Lessons learned small unit postdeployment survey results and analysis.
Author: Cannon, David W.
Pub Date: 10/01/2012
Publication: Name: U.S. Army Medical Department Journal Publisher: U.S. Army Medical Department Center & School Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 U.S. Army Medical Department Center & School ISSN: 1524-0436
Issue: Date: Oct-Dec, 2012
Accession Number: 309980601
Full Text: Small units of the Army Medical Department (AMEDD) play a vital role in providing combat health support within a theater of operations. For example, combat and operational stress control, forward surgical care, and preventive medicine functions are performed by teams that operate in remote locations such as forward and contingency operating bases. Despite the widespread use of these units on the battlefield, there is a paucity of after action reviews (AARs) and reports from operations and training exercises in the lessons learned databases. The small unit survey discussed herein was designed to fill this gap and provide unit members the opportunity to provide input on their deployment experiences.


The survey targeted small units such as preventive medicine teams, medical logistics companies, area support medical companies, dental companies, forward surgical teams, and other similar-sized units that redeployed from Operations New Dawn, Enduring Freedom, and Iraqi Freedom from July 2010 to July 2011. The survey questions were developed from the AMEDD Lessons Learned Division's postdeployment questionnaire used for end-of-tour AAR video teleconferences and information collections from other redeployed medical units. Over 100 small unit members completed the online survey. This number represented a completion rate of 10% of the total number of emails sent to small unit members via Army Knowledge Online group email accounts established on the basis of redeployment dates and unit identification codes.

Respondents provided anonymous demographic information including military rank, Army service component, * and other similar data, followed by a 22-item questionnaire. The questionnaire used a Likert-style format with a score point scale that ranged from 1 (strongly agree) to 5 (strongly disagree). The questions were designed to determine what operational challenges units faced during predeployment activities and deployment operations. The questions were reversed on some items so that a numerical low score of 1, indicating strong agreement, was sometimes associated with a positive view (for example, "our unit had adequate training") and other times with a negative view ("our unit had communications challenges"). In addition to the scaled questions, respondents could expand their answers and provide additional details about their training, preparations, and medical support experiences in free-text blocks.


The results of the correlation data analysis revealed several small but significant correlations at the 0.05 level between the independent variables and the respondents' answers on the questions. Higher military rank was negatively correlated to ratings on 3 questions indicating strong agreement with the following statements: "the medical supply process, including automation systems, posed challenges/difficulties"; "Advanced Leadership Course (ALC)/Senior Leadership Course (SLC) training prepared our NCOs ([dagger]) for the deployment," and "predeployment training for Soldiers was relevant to meet our needs."

Older respondents showed strong agreement with the statement "during the deployment our unit faced challenges in the area of life support." Time in service (TIS) produced 2 significant effects on respondents' answers. Those individuals with more TIS expressed strong disagreement with the statements "predeployment training for professional filler system (PROFIS) * personnel was adequate for their roles and responsibilities" and "our unit utilized nonstandard (non-Department of Defense) automated equipment and/or commercial systems and programs for operations." Respondents who spent more months in theater were much more likely than those with fewer months to have favorable views of their units' predeployment training and the use of updated materials from lessons learned. Similarly, respondents with more months in theater held more positive views than those with fewer months of their units' ability to provide a wide range of coverage.

The analysis of variance data showed no significant differences in responses based on the respondents' deployment theaters. However, the results indicated that respondents' geographic/environmental location within the theater of operations had an effect on unit members' responses on a number of questions. The questions about the degree to which ALC/SLC training prepared the units' NCOs for deployment, whether or not the unit was correctly structured for its mission, the adequacy of the medical supply process, challenges with the Medical Communications for Combat Casualty Care (MC4) system, challenges with theater-provided equipment, and additional materiel and equipment needs to meet operational demands all produced F scores with high degrees of confidence. These results indicate that the geographic area to which the respondent was deployed was a key variable affecting his or her perceptions on these questions.

The type of unit with which the individuals were deployed was a key factor in respondents' answers on the following 2 areas of inquiry (questions paraphrased):

* Did unit predeployment training include both updated lessons learned and tactics, techniques, and procedures from deployed units?

* Was the unit correctly structured for its mission in terms of personnel and equipment and was it able to adapt to rapidly changing situations?

Respondents' answers on those 2 questions varied significantly, depending on the type of unit with which they deployed.

Individuals from the 4 Army service components responded with significant differences on the question of their unit's wide-range mission capability.

Respondents provided additional details to emphasize or expand answers to the survey. These responses highlighted issues with forward surgical team (FST) split based operations, PROFIS, and medical refresher training. For example, MC4 was a significant concern for a number of the small unit members, and respondents provided comments about challenges associated with the system. Surveys reported issues with the network connectivity of the MC4 system and image version. While some respondents wrote they had useful MC4 training prior to deployment, the MC4 system's status often varied widely and went from operational to nonoperational throughout the deployment.

