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Chapter 27 MILITARY MEDICAL OPERATIONS in MOUNTAIN ENVIRONMENTS

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Chapter 27 MILITARY MEDICAL OPERATIONS in MOUNTAIN ENVIRONMENTS Medical Aspects of Harsh Environments, Volume 2 Chapter 27 MILITARY MEDICAL OPERATIONS IN MOUNTAIN ENVIRONMENTS † PAUL B. ROCK, DO, PHD*; AND EUGENE J. IWANYK, MD INTRODUCTION ESTIMATING DISEASE AND NONBATTLE INJURY AND PERFORMANCE DECREMENTS Disease and Nonbattle Injury Performance Decrements HEALTH MAINTENANCE Prevention of Environmental Injury and Illness Treatment of Environmental Injury and Illness DEPLOYMENT OF MEDICAL SUPPORT ASSETS Environmental Effects on Medical Support General Principles for Deployment of Medical Assets SUMMARY *Colonel, Medical Corps, US Army (Ret); Associate Professor of Medicine, Center for Aerospace and Hyperbaric Medicine, Oklahoma State University Center for the Health Sciences, Tulsa, Oklahoma 74132; formerly, US Army Research Institute of Environmental Medicine, Natick, Massachusetts 01760 †Lieutenant Colonel, Medical Corps, US Army (Ret); Ellis Eye and Laser Medical Center, El Cerrito, California 94530 854 Military Medical Operations in Mountain Environments INTRODUCTION One of the fundamental challenges faced by medi- •providing a health maintenance program to cal personnel supporting military units deployed in (a) prevent environmental medical prob- mountain regions is to deal with the effects of the en- lems and (b) treat them effectively when vironment on the health service support mission. they occur; and Mountain environments have an impact on virtually • managing the field medical support assets all aspects of the mission. On one hand, mountains to allow efficient treatment and return to add to the spectrum of disease and injury that nor- duty or evacuation of casualties. mally occurs during military operations. Indeed, in the absence of combat, environmental injuries are the In this general formulation, the mission is appli- biggest source of casualties that reduce unit fighting cable to most organizational levels of medical sup- strength. On the other hand, they affect the health port to most tactical units. service support system itself, constraining the options The information presented here is organized for prevention or treatment of casualties. Factors in around the simple formulation of the health service the mountain environment degrade the performance support mission stated above. The first section of of medical personnel and equipment and limit the this chapter reviews the potential impact of moun- ways in which medical assets can be deployed. If the tain environments on military units and counter- effects of mountain environments are not anticipated measures that can be recommended to lessen envi- and successfully avoided or abated, the health sup- ronmental effects. The next section discusses health port mission, and with it possibly the tactical mission, maintenance in units deployed to high altitude. The will be jeopardized. final section deals with the effect of the mountain The purpose of this chapter is to provide infor- environment on the medical support system itself. mation that will help medical personnel success- The considerations underlying the concepts pre- fully manage the impact of mountain environments sented are based on providing support to “tradi- on the health service support mission. In its sim- tional” ground combat units such as infantry, light plest form, that mission is to conserve the fighting infantry, armor, and cavalry units. Although many strength of the tactical unit by of the general concepts are relevant to other types of military units, including special operations units, • advising the unit commander about the po- the unique aspects of medical support of special tential impact of the environment on unit operations are discussed in Chapter 37, Medical personnel and operations, and recommend- Support of Special Operations, and Chapter 38, Or- ing means, countermeasures, or both to ganizational, Psychological, and Training Aspects lessen that impact; of Special Operations Forces of this textbook. ESTIMATING DISEASE AND NONBATTLE INJURY AND PERFORMANCE DECREMENTS Military leaders need good estimates to plan ef- ronments on unit strength and performance ideally fectively for their unit’s mission. Combat leaders would be based on experience, in the same way as need estimates of the unit’s fighting strength (man- the most useful estimates of battle casualty rates power) and performance capabilities in the envi- are derived from “experience tables” based on data ronment in which the unit will operate. In the from previous battles. Unfortunately, there are few mountains, they need estimates of the extent to useful data about medical problems available from which the mountain environment itself will degrade the mountain warfare experience. For