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Medical Logistics at the Salang Pass Avalanche

Medical logistics personnel responded quickly to an avalanche that occurred in Afghanistan last winter and used their lessons learned to create plans for responding to future disasters.

The ninth day of February 2010 began like any other day at Bagram Airfield, Afghanistan, but initial reports of an incident came filtering into the joint operations center (JOC) around 0900. An avalanche had occurred in the Salang Pass (just north of Kabul), and around 30 people were either injured or in need of assistance. U.S. Air Force parajumpers had already been dispatched and were in the area helping.

Around 1100, calls were received in various tactical operations centers (TOCs) indicating additional people were affected by the avalanche and a larger response would likely be required. With each subsequent report, the situation only grew worse and more agencies began to receive requests for assistance. Around 1230, the JOC notified multiple agencies that a 5-kilometer wide avalanche had carved a swath through the Salang Pass, injuring hundreds, potentially trapping thousands, and killing an estimated 165 (this was not known definitively until after the event).

The U.S. military had helicopters in the area and was evacuating people with an unknown array of injuries to Bagram. Medical personnel from multiple branches of service and civilian agencies were preparing to triage and treat victims. Immediately, medical response personnel began rallying crisis response teams into what had just become an unexpected natural disaster relief effort.

The base’s hospital, under the leadership of the supporting headquarters, announced a mass casualty (MASCAL) incident, and decisions were made to employ the base’s airport terminal as the central patient triage point for the disaster evacuees. Military police assistance was requested, and much to the chagrin of travelers awaiting flights, the airport was closed to personnel transiting the theater of operations. Those people flying to other locations were asked to wait outside the terminal for their flights or were asked to move into the USO [United Service Organizations] building, where they would be notified of boarding times and flight departure information. A critical incident response was underway, and the 30th Medical Command (MEDCOM) and the 484th Medical Logistics (MEDLOG) Company at Bagram Airfield were among the many agencies that responded. Immediately, the Soldiers went to work in support of the disaster.

Disaster Management: An Overview

Disaster management ordinarily occurs in four phases: preparedness, response, recovery, and mitigation. Current practice favors an all-hazards approach, and literature indicates that first-response agencies should develop response plans for multiple scenarios. Combat units in Afghanistan normally prepare only for battlefield scenarios. Preconfigured medical “push packs” involve surgical and trauma-related equipment. Natural disasters are not among the common missions for a MEDLOG company supporting a theater of operations.

Bagram Airfield, like most other larger military installations, has a MASCAL response plan in place. The plan is exercised at least once per quarter, but with the attitude that this will never happen to us. The base employs a working group of medical professionals who assist in developing the right strategy for providing for the needs of a populace under duress.

Before this real-world event, the MASCAL working group had conducted two training exercises involving the various task forces stationed on the installation that have responsibility for casualty collection points. The scenarios involved coalition medical teams caring for coalition forces within the confines of the base; no one could have predicted a MASCAL of the avalanche’s magnitude that required injured Afghan people to be brought through the base’s gates.

Although medical support was only a portion of the larger response effort, healthcare practitioners were the defining factor in ensuring that victims received, at a minimum, an initial screening and evaluation when they arrived at Bagram. Please note that the efforts at Bagram were only a portion of the overall response; the Bagram healthcare teams were the first receivers in support of the first responders at the actual scene of the disaster.

MEDLOG Response

The 484th MEDLOG Company was first notified of the incident around 1330 by the MEDCOM G–4. Directives from MEDCOM included having trauma supplies ready for an impending MASCAL. Blankets and warming packs also were recommended. Because of the large number of victims expected, it was critical to have a MEDLOG company representative stationed at the terminal with a means of contacting the warehouse for additional supplies as they were required.

Logistics leaders at the critical incident site began communicating with clinicians to determine what supplies were needed to treat the types of injuries being seen. As a result of this ongoing communication, items such as warming blankets, various types of fluids, hand-warming packs, intravenous therapy items, hypothermia kits, and bandaging materials were requested from the warehouse. MEDLOG trucks began moving to and from the flight line bringing all available items as quickly as they could be loaded and dropped off.

Both Soldiers and leaders observed several issues of concern that affected the MEDLOG company’s support of the disaster relief efforts. Potential shortfalls in continued operations were reported immediately to the incident commander, and he assisted in on-the-spot corrections.