Other respondents noted that units operating on forward operating bases (FOBs) and contingency operating bases (COBs) had to improvise ways to receive medical supplies via MC4 and rely on resupply help from other units to accomplish the mission. One survey indicated that it took at least 60 days for supplies to arrive, and another recommended additional MC4-trained "super users" in theater since contract support for MC4 was limited to certain areas. Unreliable and slow internet connectivity exacerbated this issue because connectivity was dependent on each FOBs signal capabilities. In some instances, this made MC4 virtually a standalone system with little support for ongoing system failures in remote areas. However, MC4 is designed to function as a standalone system in areas of low to no connectivity, ensuring continuous documentation of electronic medical recording with data transfers occurring when a unit gains internet connectivity. Patient transfer and accountability functions were hampered since paperwork often had to be re-created each time a patient was moved to a new facility due to system firewalls or lack of connectivity. A respondent who served in an FST wrote that MC4 information did not upload in real time to the Theater Medical Data Store or other higher level servers and noted that Role 3 medical treatment facilities could not review their records digitally. According to MC4, when internet connectivity is secured, data entered into MC4 flows to the Theater Medical Data Store every 2 to 3 minutes on average. Users indicated that MC4 was also inadequate in its current form for the documentation of anesthesia intra-operative reports, however; MC4 applications do provide this capability using a software workaround.

Post hoc multiple comparison test results on the data are available and may be requested from the author (210-221-6174).


The data analysis provides an insightful view of AMEDD small units that redeployed over the past year and complements findings from recent Operation Enduring

Freedom medical task force AARs. The survey results indicate that higher ranking respondents rated their units as having difficulties with the medical supply process and believed that automation systems posed challenges and difficulties to their units. This finding is not surprising in light of free-text comments that reported deficiencies in application capabilities developed for the MC4 system. The MC4 challenges have been recognized in past AARs and changes are ongoing to resolve systemic issues in the current deployed environment. For example, MC4 has instituted training opportunities at the CONUS* Replacement Center, Fort Benning, Georgia, to ensure PROFIS personnel are trained prior to arriving in theater. The MC4 has also institutionalized classes at the AMEDD Center and School, injected system use in more than 50 annual exercises, and, to build system proficiency, installed it as a sick-call tool and train-as-you-fight mechanism at battalion aid stations and brigade medical supply offices in garrison. Additionally, MC4 has been added to various in-theater networks to enable remote technical support delivery to FOBs without contractor or organic support personnel. At the same time, the results indicate that respondents with higher rank believed that ALC/SLC training prepared their units' NCOs for deployment missions, and that Soldiers' predeployment training was relevant to meet the units' needs. These findings may reflect leadership beliefs that their unit personnel received the proper predeployment training and had the necessary skills and training to carry out their duties. Despite these overall positive attitudes of unit leadership about predeployment training, medical supply and automation systems remain concerns that warrant continued command emphasis and actions to facilitate small unit operations.

Age and TIS correlations produced mixed results. In general, respondents with more TIS were likely to view the predeployment training of their unit's PROFIS personnel as inadequate for their roles and responsibilities, but these respondents also have positive feelings and rate their units as not requiring nonstandard automation equipment or commercial systems and programs for operations. On the other hand, older respondents were more likely to rate their units as having greater challenges in the area of life support than were younger respondents.

The data produced several significant correlations between respondents' length of time in theater and their answers about predeployment training, including updated lessons learned materials and the ability of their units to provide a wide range of area coverage, including remote FOBs and COBs. The data suggest that the longer individuals stayed in theater, the more likely they were to develop positive views of the adequacy of predeployment training and the units' ability to meet challenges in providing support to remote locations.

The results show a significant difference based on type of unit to which respondents were assigned in their views on the question dealing with predeployment training and availability of lessons learned and tactics, techniques, and procedures from units already deployed. Follow-up action will ensure these materials are readily available for units prior to deployment. Respondents also differed significantly in perceptions of their unit's structure for its mission and ability to adapt rapidly to changes in mission. These differences may reflect the need to determine how to update small unit equipment and organizational structure to best meet the situational demands within a given theater, to ensure these units remain flexible and capable of accomplishing full spectrum operations.

Respondents' free-text comments about PROFIS, theater-provided equipment, and medical refresher training produced positive comments that showed how small unit personnel were proactive and worked through personnel and equipment shortages to support numerous FOBs and COBs, as well as detention facilities. To quote one respondent, "we arrived in theater with ten personnel; we successfully completed our mission with eight." There were challenges to overcome and issues that needed resolution, but units perservered through innovation and team effort to accomplish their missions.

