“Interoperability will not work in a joint and multinational environment if forces do not practice, train and exercise together.”
Speaking about the “battle rhythm” of the NATO Centre of Excellence for Military Medicine (MILMED COE) we clearly identify two milestones: a multinational medical field training exercise Vigorous Warrior (VW) which takes place every second year and a specific military medical conference which is organized on each non-leap year. An article about the multinational military medical Exercise Vigorous Warrior 2013 (VW13) published in MCIF 2013/4 describes the scale and the overall impact of the exercise. This article is meant to disseminate lessons identified and lessons learned taking into consideration multiple perspectives from organizers, participants, trainers and evaluators. It is not the intention to supersede the lessons identified which were consolidated during the VW13 Evaluation Conference, held in Budapest in 28 – 29 January 2014. Also the authors’ intention is to give a better start for the upcoming edition of the exercise Vigorous Warrior 2015.
The best way is to learn from others’ mistakes, not from yours. And here, in this article, we would like to talk about challenges, at least, to open a debate for your further considerations. While the preparation for the next edition of the exercise already started we would like to “equip” our comrades with our mistakes and see if there is a way not to repeat them and to avoid new ones.
See you in Czech Republic for Vigorous Warrior 2015 and until then, check our programme for upcoming events like the Force Health Protection NATO Conference 2014 that will take place on 23 – 26 June 2014. This event might be a very good momentum to share experiences and results from the academic perspective rather than from the tactical and operational level.
Check, check and re-check. Evaluate, verify and validate
The VW series are dedicated to exercise multinational medical cooperation. Similar exercises have been organized many years ago, one of the latest medical exercises of equal proportion and multinationality was Broken Body 1998. Vigorous Warrior 2013 was conducted in Feldkirchen, Germany from September 16 until September 24 with NATO MILMED COE in the organizer posture. The lead nation and gracious host for this exercise was Germany, the Sanitätsdienst der Bundeswehr (Medical Service of the German Armed Forces).
Unlike the 2011 edition, which was more focused on a “display” dedicated to the 35th COMEDS Plenary, VW13 provided a unique training opportunity for medical personnel, medical support personnel, medical command and control and, in addition, embedded a platform for educating and training of exercise planners, controllers and evaluators.
The overall aim was: “to exercise a modular constructed multinational Military Medical Support System in line with Smart Defence and the NATO Connected Forces Initiative (CFI) under field conditions in a simulated Non-Article 5 scenario.”
NATO MILMED COE’s focus for this exercise was on training in multinational settings. The exercise preparations were done accordingly.
Talking about challenges, the main lessons identified
The definitions in use were not clear or were interpreted differently. For example the definition of deployment was understood in different ways. Some contingents understood it as reaching Initial Operational Capability (IOC) while others aimed to reach Full Operational Capability (FOC) before the deployment phase was completed. Some nations see the deployment as a period to build a facility, setting up tents and hooking up utilities (power, climate control and water). Medical personnel would deploy in later phase.
Command and Control (C2) Structure
The C2 structure in a multinational environment is complex and not always clearly understood. In the multinational settings we need to stay politically correct, as much as we can. That is: initially! Nations, units or individuals who are used to work independently will use the provided room to do their tasks in the way they are used to or prefer and that is not necessarily what the C2 structure prescribes, needs or wants. Others who are accustomed to clear and strict guidance are lost when the structure is not explained clearly and thus in their opinion C2 fails.
Tasks and responsibilities and the understanding of who had the authority to act were explained or experienced differently. This is of course directly related to the C2 structure but is also related to the national way of operations. Units, modules or individuals are accustomed to a way of work and trained accordingly. In this exercise they assumed tasks and responsibilities as usual that in this multinational exercise were arranged differently. Assumed responsibility or authority might, and in some situation, will conflict with the neighbouring unit, module or individuals’ perception of the responsibilities. A lead nation SOP must clearly define how the system is organized and who is responsible for what.
