DTIC ADA519175: Skill Set Requirements for Nurses Deployed with an Expeditionary Medical Unit Based on Lessons Learned

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by  Defense Technical Information Center

CritCareNursClinNAm20(2008)13–22
Skill Set Requirements for Nurses Deployed
with an Expeditionary Medical Unit Based
on Lessons Learned
John J. Whitcomb, PhD, RN, CCRN, CDR, NC, USNa,*,
Kimberly J. Newell, RN, MSN, CCRN, CNS, CDR, NC, USNb
aNavalMedicalCenterPortsmouth,620JohnPaulJonesCircle,
Portsmouth,VA23708,USA
bNavalHospitalCampPendleton,Box555191,CampPendleton,CA92055,USA
Based in Kuwait 3 years apart, the authors Camp Coyote,Kuwait,2003
recount how nurses and corps staff, along with
In February 2003, the 1st Force Service Sup-
their physician counterparts, came together to
portGroup(FSSG),4thHealthServicesBattalion
form well-run medical facilities under adverse
(HSB)wasactivatedinsupportofOperationIraqi
circumstances. Their respective hospitals became
Freedom. Active-duty health care professionals
competent organizations because of specific
and mobilized reservists with various health care
formulas for success, along with preparation,
backgrounds combined forces to form a cohesive
identification of required skill sets, and making
combat-support hospital located approximately
improvements based on experience. This article
30 miles from the Iraq border, at Camp Coyote
describes the training of medical, nursing, and
in Kuwait. This unit, the 4th HSB, was designed
corpsstaff,thefacilitiesandresourcesrequiredfor
to deploy to an area of conflict where it would
managing casualties, and some of the more
receiveandtreatwarcausalities.Regardlessofthe
commonly encountered combat injuries and
mission, and although segments of the support
conditions.
grouphadyettoarrive,thisadvanced-partyteam
had the means and ‘‘can-do spirit’’ that allowed
themtobereadytoreceivecasualtieswithindays
of itsarrival inKuwait.
The views expressed in this article are those of the Brief historical review
authors and do not reflect the official policy of
the Department of Navy, Department of Defense, nor On the same ground where Desert Storm
the US Government. The authors are military service occurred, the 4th HSB was set up to provide
members.Thisworkwaspreparedaspartoftheiroffi- emergency resuscitation and definitive surgery,
cial duties. Title 17 U.S.C. 105 provides that saving lifeand limb, andto offer general medical
‘‘Copyright protection under this title is not available care under field and combat conditions. Medical
for any work of the United States Government.’’ Title specialtiesthatdeployedwiththe4thHSBincluded
17 U.S.C. 101 defines a United States Government
trauma,thoracicsurgery,orthopedicsurgery,psy-
workasaworkpreparedbyamilitaryservicemember
chiatry, ophthalmology, general surgery, internal
or employee of the United States Government as part
medicine, and family practice. The nursing staff
ofthatperson’sofficialduties.
specialtiesincludedcriticalcare,obstetric/gyneco-
* Correspondingauthor.
E-mailaddress:[email protected] logic,pediatric,andmedical-surgicalnurses,fam-
(J.J.Whitcomb). ily nurse practitioners, and nurse administrators
0899-5885/08/$-seefrontmatter.PublishedbyElsevierInc.
doi:10.1016/j.ccell.2007.10.009 ccnursing.theclinics.com
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1. REPORT DATE 3. DATES COVERED
2008 2. REPORT TYPE 00-00-2008 to 00-00-2008
4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
Skill Set Requirements for Nurses Deployed with an Expeditionary
5b. GRANT NUMBER
Medical Unit Based on Lessons Learned
5c. PROGRAM ELEMENT NUMBER
6. AUTHOR(S) 5d. PROJECT NUMBER
5e. TASK NUMBER
5f. WORK UNIT NUMBER
7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION
Naval Medical Center Portsmouth,620 John Paul Jones REPORT NUMBER
Circle,Portsmouth,VA,23708
9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S)
11. SPONSOR/MONITOR’S REPORT
NUMBER(S)
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14. ABSTRACT

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14 WHITCOMB&NEWELL
with varying degrees of clinical experience. The inamatterofhoursor,ifconditionsdictate,may
HospitalCorpsstaff(composedofenlistedperson- be retained for 24 to 48 hours. The next echelon
nel who perform patient care activities under the (level III)is the combatzone fleethospital orthe
direction of licensed providers) consisted of in- hospitalship.Bothairandgroundtransportation
dividualstrainedasparamedics,generaldutycorps areusedtomoveapatienttothisechelonofcare,as
staff, psychiatric technicians, pharmacy techni- dictated by the tactical situation, the presence or
cians, x-ray technicians, and independent duty absenceofenemyairthreats,and/oroverwhelming
corpsmen. Independent duty corpsmen function troop movements. The final destination for de-
similarly to physician assistants. Support services finitive care is a facility outside the combat area,
includedlaboratory,x-ray,pharmacy,administra- suchasamedicaltreatmentfacility(MTF)inthe
tion,andchaplaincy.Securityfortheentirecamp continental United States [1]. ‘‘MTF’’ is the mili-
wasprovidedbytheMarineCorps. tarytermdesignatingclinics,hospitals,andother
The4thHSBwastaskedtoprovidetheservices healthcarefacilitiesfoundinthecivilianworld.
