J R Army Med Corps 2001; 147: 161-167

Organisation and design of regular field

MCM Bricknell

ABSTRACT who will probably survive further The organisation and design of field evacuation (with appropriate sustaining hospitals within the British Army has treatment) to rear hospitals so that they been under review since the . may concentrate their efforts on This paper discusses principles for the providing primary surgery to ensure that organisation and design of field all seriously injured casualties who would hospitals and makes suggestions for otherwise die are operated upon in the further development. The paper forward within 4 hours: describes the deployment of field c. capable of sustaining themselves in the hospitals from a 25 bed hospital troop up field. to a 200 bed . The proposals contained in this paper Key words: military, hospitals, design. must be seen as separate from the grouping of Field Surgical Teams within Medical Introduction Regiments at Role 2. This capability is The organisation and design of field designed to meet the 2 hour clinical timeline hospitals within the British Army has been for resuscitative surgery, and is only viable under review since the Strategic Defence when supported by a Role 3 facility located Review. A comprehensive study of the elsewhere in the CASEVAC chain to meet requirements for land based medical units the 4 hour rule. behind the divisional rear boundary in a The function of field hospitals in the theatre of operations has been conducted by Nuclear Biological and Chemical (NBC) HQ LAND command. This has led to a environment has also been under review. careful examination of the function and This led to the procurement of equipment organisation of field hospitals.The aim of this specifically designed to meet such a threat. paper is to describe principles for the Although much of the developmental work structure and design of deployable military has also informed the requirement for the hospitals in order to inform the readership of field hospital operating in a non-NBC this Journal of current developments within environment, this paper will not specifically the regular field hospitals.The content of this consider NBC issues. paper has been endorsed by the chain of Ideally, field hospitals should be sited in command.The concepts described may have buildings with existing infrastructure utility for field hospitals within the Territorial services. However it has been stated that Army but these units are not yet resourced to regular field hospitals must be able to deliver the capabilities described. activate at full capability on a ‘green field’ site. This is the greatest challenge for field Scope hospitals. Detailed pre-planning is required The proposals contained in this paper are to ensure effective use of external logistic based on the current establishment of regular support (eg. engineers, pioneers, mobile bath field hospitals(1). This paper does not and laundry units). It has been agreed that examine field hospital structures beyond 200 templates for field hospital shelter systems bed capability. Theatre or Role 4 level should be created in order to ensure that the capabilities will not be considered. The Unit Equipment Table (UET) supports such capabilities listed in the HQ LAND Study deployment and to practice the logistic planning process. The field experience of all Lt Col MCM Bricknell are considered to be the requirement for DM MMed SciMFOM regular field hospitals. A regular field hospital 3 regular field hospitals during 2000 has MFPHM MRCGP is to be: been reviewed in order to produce this paper. DMCC DRCOG a. capable of deploying, and redeploying, in DFFP RAMC order to conform to the supported Basic Principles Commanding Officer division during manoeuvre warfare and General Design. The overall design of the 22 Field Hospital able to function in a relatively adverse field hospital site should include the Thornhill Barracks military environment. They must be following 4 functional components: clinical Gallwey Road capable of operating on a ‘green field’ site, services, command, administrative support Aldershot GU11 2DF and be modular to facilitate Task and accommodation. The size of these Organisation into smaller or larger components clearly depends on the overall Email: hospitals. capability of the complex. A schematic for [email protected] b. capable of identifying those casualties the site design of a field hospital is shown at 162 Organisation & design of regular field hospitals

Fig 1. Schematic Field Hospital site.

Figure 1. If buildings or hard standing are command group to function as a guard tent. available, this should be adapted to Regimental Headquarters (RHQ). accommodate the field hospital. The designs The RHQ has to be capable of managing a contained in this paper assume the worst ‘medical group’ and/or a full 200 bed field case scenario of a flat green field site. hospital. Thus the RHQ is a large Scales of Deployment. Field hospitals organisation which includes the Regimental are equipped with 2 communications Administrative Office and Medical Records vehicles for operational deployment. This Office functions. It is scaled for DRASH in communications equipment allows field order to provide a robust environment hospitals to be sub-divided into a maximum suitable for 24 hour working with sensitive of 2 components: a main body (max 150 IT equipment.The RHQ is separate from the beds) and a single sub-unit (max 50 beds). clinical complex in order to avoid micro- The ‘common user departments’ (A+E management by the command team. The complex, Evacuation and Support Sqn) all design for RHQ is shown at Figure 2. have a critical mass below which there is Squadron Headquarters (SHQ). The either a disproportional decrease in SHQ is a small command and capability or the equipment reduction is communications (C2) node that commands illogical (e.g. removing a bay in resuscitation the Hospital Squadron. It should work to a when there is space available in the allocated medical RHQ. This can be based on a single shelter). The basic division of these areas communications vehicle attached to a should be divided on a 75%/25% template. DRASH No 2. Where the Medical Equipment Table (MET) Administrative Support. Administrative provides for 3 modules (e.g. X-ray and support to the field hospital consists of the laboratory) then these should be divided in following functions: Quartermasters 66%/33% split. It is axiomatic that UET department, Medical Stores Section, Motor scales and the MET must be designed to Transport Section (including Light Aid support the same modular capabilities. Detachment), Catering Section, Medical and Command. There are 2 scales of Dental Support Section and Artisan Section command: Regimental Headquarters (Royal Engineer carpenter, electricians and (RHQ) and a single Squadron Headquarters plumber). These are scaled on a 150/50 (SHQ). These are based on DRASH as the basis. The designs for administrative support increasing use of computers for HQ require further development and are not functions requires robust protection from the included in this article. weather. A 12x12 tent is included in each Accommodation. The detailed MCM Bricknell 163