This small unit survey represents a new initiative within the lessons learned collection process. The survey results along with other observations, insights, and lessons were entered into the AMEDD lessons learned database and shared with both combat and training developers. The free-text responses about the limitations of the FST conducting split-based operations were combined with other FST observations, insights, and lessons, and provided to Directorate of Combat and Doctrine Development (DCDD), FST Integrated Process Action Team (IPAT). The FST IPAT conducted a capabilities-based assessment designed to determine what doctrine, organizational, training, materiel, leadership, personnel, and facilities solutions were required to meet capability shortfalls.

The capabilities-based assessment identified 10 capability gaps that were primarily generated from the need to design a more flexible and scalable future capability that allows the FST to separate into 2 teams, each of which can effectively function independently. The recommendations identified that all of the capability gaps can be addressed with nonmaterial solutions. The proposed capability structure consists of a mission command element, 2 surgical elements, and 2 resuscitation elements, and remains within the current FST force structure level of 20 personnel. In this way, the FST survey responses and other deployment lessons were used to determine ways to improve the provision of forward surgery in the years 2016 through 2028.

The AMEDD Lessons Learned staff also participates in other DCDD IPATs, including telehealth, mild traumatic brain injury and concussion recovery care, advanced trauma management, prehospital medical informatics, battlefield oxygen requirements, and en route critical care. Recent issues like feral animal management rely on lessons learned to provide insights on animal control measures and command responsibility for animal control, and emphasis on the policies prohibiting pets or mascots. Failure to act on previous lessons has consequences and can lead to outbreaks of vector-borne and/ or zoonotic diseases, especially rabies. Lessons collected through the survey process and operational AARs aid in current deployments by providing recommended practices, as well as to identify and fill gaps through the capabilities development process.

The Lessons Learned staff works with the DCDD Force Protection Branch to facilitate data collections through online surveys, setup assistance, and conducting in-person interviews during brigade combat team (BCT) umbrella week collections. The survey focus areas include nutritional intake from both military and civilian provided sources, feral animal control and rabies prevention, and mental health stability, including access to combat stress control teams. The surveys are disseminated to returning BCT personnel during the week-long collection activities that target all personnel within the BCT. Those surveys are compiled once by Lessons Learned and submitted to the Force Protection Branch for review and analysis.


The author received an overwhelmingly positive response from leaders and unit members who participated in the survey, their willingness to share experiences, and desire to receive feedback on the results. The survey gave AMEDD small unit members a unique opportunity to express views on a range of important issues. A number of respondents indicated it was the first time anyone asked questions about their deployment experiences. The findings of small but significant correlations point to the need for further study to determine how variables such as rank, length of deployment, and time in service interact to affect both attitudes and responses on issues. The survey results indicate several strong effects of the unit's geographic location while deployed as a key factor in the survey responses, as well as the need to fine-tune a unit's predeployment training and overall organization and capabilities required for specific geographic locations.

The Lessons Learned Division recently published 2 guides to lessons learned that provide unit members with a wealth of information and advice on what does and does not work in various deployment settings; one guide for the combat support hospital and the other for the forward surgical team. A lessons learned guide for the brigade surgeon section is in development, and there are plans to publish guides for veterinary and dental units. The Lessons Learned Division has already integrated recommended practices into prepackaged lessons learned documents for brigade combat teams which are distributed through medical observers and controllers at the US Army Combat Training Centers. The collection process is being streamlined by identifying returning units and ensuring their lessons learned and reports are obtained in a timely manner to assist other small units in the deployment schedule. This will improve predeployment training and enhance a small unit's ability to conduct split-based operations in support of decisive action. Future initiatives will involve contacting small units prior to deployment and providing them with lessons learned and recommended practices based on similar units' deployment experiences. Follow-on surveys will focus on specific AMEDD small units with the goal of identifying ways to improve AMEDD battlefield capabilities.

MAJ (Ret) David W. Cannon, MS, USA


MAJ (Ret) Cannon, an employee of OUTSOURCE Consulting Services, is a Combat Medical Systems and Lessons Learned Analyst for the Lessons Learned Division, Combat and Doctrine Development Directorate, AMEDD Center and School, Fort Sam Houston, Texas.

* Active Army, Army Reserve, National Guard, Active Guard/Reserve

([dagger]) Noncommissioned officers

* PROFIS predesignates qualified Active Duty health professionals serving in other units to fill Active Duty and early deploying and forward deployed units of Forces Command, Western Command, and the medical commands outside of the continental United States upon mobilization or upon the execution of a contingency operation.

* CONUS indicates continental United States
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