ofasurgicalhospital(echelonII),receivingcasu- The 4th HSB consisted of a receiving area
altiesfromforwarddeployedunits.Echelonsstart (triage) that led to two operating rooms that
with the simplest care closest to the battle zone adjoined two ICUs, each with a capacity for 12
(levelI),wheresomeonemayputonhisorherown patients. There were three wards, each with the
dressing or have a comrade do so (a procedure ability to hold 30 patients. An outpatient area
known as ‘‘buddy aid’’). If possible, this event is treated injuries that did not need inpatient care.
followed by a trip to the Battalion Aid Station, The facility offered services including radiology,
Forward Resuscitation Surgical Support unit, or abloodbank,asmalllaboratory,andapharmacy.
ShockTraumaPlatoon.Atthesestations,aphysi- Itspurposewastostabilizepatientsandtransport
cian, independent duty corpsman, or nurse pro- themwithin24hourstoahigherechelonlevelof
vides first aid or advanced trauma life support, care inKuwait (Figs. 1–3).
preserving life or limb. Given available transpor-
tationandafavorablebattlefieldscenario,ground
Staff assignment, education, andtraining
transportorBlackhawkhelicoptertransporttrans-
fersthecasualtytoalevelIIfacility,suchasthe4th The Bureau of Naval Personnel assigns mili-
HSB,forstabilization.Thecasualtymaymoveon tary members to specific operational platforms
Fig.1. Triage,CampCoyote,2003.
SKILLSETREQUIREMENTSFORNURSES 15
Fig.2. ICUset-up,CampCoyote,2003.
(ie,hospitalships,fleethospitalsandFSSGunits), Diego, California and Naval Reserve Unit, 4th
withtheirprimarydutystationbeinganMTF[2]. HSB.The4thHSBalsowassupportedbyindivid-
For the 1st FSSG, Navy military personnel are ual augmentees, military members assigned ac-
mobilized from the Naval Medical Center San cording to their clinical specialties and the unit’s
Fig.3. Wardset-up,CampCoyote,2003.
16 WHITCOMB&NEWELL
needs.Totalpersonnelforthisunitconsistedof30 participants to develop and enhance their practi-
nurses, 66 corps staff, and 20 physicians. These cal skills using mannequins and live models. The
numbersincreasedordecreasedbasedonmission sessions enable nurses to become well acquainted
requirements(Fig. 4). withemergencysituationsandexposethemtothe
The Bureau of Navy Medicine and the com- use of the appropriate equipment. Participants
manding officers of the local supporting MTFs learntoassessthepatient,identifylife-threatening
continuallyassess readiness needsand trainmed- emergencies, and identify and prioritize other
ical personnel for their assignments accordingly. injuries. A provider manual reinforces and sup-
Typically, preparation for serving with fleet hos- plements lectures and lessons in psychomotor
pitals,FSSGs,andothergroundunitsconsistsof skills. Each aspect of trauma is discussed using
fieldtrainingwiththeMarinesinasettingsimilar common basic themes: etiology, mechanism of
to the actual austere environments to which injury and concurrent injuries, anatomy and
trainees will or may deploy. While serving with physiology, pathophysiology (as a basis for key
the Fleet Marine Force, hospital corps staff train signs and symptoms), nursing care, patient edu-
to care for the warfighter on the battlefield. cation, and triage. Following completion of the
Physiciansandnursesattendcoursesthatprepare course, both theoretical and practical knowledge
them to care for trauma patients. The Trauma are assessed formally by written and practical
Nursing Core Course (TNCC) is offered at the examination.