have two-way traffic in all but the smallest design and these shelters are too narrow to allow stretchers to pass each other. Therefore the spine should be composed of corridor pairs at above 50 beds of deployment. Unfortunately this creates a 'double apex' which drains water between the corridor pairs which may degrade the floor in the corridors in heavy rain. It might be necessary to add an additional 'vertical' spine at the end of each ward if the load generates congestion in the central spine. The ground occupancy of shelter systems is greater than the internal dimensions because of the necessity for guy lines. Thus it has been found necessary to have double corridors between '4 ways' to ensure sufficient space between lateral shelters. There must be sufficient external Fig 2. Regimental Headquarters. exits to enable convenient access to the complex and rapid exit in the event of fire. accommodation plot can only be planned in Neither the '4 way' nor corridor is provided detail once the organisation and nominal roll with a groundsheet. This risks damage to has been confirmed and the breakdown by the critical thoroughfare in the clinical gender and rank is known. It is probable that complex. The ideal future design for the accommodation will be mixed by rank and spine should be a single, two-way gender at Hospital Troop and Hospital thoroughfare with a robust system for Squadron levels of deployment. protection of the ground and specifically Deployments above this scale may enable designed lateral connections to segregation of accommodation and even departments. separate mess tents. The accommodation Shelter systems. The shelter system has shelters may also be used as overflows for the the greatest influence over the clinical Reception or Ward departments. environment within which medical care is delivered. The main considerations are Clinical Complex temperature control and cleanliness. The The clinical complex comprises 4 functional appearance of the clinical environment is groupings, Accident and Emergency (A+E), also important to reinforce that they, the clinical support, surgical complex, and casualties have been removed from the wards. The following paragraphs discuss key chaos of the battlefield and are now considerations in the design of the clinical safe(3).The current basic shelter system is complex. GS tentage. GS tentage is provided in a Orientation: The majority of field variety of sizes.The most utilised size for the hospital designs are based around a central clinical complex is 18x24ft that can be spine with branches for individual joined to construct 18x48ft, 18x72ft or departments. The design of US Army 18x96ft sized shelters. GS tentage is robust, is based on simple and provides sufficient space for two several patient entry points with the spine as rows of stretchers or beds. GS tentage is a lateral connecting corridor(2). The US difficult to clean and may leak in heavy rain. Army has an electronic Whole Hospital The clinical environment may be improved Information System (WHIS) which can by the addition of white liners. These also achieve multiple, concurrent patient provide insulation and enhance the weather registration. Such a system is not currently resistance of the GS tent. The DRASH available in UK and thus initial patient shelter system is faster to erect, more registration is paper-based. A further weather proof and provides a better clinical consideration is that CASEVAC vehicles environment compared to GS tentage. It is may contain casualties of differing clinical less robust and too narrow for two rows of priority. It may be difficult to ensure the stretchers or beds. An increasing number of offload of casualties at the correct military forces are using containerised department if the hospital does not have a facilities for key components of the hospital single entry point. Therefore it is complex. The design of field hospitals recommended that UK field hospitals should specify the shelter system for each should have a single point of patient entry. department after full consideration of the This naturally leads to a design based on a merits of each system. Field trials have ‘vertical spine’. demonstrated that mobility of the X-ray The Spine. The Spine is currently based equipment is seriously constrained if the on General Service (GS) ‘4 ways’ and groundsheet laid directly onto the ground. ‘corridors’. It is considered mandatory to Every effort should be made to provide a 164 Organisation & design of regular field hospitals

