Publicly Released: June 10, 2020
Objective
The objective of this audit was to determine whether the Defense Health Agency and the Military Departments provided effective training to mobile medical teams to improve trauma care before teams deployed to the U.S. Indo-Pacific Command (USINDOPACOM) and U.S. Africa Command (USAFRICOM) areas of responsibility.
For the purposes of this report, we defined mobile medical teams as small, mobile groups of medical personnel (10 or less) operating at the tactical or intra-theater level.
Background
The Army, Navy, and Air Force employ conventional force mobile medical teams in response to combatant commander requests for forces to enable forward military operations. Mobile medical teams typically consist of a general surgeon, an emergency physician, a critical care nurse, a surgical technician, and additional trauma care professionals, to provide life-saving care, including surgery, to wounded military personnel in the field before arrival at a military medical treatment facility. Mobile medical teams need to be capable of treating trauma injuries not commonly seen at their home station military medical treatment facility, such as multiple injuries to the body that could be life-threatening. The types of trauma injuries, availability of resources, and stressors experienced by those who care for the wounded on the battlefield differ greatly from what is experienced at a military medical treatment facility. For this reason, mobile medical teams need to develop both medical skills to perform operations in austere environments and tactical skills to safely function in a combat zone.
The Joint Requirements Oversight Council assists the Chairman of the Joint Chiefs of Staff in assessing and identifying gaps in joint military capabilities and establishing joint performance requirements that ensure interoperability between the military departments. In 2017, the Council issued a document with change recommendations and associated memorandums that identified gaps in the DoD’s delivery and management of trauma care in support of deployed operations. Specifically, it stated that DoD trauma care capabilities have lacked standardization due to the absence of a single organization responsible for establishing trauma care training tools, technologies, and individual readiness standards for medical personnel across the Military Departments. To begin addressing these gaps, the FY 2017 National Defense Authorization Act (NDAA), sections 707 and 708, established requirements for the management and training of personnel providing trauma care. The FY 2017 NDAA requires the Secretary of Defense to establish, within the Defense Health Agency, both the Joint Trauma System (JTS) to organize and coordinate performance improvements in trauma care, and the Joint Trauma Education and Training (JTET) Branch to ensure units across the Military Departments are training to a common baseline for providing trauma care. Beginning in December 2016, the JTS became responsible for standardizing trauma care training for deploying mobile medical teams.
According to the Military Departments, 297 mobile medical team members either deployed or prepared to deploy to the USINDOPACOM or USAFRICOM areas of responsibility from July 2016 through July 2019. To determine the effectiveness of the training provided to mobile medical teams, we developed a 20-question survey to gather input from mobile medical team members. We provided the survey to all 297 service members and received 90 survey responses, including 29 collected during in-person interviews and 61 collected through e-mail.
In addition, we reviewed 10 post-deployment after action reports (AAR) and summaries of lessons learned that related to mobile medical team training to determine if information was collected on the effectiveness of mobile medical team training and if a standardized AAR template was used across the Military Departments.
Findings
The Military Departments provided team, environmental, and equipment training to mobile medical team members before they deployed to the USINDOPACOM and USAFRICOM areas of responsibility. Team members reported that training was generally effective.
However, based on interviews, survey results, and review of AARs and training certificates, we determined that the Military Departments need to improve surgical and tactical training to better prepare mobile medical teams for deployment to austere environments. Surgical and tactical training were not always provided to mobile medical team members prior to deployment and when provided, were often reported as ineffective. Additionally, personnel across the Military Departments stated that their home station military medical treatment facility positions did not have the trauma caseloads to prepare them to be a member of a mobile medical team. Surgical training should include treating trauma injuries on live patient models and participating in rotations to trauma centers. Tactical training should include weapons qualifications and practice on night vision equipment.
These training gaps existed because the Military Departments did not develop methods such as conducting training-specific AARs or collaborating to standardize training based on best practices. Prior to the FY 2017 NDAA, each Military Department set its own individual training requirements and was not required to collaborate with the other Departments. According to JTS and JTET Branch officials, as a part of their new responsibilities, the JTS and JTET Branch are working on standardizing mobile medical team training to be consistent across the Military Departments and incorporating trauma caseload requirements into the newly developed standardized training requirements. In addition, USINDOPACOM and USAFRICOM did not consistently identify the training and unique equipment requirements for the tactical conditions in their areas of responsibility; therefore, the Military Departments did not tailor their training to reflect combatant command requirements.
As a result of gaps in surgical training and a lack of exposure to trauma cases, mobile medical team personnel are at risk of not gaining and maintaining essential surgical experience necessary for medical readiness. Additionally, according to a USAFRICOM component command official, without better tactical training, teams may not be able to defend themselves and their patients and they may become a liability to the forces they are intended to support. Lack of standardization in training also means combatant commanders are not fully aware of the capabilities or limitations they are receiving with each type of mobile medical team.
Recommendations
We recommend that the JTET Branch Chief continue efforts to complete and implement standardized medical training, to include an austere surgical resuscitative course, in accordance with the FY 2017 NDAA and Joint Requirements Oversight Council Memorandum 125-17.
We recommend that the Surgeons General of the Army, Navy, and Air Force:
• issue guidance implementing the JTET Branch’s standardized training program for all mobile medical teams;
• update training curriculums at the Military medical training commands, for tactical training of mobile medical teams; and
• require all mobile medical team personnel to complete the standardized post-deployment AARs and submit them to the Joint Lessons Learned Information System.
We recommend that the JTS Chief and the JTS Performance Improvement (PI) Branch Chief develop a standardized post-deployment AAR template to gather information on the effectiveness of training provided to mobile medical team members.