three main Navy MTFs and is required for all Physicians attend the Advanced Trauma Life
Navynurses. SupportCourse,whichteachesthemtoassessthe
The TNCC is a fundamental course that patient’s condition rapidly and accurately, to
enhancescognitiveskills,sharpenstechnicalskills, resuscitate and stabilize the patient according to
and provides a foundation for future learning to priority,todetermineifthepatient’sneedsexceed
nurses actively involved in caring for injured a facility’s capabilities, to arrange appropriately
patients. The TNCC is presented in lectures and forthepatient’sdefinitivecare,andtoensurethat
in six psychomotor-skill stations. The focus is on optimal care is provided. Another course that is
airwaymanagement,spinalimmobilization,initial available, developed by the Society of Critical
assessment, multiple trauma intervention, and Care Medicine, is the Fundamentals of Critical
splinting. These foundational sessions allow Care Course. This 2-day course is designed for
Fig.4. NurseCorpsstaff,CampCoyote,2003.
SKILLSETREQUIREMENTSFORNURSES 17
nurses and physicians who are not intensivists in
critical care. It offers skills stations, lectures, and
guidance for decision making during the initial
hoursof management ofcritically ill patients.
Assessment ofpersonnel
Because providers have different backgrounds
andexperience,theyareassessedbythe4thHSB
leadershipteamtodeterminehowbesttousetheir
skills and to determine who needs training in
specificassessmentandskillsets.Thefirstauthor
was named the unit’s Director for Nursing Care.
He managed the clinical aspects of nursing care.
Anotherseniornursemanagedtheadministrative
nursingfunctions.TheDirectorforNursingCare
divided the nursing personnel into four groups,
each containing at least two critical care nurses
andcorpsstafftrained inthe Fleet Marine Force
or as paramedics. Personnel then were placed in
groups based on level of expertise to ensure that
no one team had all the expertise. A team leader
was identified to orient, train, and manage per-
sonnelin patientcare. Thistraining hadto occur Fig.5. Multidisciplinaryrounds,CampCoyote,2003.
within a few days of arrival because of the
imminent influx of causalities. This team ap-
health care professionals who treat patients with
proach proved highly successful, because those
combat trauma.
whohadnotraumaorcriticalcareexperiencefelt
supported by being grouped with those who had
experience (Fig. 5).
Posttraumatic stressdisorder
In preparation for the receipt of patients, the
Director for Nursing Care and his team leaders PTSD is commonly associated with soldiers
provided personnel with refresher training, using plaguedbyhorrificmemoriesofbattle.Itcanalso
the TNCC curriculum coupled with the team befoundamongthosewhotreatinjuredsoldiers.
leaders’ past experiences. They ‘‘got back to the Experiencing or witnessing a frightening event
basics’’ of nursing care. They assembled and that arouses intense feelings of fear, helplessness,
tested medical equipment and held classes to orhorrorsetsthestageforPTSD.Thetraumahas
discuss the plan of action with the threat of air suchastrongimpactthatthevictimcannotshake
orgroundattackandthepossibleuseofchemical the experience and relives the painful emotions
or biologic agents. Most personnel had been associated with it. Sudden flashbacks may occur.
trained previously, to some extent, to respond to Other symptoms include an exaggerated startle
these threats; in the field, however, such threats reflex, sleep disturbances and nightmares, irrita-
were compounded by the intense heat and never- bility, angry outbursts, difficulty concentrating,
ending sand storms, which created a heightened hallucinations, sexual dysfunction, and an inabil-
sense of anxiety. A matter of great concern was itytospeakaboutthetragedy[3].Theaustereen-
that many of these individuals had never wit- vironment and extreme weather conditions in
nessedtraumaorbeeninareal-timecombatzone. Kuwait contributed to provider stress and anxi-
Therefore, discussing possible scenarios was ex- ety, as did the use of equipment that was not as
tremely valuable in providing anticipatory guid- sophisticated as that to which staff were accus-
ance.Encouragingthestafftotalktoandsupport tomed. Temperatures reached well into the
each other also was extremely helpful to them. 110(cid:2)F range, creating concern for personnel
Such discussions were key to the prevention of safety. Extreme temperatures also made running
posttraumatic stress disorder (PTSD) among simple laboratory tests difficult. Sand storms
18 WHITCOMB&NEWELL
ragedwithoutwarning.Discussingthreatsandlis- Expeditionary MedicalFacility Kuwait,2006
tening to staff concerns about the capabilities of
In the 3 years between the first and second
the equipment, the working environment, and
author’sdeployments,theNavy’smedicalsupport
theweatherpreparedthemformanyeventualities
in the Kuwaiti theater of operations transitioned
and helped them cope with anxiety. Staff were
from an echelon II to an echelon III facility and
encouraged to have open discussions among
was relocated from the northern part of the
themselves and to support one another, an effec-
country to the southern part. Like the Camp
tive strategy that was used many times during
Coyotefacilityin2003,DetachmentBofExpedi-
thisdeployment.