After the avalanche response, Soldiers and leaders discussed what happened, what went well during the event, what did not go very well, and what could be done to improve operations in future situations. The resulting information was passed to multiple higher headquarters for inclusion in a macro-level after-action review for theater commanders to use in planning for future community-wide responses.

What Went Well

The response time from the initial notification to the arrival of the first load of supplies was noted as a tremendous success. What was not known, and was later discussed by noncommissioned officer (NCO) leaders throughout the company, was that the 484th MEDLOG had rehearsed a MASCAL response during training at Fort Hood, Texas, before deployment. NCO leaders recalled how unsuccessful the Soldiers were in training; yet when the “real deal” occurred, the Soldiers responded as if they had always been responding to disasters. The Soldiers formed themselves into self-directed teams (such as data entry, puller and picker, load, and communications teams) and apparently began instinctively managing various aspects of support and sustainment for providers at the triage site.

By having some preconfigured trauma and surgical push packs, the 484th MEDLOG was able to push many of the supplies to the point of need before true demands were established. The trauma packs were already filled with necessary items that clinicians were asking for, so they did not have to initiate requisitions for critical items. Trauma packs were already packed in a tri-wall container, so the 484th MEDLOG was able to place the container in the back of a truck and send supplies to the triage site without asking which items were actually needed. Workers at the site set up a supply point operation and requested that the warehouse send items needed in addition to what was already in the boxes.

Approximately 20 line items were used consistently throughout the incident, and over 2,000 individual items were distributed during the disaster response. As a result of simplified record-keeping initiatives on site, the Soldier responsible for maintaining accountability began developing a cold-weather injury push pack based on volumes of use and for the express purpose of being ready should this type of event ever present itself again. (See chart below.)

The NCOs noted that placing a liaison at the patient triage site allowed supply chain management personnel to know demands in real time without disrupting the care being provided on site. This allowed clinicians to turn to one person and communicate needs without having to use telephone lines or other media to convey critical supply demands. This enabled the NCOs to have resupply ready to go when the trucks returned to reload.

At one point, because of misunderstandings related to what was actually needed at the incident command site, a medic and a pharmacist were even sent to the warehouse to “translate” requirements to supply personnel. This helped the team to process demands for items that they were unfamiliar with. The pharmacist provided invaluable assistance to logistics personnel when clinicians at the site were requesting specific types of medications that the enlisted logisticians knew little about or could not understand through radio communications.

As each truckload of supplies was sent out of the warehouse, data entry clerks placed orders into the Defense Medical Logistics Standard Support Customer Assistance Module. Orders were transmitted to the U.S. Army Medical Materiel Center-Southwest Asia (USAMMC–SWA) when each load left the warehouse. During the after-action review, NCOs related how USAMMC–SWA, at one point during the turmoil, actually called and asked what was going on. Once the distribution center was advised of the incident and understood the ensuing MASCAL, USAMMC–SWA responded accordingly and began to fill the theater’s demands related to the MASCAL immediately.

Because of the volume of patients flowing into the Bagram triage site and estimates about what to expect throughout the next 24 to 48 hours, it became evident that an emergency resupply would be needed. The data entry clerks and customer service team in the warehouse placed a call to the theater distribution center and advised USAMMC–SWA of the impending critical shortages of cold-weather injury supplies. USAMMC–SWA responded by filling critical shortages and pushing supplies into Afghanistan immediately. By 1000 the next morning, the MEDLOG warehouse was restocked and operating at full capacity again.

As a result of this experience, the MEDLOG company’s leaders drafted a 48-hour continuity of operation plan that emphasized conserving manpower. During the incident, the incident commander advised staff members to expect the operations to continue over a 24- to 48-hour period. Since the MEDLOG company still had to support its organic, theater-wide mission—sustaining the entire theater of operations—its leaders developed a work-rest cycle for the Soldiers. Leaders were concerned about depleting the company’s manpower during the initial response, so NCOs divided the company into teams and sent some home for rest while others continued to support the relief efforts.

What Didn’t Go Well

Medical logistics support could have been executed better in three areas: communications, preconfigured loads related to cold-weather injuries, and basic supply chain management responsibilities.