instance, al- unit strength (ie, disease and nonbattle injury though Houston’s excellent review of the effects of [DNBI]) and performance over time. Medical sup- the environment on past military campaigns in the port personnel need estimates of the number of ca- mountain regions of Europe and Asia (Chapter 20, sualties so that they can plan for the care of those Selected Military Operations in Mountain Environ- casualties. In the mountains, they need estimates ments: Some Medical Aspects) graphically illus- of the effects of the mountain environment on man- trates the deleterious impact that mountains can power and performance to accurately brief the com- have (eg, what commander today would want to bat commander, guide health maintenance activi- suffer the nearly 50% reduction in force that ties, and allocate the medical support resources. Hannibal experienced while crossing the Alps), Useful estimates of the effects of mountain envi- much of that historical information is not particu- 855 Medical Aspects of Harsh Environments, Volume 2 larly applicable to current military operations, ow- are not necessarily related to hypoxia (eg, increased ing to differences in equipment, transportation, and chance of lightning injury, decreased chance of medical technology. Similarly, the information on mosquito-borne diseases). Experience tables for combat injuries from previous battles with swords DNBI are available for the United States6 and most and shields is not especially applicable to the other military forces. Estimates of DNBI for tem- present-day battlefield, with its high-velocity bal- perate climate operations are a reasonable starting listic weapons. Of the conflicts that took place in point for altitudes from 1,500 to 4,000 m because the mountains during the 20th century and, there- the climate conditions at those elevations are fairly fore, might be more applicable, the only readily similar. Estimates for arctic regions may be a better available data on environmental casualties are from baseline for mountain regions above 4,000 m eleva- the Sino–Indian border conflict (1962–1963).1 Ad- tion, where increasingly cold ambient temperatures ditionally, some data are also available from stud- prevail. ies of military training activities in the mountains,2–5 Considerations for estimating the additional ef- but the information is based on limited numbers of fect of altitude on incidence of hypoxia-related and individuals. other environmental injuries are drawn from the Even in the absence of extensive experience- military and civilian experience in the mountains. based data, medical personnel can make reasonable Reports from civilian experience are mostly related estimates of the effects of mountain environments to recreational activity, however. Because tactical on unit strength and performance by combining some considerations dictate the timing, duration, and lo- general concepts with extrapolations of the limited cation of environmental exposure during military data available. Estimates are, after all, estimates. operations, civilian recreational exposure is not Considerations for making reasonable estimates of DNBI and performance decrements for mountain terrain are presented below. EXHIBIT 27-1 Disease and Nonbattle Injury HEALTH THREATS TO MILITARY The major components of DNBI in high mountain PERSONNEL FROM MOUNTAIN terrain are listed in Exhibit 27-1 and extensively dis- ENVIRONMENTS cussed in Chapters 24, 25, and 26, which deal with acute mountain sickness (AMS), high-altitude cere- Hypoxia Related bral edema (HACE), high-altitude pulmonary edema Acute mountain sickness (AMS) (HAPE), and other edematous and nonedematous High-altitude cerebral edema (HACE) illnesses. They include conditions that are caused by the hypobaric hypoxia that is characteristic of High-altitude pulmonary edema (HAPE) high-altitude and conditions related to other environ- High-altitude peripheral edema mental factors. That both hypoxia and other envi- High-altitude eye problems ronmental factors play a role during military opera- Sleep problems with sleep deprivation tions in the mountains was strikingly demonstrated Thromboembolism during a training exercise at 3,600 to 4,000 m alti- Exacerbation of preexisting disease tude in the Colorado mountains.3 The number of High-altitude pharyngitis/bronchitis soldiers evacuated during 5 days of mountain op- erations was more than 10-fold that for the same Performance decrements unit doing the same maneuvers for the same Not Related to Hypoxia amount of time in North Carolina. The casualties Trauma at altitude were caused by AMS and HAPE, both Thermal injury (especially cold injury) related to hypobaric hypoxia; traumatic and over- Ultraviolet (UV-A, UV-B) radiation energy use injuries, related to the rugged topography; and one fatality and five injuries from a lightning strike. Lightning
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