tionaryMedicalFacility(EMF)KuwaitinCamp
Arifjanin2006wasameltingpotforbothNurse
Patientcareandlessons learned
Corps officers and Hospital Corps staff. The 40
On April 15, 2003, the 4th HSB began re- nursing staff members assigned to the Inpatient
ceivingcasualtiescausedbyheatexposure,explo- Nursing Department deployed from 12 MTFs,
sive devices, gunshots, and motor vehicle including ambulatory clinics, small and medium-
accidents. The providers at Camp Coyote also sizedcommunityhospitals,andlargetertiary-care
were responsible for treating illnesses unique to teachingfacilities.Withinthesefacilities,staffhad
the country and for attending to the day-to-day performed various functions and represented
medicalneedsofthetroops.Inall,fromApril15 assorted clinical services: administrative, bedside
until June 25, the staff treated more than 200 clinician, clinical nurse specialist, and division
casualties. It was amazing to see the staff in officer (unit manager). These individuals came
action, working as a team, mentoring and sup- from dental,medical/surgical,maternal/child,pe-
porting one another day and night. Each in- diatric,emergencyroom,intensivecare,andpost-
dividual knew that he or she could call on anesthesiacareenvironments.Althoughfewknew
a fellow shipmate in time of need. The formula each otherbeforecoming togetheras afullEMF
for success included the staff’s positive, ‘‘can-do’’ detachmentinMarch2006,thediversegroup,like
attitudeandtheirstrongnursingeducationinthe the4thHSB,quicklybecameacohesiveunitthat
areas of trauma management and critical think- learned to capitalize on one another’s strengths
ing. Past experience and key concepts from the (Fig. 6).
TNCCandadvancedcardiaclifesupportcourses The first of two waves of medical personnel
also prepared the nurses for their wartime arrivedinlateFebruary2006andreceivedturnover
experience. informationfromtheoutgoingdetachment.Three
Navy Nurse Corps officers led by example. weeks later, the second wave arrived and turned
They never asked a lower-ranking officer or over with the remainder of the outgoing detach-
enlisted person to do anything they would not ment along with the first wave in the EMF’s
do themselves. Selecting the right people for the detachmentdtheir new ‘‘shipmates.’’ With less
right job was highly effective, because those with than2weeksoforientationandturnover,thegroup
more experience provided education and leader- assumedthereinsofafour-bedcasualty-receiving
ship and knew when it was appropriate to in- (CASREC)unit,afour-bedICU,and24medical/
tervene or support other team members. Finally, surgicalbedsthatcouldbeexpandedtoatotalof
thenursingleadershipofthe4thHSBplannedfor 44bedsforamass-casualtysituation.Thesecond
the worst-case scenarios, and this planning pre- authorwasassignedasheadofthe40staffmembers
paredthemtoberesilientandflexiblethroughout and44bedsoftheInpatientNursingDepartment.
the deployment. Personnel understood that plans Staffweredividedintofourteams,eachconsisting
couldchangeatamoment’snotice.Theterm‘‘day offournursesandfivecorpsstaff.Tocapitalizeon
off’’ did not apply. When casualties arrived, nurses’advancedknowledgeandskills,onenurse
everyone joinedin to supportthoseon duty. whohademergencyexperienceandonenursewho
Lessons learned were that more real-time hadintensivecareexperiencewereassignedtoeach
hands-on training would be desirable in future team. Low numbers of ICU patients at the time
deployments. Also prior training on the equip- provided an opportunity for the staff to expand
ment to be used in the field, along with gaining theirknowledgeandskillsbyrotatingbetweenthe
experience at civilian trauma centers, would three clinical areas. Teams spent 2 weeks on the
greatly benefit those who had never treated wardand2weeksinCASREC.Theythenreturned
atrauma patient. tothewardfor2weeks,afterwhichtheyworkedin
SKILLSETREQUIREMENTSFORNURSES 19
Fig.6. CasualtyReceiving,USMilitaryHospital,Kuwait,2006.