Communications. Although a Soldier was positioned on the flight line to communicate demands between the triage site and the warehouse, no other means of communication was available. As each resupply order was loaded into trucks and dispatched to the scene, no knowledge of its arrival was available to the incident command team. The only way the logistics team at the site knew the resupply was coming was when they saw the trucks arriving on scene. To correct this, the 484th MEDLOG was advised to purchase two-way radios for communicating the various stages of the ongoing resupply during critical incidents.

Another element of communication that could have resulted in significant shortfalls was the use of clinical vernacular when requesting supplies. Clinicians are accustomed to asking for things by their “street names” inside the clinics, where time is available to find out exactly what is needed or when a resupply can happen before an incident occurs. In a critical incident, MEDLOG professionals may not know or understand this vocabulary and may be unable to respond appropriately to clinical needs.

For example, clinicians were asking for pulse-oximeters (devices for measuring the levels of oxygen saturation in a victim’s blood). One Soldier thought instead that the clinicians were requesting “pole boxes” (pulse-ox is often what the device is called) and was unclear about what was needed. A biomedical maintenance NCO realized quickly what was needed—SpO2 monitors—after a medic was brought to the warehouse to describe what was being requested.

In another instance, clinicians at the incident site were asking for “Christmas trees,” which caused several minutes of confusion about what was actually being requested. The confusion this caused for inexperienced personnel is obvious. The Christmas tree is small green triangular connector used to connect tubing between an oxygen cylinder and patient mask.

Preconfigured loads for cold-weather injuries. As previously noted, the avalanche inspired MEDLOG Soldiers to develop a cold-weather injury push pack. This need had not been identified as even a remote possibility before this incident. A variety of fluids for intravenous (IV) therapy and medication management, wound care, and drinking should be included in the push of materials to a critical incident site.

Simple things, such as warm fluids, are required when responding to a cold-weather incident. Warm fluids are less traumatic for patients during IV therapy and while rewarming the body. Steps such as placing various types of medical fluids, including drinking water, in a heated area immediately upon notification of a cold-weather incident are critical when managing patients who have been exposed to hours of cold weather and freezing temperatures.

Simple and impromptu steps such as turning on a heater inside the transport vehicle and placing fluids inside the cab of the truck could also help in warming fluids while en route to the scene. Finally, if available, a warming cabinet should be taken to the triage site to maintain warm fluids on scene.

Basic supply chain management responsibilities. The 484th MEDLOG company NCOs said that the biggest lesson learned was to have multiple skill sets at a critical incident site. During the avalanche response effort, only one junior medical logistics technician was sent to the site to relay supply demands to the warehouse team. In some instances, this resulted in miscommunication of what was needed. The NCO leaders asked that in the future they be permitted to dispatch a self-developed crisis response team that includes a medical logistics technician, a biomedical repair technician, and a pharmacy technician.

Another key discussion point during the after-action review involved the availability of supplies outside of what would ordinarily be required. Pediatric supplies were being requested at the site but are not commonly stocked in the MEDLOG warehouse since most of its supplies are for adult Soldiers involved in combat. NCOs recommended that for future incidents, the MEDLOG warehouse be permitted to maintain minimal stocks of pediatric supplies since those items are commonly needed during MASCAL events in Afghanistan.

As the incident closed and no more patients were being received at Bagram, excess supplies were brought back to the warehouse for reintegration into routine operations. This resulted in overstocking of some items throughout the warehouse. Although this cannot be completely avoided, having a packing list or push pack for future incidents of this nature could prevent overstocking during post-incident recovery operations.

Another issue that resulted in overstocking was having multiple agencies requesting and receiving supplies throughout the incident. The MEDLOG company’s leaders recommended that incident command teams stay with one source of supply so that what belongs to the warehouse returns to the warehouse after the scene is cleared. In this incident, much of the overstock was the result of multiple agencies bringing supplies to the triage site and leaving them behind after the incident response efforts concluded.

What Could Be Improved for Next Time

The MEDLOG company’s leaders identified actions that could be taken to improve operations should they be faced with a future incident of this kind. Primarily, areas identified for improvement were directed toward communication and supply chain control.