Management Actions Taken
During the audit, we notified officials from the Joint Staff, Defense Health Agency and subordinate organizations, the Military Department medical training commands, USINDOPACOM, and USAFRICOM of our concerns related to the effectiveness of surgical and tactical training. All organizations agreed with our finding and recommendations and either initiated or continued ongoing corrective actions to address some of our concerns and the requirements of the FY 2017 NDAA. During the audit, JTS and JTET Branch officials stated that they had identified areas for improvement in trauma care through communication with combatant command medical personnel and the Defense Committee on Tactical Combat Casualty Care. As of October 2019, the JTET Branch had identified five standardized medical training courses that should continue to be offered and planned to develop three more. In addition, JTS PI Branch officials stated that they are working to standardize AAR template completion and submission to ensure comparable information is collected across the Services.
Management Comments and Our Response
As a result of management comments, we revised a recommendation to clarify that curriculums at Military medical training commands should be updated to ensure tactical training is provided to mobile medical teams to prepare for operations in an austere environment to ensure standardization above the unit level. While coordination with geographic combatant commands on theater specific requirements and unit level tactical training is a best practice, we believe that a portion of tactical training should be the responsibility of the Service Surgeons General, in coordination with the Military medical training commands.
The JTS Chief of Strategic Plans and Operations/Military-Civilian Partnerships agreed with our recommendation to implement standardized medical training, stating that the JTS, JTET Branch, and JTS PI Branch would work to establish baseline training standards, formulate Clinical Practice Guidelines, and serve as a basis for Joint Knowledge, Skills, and Abilities. The Chief also stated that the JTET Branch is not currently resourced or manned to meet the recommendation. We will close the recommendation once we verify that the information provided and actions taken by the JTET Branch fully address the recommendation.
The Army Surgeon General Chief of Staff and the Navy Bureau of Medicine and Surgery Executive Director agreed with our recommendation to issue guidance implementing the JTET Branch standardized training program for all mobile medical teams. The Air Force Deputy Surgeon General partially agreed with our recommendation to issue guidance implementing the JTET Branch standardized training program for all mobile medical teams. However, the comments provided did not address the specifics of the recommendation; therefore, the recommendation is unresolved. We ask that the Air Force Surgeon General provide comments in response to the final report, identifying specific actions to ensure the implementation of the JTET Branch standardized training program.
The Navy Bureau of Medicine and Surgery Executive Director and the Air Force Deputy Surgeon General agreed with our recommendation to update training curriculums for tactical training of mobile medical teams. The Air Force Deputy Surgeon General stated that tactical training to meet Combatant Command theater entry requirements is not specific to mobile medical teams or to medical training, and that the Air Force Medical Service provides training to all personnel tasked to deploy within a given theater of operations in accordance to theater requirements. Comments from the Deputy Surgeon General did not address the specifics of the recommendation; therefore, the recommendation is unresolved. The intent of our recommendation is to address areas for improvements to tactical training the Air Force is already providing. We ask that the Air Force Surgeon General provide additional comments in response to the final report, identifying specific actions taken to update tactical training provided to mobile medical teams at Military medical training commands.
The Army Deputy Surgeon General disagreed with the recommendation, stating that the Surgeon General is not the proponent for updating training relating to tactical readiness, and that Army unit commanders should update relevant tactical readiness training. We disagree with the Army Deputy Surgeon General’s response. The intent of our recommendation is a cross-service effort to ensure standardized training and leveraging of best practices for the improvement of additional tactical training provided as part of the Military medical training commands’ programs. Therefore, this recommendation is unresolved, and we request that the Army Surgeon General provide comments on the final report to reconsider updating tactical training curriculums for mobile medical teams provided at the Military medical training command level.
The JTS PI Branch Lead agreed with the recommendation to develop a standardized post-deployment AAR template to gather information on the effectiveness of mobile medical team training.
The Navy Bureau of Medicine and Surgery Executive Director and the Air Force Deputy Surgeon General agreed with the recommendation to implement the JTS PI Branch AAR template; however, comments from the Deputy Surgeon General did not address the specifics of the recommendation, stating that post deployment AARs and lessons learned are already required. The intent of our recommendation is that the JTS standardized post-deployment AAR template be used to collect mobile medical team specific information for submission to Joint Lessons Learned Information System.
The Army Surgeon General Chief of Staff disagreed with the recommendation, stating that the Surgeon General cannot implement the recommendation because Army Regulation 11-33 mandates the process used by Army units, including mobile medical teams. We acknowledge the applicability of Army Regulation 11-33; however, the intent of our recommendation is that mobile medical teams complete the JTS PI Branch Joint standardized AAR form. Once issued, this form will be a new requirement that is not Service-specific nor currently addressed in Army guidance. Therefore, the recommendation is unresolved, and we ask that the Army and Air Force Surgeons General provide additional comments in response to the final report, identifying specific actions to ensure the use of JTS PI standardized post-deployment AARs specific to mobile medical teams.
Originally, the Draft Report included a recommendation stating that the Joint Staff Surgeon should coordinate with the Command Surgeon from each geographic combatant command to define mobile medical team tactical theater entry requirements. The Joint Staff Surgeon General provided comments and cited a Secretary of Defense memorandum, dated December 19, 2019, that stated, “Effective immediately, the planning and conduct of pre-deployment training for service members and units, a statutory function of the Military Departments as Force Providers, shall be the responsibility of the Military Departments, executed in consultation with the respective Geographic Combatant Commanders.” As a result, the Joint Staff Surgeon and the geographic combatant commanders are not responsible for defining any pre-deployment training requirements and the recommendation was no longer applicable; therefore, we removed the recommendation from the report.
This report is the result of Proj. No. D2019-D000RJ-0143.000