theICUfor2weeks.Iftherewerenopatientsinthe Initially,toprovideanopportunityforallstaffto
ICU, the nurse would cross-train in the post- learn a little bit about each other, brief self-
anesthesiacareunitortheoperatingroomorwould introductions were made at a staff meeting. This
serveasanadditionalnurseinCASRECoronthe author and her senior enlisted leader then met
ward,asneeded.Ancillaryservicesincludedlabo- individually with each of the staff members to
ratory, pharmacy, and radiology. Medical and learn more about their personal and clinical
dental specialties available during the 6-month backgrounds, strengths, and goals for the
rotation included anesthesia, general surgery, 6-month deployment. She then developed and
gynecology,orthopedics,internalmedicine,cardi- conductedaneducationalneedsassessmentbased
ology,gastroenterology,infectiousdisease,pulmo- on the current and future conditions for the
nology, pediatrics, psychiatry, dentistry, and oral expected patient population.
surgery. Gastroenterologists, infectious disease To assess the educational needs of the staff
specialists, and pediatricians were deployed as properly, it was important to determine the
general internists, but their respective specialty expected patient population for the next 6
skillsprovedtobequiteuseful. months. A review of the admission International
As noted in Fig. 7, the main hospital building ClassificationofDiseases(edition9)codesforthe
consisted of five interconnecting sets of modular prior months of February and March revealed
tentsplacedparalleltooneanother.Onemainper- that chest pain, appendicitis/status-post appen-
pendicularpassagewaythroughthecenterofeach dectomy, hernia/status-post hernia repair, and
tentconnectedneighboringtentswithoneanother. cellulitis were the top four admission diagnoses.
Additional tents housed administration, commu- Realizing that the knowledge and skill levels of
nications,supplies,thearmory,andoperations. thestaffwerevariedandthattherewasapotential
forreceivinghigh-acuitypatients,sheassessedthe
need for staff training to care for these possible
high-volume or high-risk diagnoses. She also
Assessment ofpersonnel
assessed equipment-training needs for these
The second author rapidly realized that an higher-acuity conditions.
assessment of the knowledge and skill of the Areviewoftheresultsfromastaffeducational
recently arrived new personnel was required. needs survey revealed that they had little to no
This assessment was accomplished in three ways. knowledgeorexperiencecaringforcriticallyillor
20 WHITCOMB&NEWELL
Fig.7. ExpeditionaryMedicalFacility,Kuwait,2006.
critically injured patients or in using the equip- herniarepair,andventilatorconcepts(eg,modes,
ment seen in a fleet hospital ICU. Working with settings, weaning). Incidentally, the Alaris Med-
a fellow clinical nurse specialist, a training plan System III infusionpumpis the onlyintravenous
was developed that included a combination of infusion pump authorized for use in the military
hour-long continuing education lectures, 10- to aeromedical evacuation system, but few Navy
15-minute in-services, skills laboratories, and MTFs use this particular model as the primary
a plan to perform an educational needs postas- pump for intravenous fluid infusion; therefore,
sessment toward the end of the 6-month deploy- in-services on this piece of equipment were
ment. On average, one nursing continuing needed. As stated previously, cellulitis and her-
education lecture and one or two in-services nia/status-post hernia repair were two of the top
were scheduled each week, in addition to a total three admission diagnoses during February and
of six skills laboratories specifically targeting the March,andthistrendcontinuedthroughSeptem-
topics with the lowest mean knowledge and/or ber.Therefore,theincreaseinknowledgedirectly
experience scores. reflects the experience acquired with this patient
Several months later, the same educational population during this deployment. Although
needssurveywasredistributedforpostassessment the EMF only had one patient who required me-
purposes. A review of the results revealed the chanical ventilation, this was the topic of one of
itemswiththelowestincreaseinknowledgefrom the continuing education lectures provided by
the pre- to the postassessment were care of the the pulmonologist, who also was certified as an
patientincardiorespiratoryarrestandcareofthe intensivist.
pulmonary/respiratorypatient,probablybecause, Items with the lowest increase in experience
throughout the 6-month deployment, only one from the pre- to the postassessment were intuba-
patient required cardiopulmonary resuscitation, tion/extubation assistance and cardioversion.
and only a few had reactive airway disease or Throughout thedeployment,onlyonepatient re-
pneumonia. Items with the highest increase in quiredintubation.Becauseitwasexpectedthatthe
knowledge from the pre- to the post-assessment staffwouldcareforpatientsrequiringintubation/
were use of the Alaris MedSystem III infusion extubation,however,traumaairwaymanagement
pump (Cardinal Health, Dublin, Ohio), cellulitis, wasoneofthecontinuingeducationlecturespro-
careofthepatientwithwounds,hernias/status-post videdbyoneoftheEMF’snurseanesthetists.