Communication. Communication is a variable that routinely causes the most consternation in a critical incident. Although it can never be completely perfected, elements of more effective, efficient communication can be adopted to mitigate shortfalls during future events. The MEDLOG company’s Soldiers identified a need for additional communications assets. The two radios they had at the time of this incident were not configured for short-range communications or prepared for the response. (The batteries were not fully charged.) As a result, the company leaders evaluated the cost of buying different styles of two-way radios with charging stations to have more resources available at a time of need.

Another element of communication involved personal communication and the exchange of requirements between the triage site and the warehouse. To address the issue of the warehouse personnel not recognizing the terms used by medical clinicians when requesting supplies and equipment, the MEDLOG Soldiers recommend having a medic positioned at the warehouse to provide immediate translations. The medic would serve as the medical liaison, much like the MEDLOG Soldier at the critical incident site. By establishing this type of relationship at the initial onset of the response, supplies can flow into a critical incident site more efficiently and with less disruption.

Supply chain control. Agencies involved in a disaster situation have little regard for what is being used or how often it is needed. Therefore, one person should be identified from the outset to be a store keeper at the site. Foot traffic into and through the supply distribution point should be controlled, and each request should be documented so that reorders can be filled according to need. The Soldier should know which items are being used most and which supplies are not needed at all; resupply should be based on the volume of use.

For example, Proventil (an inhaler device for someone experiencing bronchial distress) was available—several 100-count boxes of inhaler devices—and was never used throughout the incident, but blankets could not be kept on hand because they were being used so frequently. This type of mistake results in space being used to store items that are not needed throughout the incident while other more-needed items are not stocked.

The medical logistics supply point should be the single source of medical supply throughout a critical incident response. While agencies should never be prevented from bringing additional medical supplies to the site, all materiel should be consolidated at one issue point to prevent clinicians from having to search for supplies. Items can be stored in containers labeled to identify the agency that brought them to ensure that agencies get their supplies back once the event concludes. The Soldier assigned the duties of accounting for materiel can be used to assist in this effort.

An element that is often overlooked in a critical incident is warehouse security and control. In many MASCAL incidents, every customer may not be aware of the circumstances. Having a person at the warehouse entrance to explain the situation gives customers the opportunity to return later to obtain supplies that are not needed immediately. The Soldier at the entrance can take requests of customers involved with the incident so that they do not have to search for someone to manage their orders. The warehouse personnel also can serve multiple agencies trying to respond to the same situation without inundating the warehouse team with duplicate requests.

Security and control are essential during a MASCAL incident. People will continue to need routine supplies. While customers should not be dissuaded from getting what is required, without control in place during a critical incident, shelves can be quickly exhausted without the knowledge of the warehouse personnel if the flow is not monitored and regulated. Obviously, this can result in significant shortfalls for multiple agencies involved in a variety of operations—some unrelated to the incident itself.

At the conclusion of the MASCAL incident, the medical teams that responded to the avalanche had treated, processed, and assisted 276 patients in approximately 6 hours. Of the 276 patients who were treated at the triage site, 2 died and 11 were sent to the base hospital, leaving more than 250 people who were able to be treated on scene at the triage site and released.

A direct contributing factor in this success was the ability of medical logistics professionals to respond to the immediate needs of clinicians at the triage site. In this instance, medical logistics competence, adeptness, and professionalism assisted in the tremendously successful outcome of what could have been a greater tragedy.

Captain Jerry D. VanVactor was the deputy G–4 for the 30th Medical Command during the Salang Pass avalanche. He holds a B.S. degree from Athens State University, an M.S. degree from Touro University International, and a doctor of health administration degree from the University of Phoenix.

Captain Jason Donovant, USAF, is the chief of medical logistics for the Combined Joint Task Force-82 Surgeon’s Cell. He holds a B.S. degree from Colorado Christian University and an M.B.A. degree from North Central University. He was recently selected as the Air Force’s Outstanding Medical Logistics Company Grade Officer of the Year.

First Lieutenant Michael Dinh-Truong, USAR, is an Active Guard/Reserve officer. He was the medical logistics officer for the 484th Medical Logistics Company when he wrote this article. He holds a bachelor’s degree from Edinboro University of Pennsylvania and a doctoral degree from Texas Chiropractic College.

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