flat surface onto which the ground sheets an ‘Evacuation’ ward close to Reception to may be laid. Finally a sunshade may be save unnecessary carrying of less serious erected over the entire complex to reduce cases through the complex. This is the the transmission of radiant heat into the 'Treatments' area that could also be used as clinical complex. The Improved Tented an overflow for Reception in rush Camp shelter system may provide a suitable periods(5). Historical reports describe the replacement for GS tentage for those function of a pre-operative ward in which departments that can be satisfactorily serious casualties may be assessed by a accommodated in soft-walled shelter surgeon and anaesthetist and resuscitated systems. prior to surgery(6). This function will be Containerisation. Many military undertaken in the resuscitation area of the medical services have procured A+E complex. containerised systems for components of Clinical Support Complex. The term deployable field hospitals.The extent of this ‘Clinical Support Complex’ has been 'containerisation' varies but the operating chosen to encompass the specialist theatres are most common department departments of laboratory, X-ray, affected. Intensive Therapy Units, physiotherapy, dental and psychiatry. These laboratories, imaging suites, and Central departments may be integral to the function Sterile Supplies Departments are also of the field hospital or may be organised as containerised in some Armies. Whilst these assets within a theatre of operations. These may seem ideal systems, detailed are included as separate departments at engineering solutions are required to deliver ‘150 beds’. At ‘50 beds’, the laboratory and an effective interface to soft-walled shelters, X-ray have separate space but power and environmental control, lighting, physiotherapy, dental and psychiatry are not and cold water systems. included in the clinical complex. It is UK is developing containerised facilities recommended that the laboratory and X- called the Mobile Transportable Surgical ray departments should be placed before Facility (MTSF). This will be a major the surgical complex in the 'patient-flow'. enhancement to the ability of the AMS to This enables the services needed by the provide a standard of care as near to most urgent cases to be placed close to the peacetime best practice as practicable(4). resuscitation area of the A+E complex. Once successfully fielded, there will need to Surgical complex. The Surgical be a detailed review of the design of field Complex must provide sufficient space for hospitals. It is suggested that: the functions of anaesthesia, surgery, intensive care (ITU), high dependency care a. When a field hospital deployment (HDU), post-operative recovery, Central requires ISO containers then MTSF will Sterile Supplies Department (CSSD), and normally be included. It may be theatre management. The critical care necessary to deploy a limited Role 3 support should be routinely based on 2 x capability by air and thus at least 1 ITU beds and 2 x HDU beds per surgical surgical team must be configured for table.The containerised systems such as the this. Modular Transportable Surgical Facility b. The ‘resuscitation’ shelter contains 4 (MTSF) equipment must be the shelter bays. These are used: 2 x Intensive system of choice. However the aspired Therapy Unit (ITU) beds and 2 x High scaling of 2 per regular field hospital only Dependancy Unit/recovery beds. The provides space for 2 surgical tables. The resuscitation function occurs within the benefits of DRASH outway the restrictions A+E complex. in space compared to the environmental c. At full scaling the MTSF will replace 2 limitations of current GS tentage for an surgical teams scaled to operate inside operating theatre. Therefore the remaining DRASH.The remainder will still need to 4 general surgical teams and the burns team function using DRASH. should be scaled to work in DRASH tentage. It is recommended that these Clinical Functional Groupings should be scaled as pairs joined by a Accident + Emergency (A+E) Complex. DRASH No 2 shelter. A single ‘light’ scaling This area must include sufficient space for in a DRASH No 6 is required for the final reception & , treatments, resuscitation surgical team to support the Hospital and an evacuation point (for return to duty Troop. It may be necessary to include this (RTD) or evacuation without further 'light' scale with all deployments of MTSF treatment). At the 25 or 50 bed scale of to provide redundancy should the utilities deployment these functions can be module fail. The reverse balance on choice contained in a single 18x72 GS tent. Above of shelter applies to the ITU which should '50 beds' the functions should be contained be placed in GS tents with white liners.The into a T shape of 18x72 GS tents in separate designs shown in the figures will be departments. It should be noted that the amended to include MTSF after the user Casualty Clearing Stations in World War 2 trials have been completed. found it to be greatly advantageous to have Wards. The field hospital has been scaled MCM Bricknell 165