SKILLSETREQUIREMENTSFORNURSES 21
Items with the highest increase in experience ofthenursesshouldbecertifiedinbothadvanced
from the pre- to the postassessment were hernia/ cardiac life support and TNCC. Because of the
status-post hernia repair, use of the Welch Allyn operational tempo and the determination to de-
Propaq Monitor (Welch Allyn, Beaverton, Ore- ploy everyone once before any one person was
gon),nephrolithiasis,andcareofthepostoperative required to return for a second deployment,
patient. Because of its portability and air-worthi- recommendations regarding clinical experience
ness(ie,itscapabilitytofunctionduringairtrans- could not always be met. In this case, any
port), the Welch Allyn Propaq Monitor is the exposure to medical, surgical, mental health,
cardiacmonitoringsystemfoundinthefleethospi- intensive care, or emergency nursing that can be
talsystem.TheEMFuseditintheICUandduring obtained beforedeployment is beneficial.
ground and aeromedical evacuation. Because of
the absence of a central monitoring system, and
in lieu of telemetry monitoring, it also was used
Summary
on the ward for patients requiring cardiac moni-
toring. Like the Alaris MedSystem III, few Navy The authors, in describing their respective
MTFsusethisequipmentastheprimarymodeof experiences in Kuwait, have shown that recogni-
cardiacmonitoring.Althoughdataareunavailable tion of required skills and appropriate education
at this time regarding the number of patients ad- provided before deployment is vital to the suc-
mitted with nephrolithiasis, it is estimated that cessful operation of echelon II and III medical
two to four patients per month were admitted facilities. In addition, they demonstrate that the
withthisdiagnosis.Aswithchangesinknowledge, experience gained and the training provided
changesinexperiencedirectlyreflectedthepatient during deployment are essential for optimal out-
populationservedduringthedeployment. comes in current and future missions. Because of
Some would view this 6-month experience as changes in stability of the area, a better geo-
agroupofindividualsintherightplaceattheright graphic location within Kuwait, a less-acute
time;otherswouldviewthissamegroupasbeingin patient load in general, and improved medical
thewrongplaceatthewrongtime.Asitturnsout, equipment in the Kuwaiti theater of operations,
theaveragepatientcaredforbyDetachmentBof the 2006 mission was able to assess needs
EMF Kuwait was low acuity, primarily because systematically, provide formal training, and eval-
thelocationwastoofarawayfromthe‘‘front-line’’ uate the success or failure of that training more
toreceivecombatcasualties.ThislevelIIIfacility easily than could their colleagues from earlier
in southern Kuwait provided garrison-level care deployments.
but also was a receiving facility for patients Despite their different circumstances, the au-
requiring specialty services from throughout the thors took advantage of every possible opportu-
Persian Gulf region. This low-acuity population nity to prepare, train, and support their staff
wasnotthecaseforDetachmentB’spredecessorsd membersbyexpandingtheirknowledgeandskills
Detachment Ador successorsdDetachment Cd toprovidethebestpossiblecaretothosewarriors
who experienced at least one mass-casualty event entrusted totheir carewhile stillin theater.
ofhigher-acuitypatientsduringeachdeployment.
A forward-deployed level III facility, such as
Acknowledgments
this EMF, would expect to care for more and
higher-acuity patients than the second author’s TheauthorswishtoacknowledgeJuneBrock-
detachment did during this particular 6-month man, Medical Editor, Naval Medical Center,
deployment. Portsmouth, Virginia, for her contributions in
Ideally, in planning for the staffing of these thepreparationofthisarticle.CDRNewellwould
facilities,25%oftheinpatientnursingdepartment like to acknowledge and thank CAPT Kriste
staff should have at least 1 year of emergency Grau,NC,USNandallthenursesandcorpsmen
nursing experience, 25% should have at least of the Inpatient Nursing Department who em-
1 year of ICU experience, and the remaining braced coming together in an austere environ-
50% should have a combination of medical, ment, who never backed down from a challenge,
surgical, and/or psychiatric experience. Because and who made the deployment as enjoyable as it
staff are rotated through all clinical areas, and was. Finally, they both thank their spouses and
because a primary responsibility of Navy Nurse families for their unwavering support during the
Corpsofficersistotraincorpsstaff,atleast75% deployments.