual patients. This allows a more refined estimate of the medical requirements for a given operation. For example, it would determine the number and type of surgical patients in a casualty stream, enabling a medical planner to determine the number and type of surgeons that would be necessary, ultimately increasing the number of warfighter lives saved.
The Expeditionary Medicine Requirements Estimator absorbs the time-phased patient stream from the Casualty Rate Estimation tool and calculates the number of operating tables, intensive care unit beds, ward beds, and blood products necessary to satisfy the demand of the patient load. The estimator factors in the medical planner’s inputs on evacuation delay, evacuation policy, and the availability of critical care teams into the requirements estimation.
The Estimating Supplies program uses the scenario-specific patient stream created by the Casualty Rate Estimation Tool and service-specific inventories of medical supplies to estimate the consumption of medically related supplies necessary to treat the patient stream. The supply estimate is time-based, which permits users to estimate the logistics requirements by time period.