around 25 bed wards. DRASH has been of Arrival Staff Table (DOAST) of a theatre found to be too narrow for 2 rows of entry or theatre activation force. This and thus there is insufficient grouping will compromise the mobility of nursing staff to manage 25 beds laid out in the Role 2 unit and therefore the utility of DRASH tentage. Therefore the wards this grouping may be limited in a war- should be built from GS tents with white fighting senario. The Hosp Tp may be liners. In order to provide sufficient space packed on pallets in order to be air portable. between beds, the ideal size of shelter for a Thus these are light scales based solely on ward is an 18x96, and a 12x12 (for the clinical capability and the Hosp Tp will sluice area). Unfortunately trials by 22 require infrastructure support from host Field Hospital has shown that the metal unit (C2, food, water, accommodation etc). frame cannot sustain the weight of GS It also lacks integral lift and this should be tentage and white liners at 18x96 size. The grouped from another unit for the duration current choice is 18x72 with white liners of deployment if the Role 2 is to retain (with limited but manageable space mobility.The surgical shelter system is based between beds) or 18x96 without. A ‘4 way’ on DRASH.The overall clinical capability of and 2 corridors are included in the Ward the Hosp Tp is: 1 surgical team, 2 ITU and scale to enable a ward to join onto any field 2 HDU/recovery beds, laboratory, X-ray hospital design. Ideally patients should be (including ultrasound) and a 25 bed ward. taken directly from the ward to an This is shown in Figure 3. evacuation vehicle. In periods of high casualty flow it may be necessary to hold 25 Bed Hospital Squadron patients after transfer from beds to (Hosp Sqn) stretchers and therefore an evacuation The Hosp Sqn is designed as an department is required.This should be sited autonomous sub-unit that might be so as to allow an to reverse up to commanded by a RHQ (most probably that the complex and reduce the exposure of the of a Medical Regiment) as part of a medical casualty to the weather. group. It contains the full range of Role 3 clinical functions by reinforcing the Hosp Capability Groupings Tp with an A+E Complex and evacuation The endorsed capability groupings are (at 25% of the Field hospital scaled described below.These generic descriptions capability). It is self-sustaining and is have been supported by detailed plans for capable of establishing at an independent use within units. location. The deployment of the Hosp Sqn is based on ISO containers due to the size of 25 Bed Hospital Troop (Hosp Tp) the support troop required. Therefore The Hosp Tp is designed to operate in MTSF should be utilised as the surgical support of a Role 2 medical unit (Medical shelter system. The sub-unit lacks integral Regiment dressing station) in order to lift and this should be grouped for the provide a Role 3 capability. The Hosp Tp duration of deployment if mobility is needs to integrate with the reception, required. This is shown in Figure 4. treatment and evacuation functions of the host unit. This medical grouping may be 50 Bed Hospital used to support a Bn Gp operation or to The 50 Bed Hospital is the smallest deploy early in the medical Desired Order independent element of a field hospital. It is

Fig 3. Hosp Tp (25 Beds). Fig 4. Hosp Sqn (25 Bed). 166 Organisation & design of regular field hospitals

Fig 5. Hosp (50 Bed).

Fig 6. Hosp (200 Bed).

completely self-contained for C2 and been detached after deployment of the full infrastructure support. This includes the 200 bed capability. It lacks integral lift and deployment of the RHQ and is able to take will require external assistance for other medical sub-units under command. deployment and redeployment. External The Hosp Sqn clinical capability is sub-units such as a GD section, band and augmented with a second operating mobile bath and laundry may be grouped theatre, ITU/HDU suite and a second with the unit. The surgical shelter systems further 25 bed ward. The size of a 50 bed would usually be based around two hospital makes it unlikely to be suitable for modules of MTSF.This is shown in Figure a sub-unit level of command unless it has 5. MCM Bricknell 167

100 Bed Hospital and 200 Bed of regular field hospitals. A series of designs Hospital for each scale of field hospital deployment The designs for the 100 Bed Hospital (4 are shown in Figures 1 - 6. surgical teams and 4 wards) and 200 Bed Hospital (7 surgical teams and 8 wards) are References: very similar except for the number of 1. AF C7005 dated 1 Apr 00 endorsed LAND surgical teams and wards. The ‘common- 220/99 and ASD2C 57999. user’ areas are similar at both levels of 2. US Army Field Manual 10-14 Employment of the Combat Support Hospital Tactics,Techniques and deployment (based on 75% of total scale). Procedures. At 200 beds the 50 bed capability from the 3. Army Doctrine Publication Volume 3 Logistics ‘common-user’ area may be subsumed into Medical Supplement May 2000. the complex or remain separated in order to 4. NATO Medical support principles and policies. maintain the ability to detach a sub-unit. NATO MC 326/1 dated 14 Jun 99. The design for the 200 bed hospital is 5. ED FAE Crew Medical History of the Second shown in Figure 6. World War. Army Medical Services Campaigns North West Europe. Volume IV. HMSO London Summary 1962. This paper describes as series of principles 6. Fiddes FS. Surgery at the Casualty Clearing for the organisation, design and deployment Station. J Roy Army Med Corps 1945; 84: 276-280.