Exercise Battle Rhythm
Establishing an integrated Battle Rhythm is important for all nations to be able to match their national rhythm to that of the multi-national medical unit. Daily meetings and reports are required to provide information to the C2 structure. This information enables the commanders and their staff elements to make timely adjustments or to anticipate situations or circumstances that need modifications or corrections. Not having regularly situational updates will not only hamper efficient C2 but also has an impact on the successful execution of the exercise scenario.
All applicable or procedures and their reach must be identified and recognized. Locally used procedures may or may not have an effect on adjacent modules. Commonly used procedures must be communicated and trained with all parties involved well in advance. The Lead Nation has the ultimate responsibility to ensure or to (re)enforce the use of common procedures.
Most problems and errors find their cause in miss-communication. Essential for multinational operations is the availability of functional communication equipment, systems, programs (JChat/mIRC) and procedures. The different cultural and educational background, level of education and language skills form a great challenge for multinational cooperation and command and control. A Role Specialist Nation for Communication and Information Systems (CIS) is preferred to ensure functionality, compatibility, technical and logistical support and training. Without proper training on CIS, communication is likely to fail or will be seriously hampered. Training on communication equipment and procedures is mandatory to ensure the successful execution of an exercise or operation.
The different national forms for reporting, documenting patient information, medical field cards, MASCAL forms etc. were initially in use. Within a medical unit it was quickly decided what forms to use but time is needed to coordinate and agree on the use of a single type of form throughout the medical support system.
Standardization of medical equipment
Standardization is still (and will always be?!) a major challenge. Most medical equipment in use has similar functionalities and functions. Colour, size and dimension may vary but in general it is safe to say that with a little training the use of other forces’ or countries’ medical equipment is not a problem. The technical connection and required consumables can be and should be identified in the earliest possible phase of preparation. Remaining incompatibilities can be resolved by the implementation of well-defined protocols procedures (litters compatibility for the use in ambulances and helicopters). On the down side we recognized that NATO nations are still developing or procuring equipment that do not meet standardization agreements (STANAGs).
Centralized general support arrangements are crucial for a successful execution of the mission. Every deployed member is nationally prepared for his or her primary task. They are educated, level 1 and 2 trained and after the multinational integration and training they will be capable of performing as required. What should not be underestimated is the general support varying from the provision of office supplies and copying services to mail, meals, sanitary and laundry services. Especially the sanitary and meal provisions for patients and on-duty medical staff require special attention. These specific provisions are seldom available or trained in exercises and also in missions we have encountered these short comings.
When we prepare for a mission we are educated on the culture of the country we are deploying to. Generally we do not spend time on explaining the culture of the nation we are to work with. Differences in rank, education, training, competencies, responsibility, accountability and authority are not always known or understood. For example the rank of an individual may represent a position, an education, an authority or just a financial grade. The name of a capability does not always represent a standard level of training. Medical skills, responsibilities and authorities are mostly bound by national civil laws. These differences should be identified by means of a NATO Medical Evaluation to mitigate risks and to ensure the desired capability.
Despite or because of the lack of multinational exercises of this size and composition the participants displayed a high level of willingness and flexibility to cooperate. There was a “Can-Do” attitude among all participants of Exercise Vigorous Warrior 2013. The same attitude you normally see when preparing or starting a new mission. Smaller technical or procedural errors were solved on the spot and some bigger problems after some coordination. The down side of this “Can-Do” attitude is that some problems were solved before they were noted and documented by observers and evaluators.
Treatment of patients
Medical personnel are always eager to treat a patient. Every patient entering a facility was treated as expected and went through the system as planned. Patient safety was never an issue and the level of care was according to the available capability. It might not have been very efficient, patient tracking was definitely not flawless and it required extensive communication.
What did we learn?
To be able to operate effectively all involved should speak the same language. What is meant with this is that there must be a clear understanding of the definitions, tasks, roles, responsibilities and authorities. This starts with clear and understandable definitions that must be explained in an overarching Standing Operation Procedure (SOP). This SOP should be developed and distributed in the earliest possible phase of the preparation for the exercise or mission.
The same SOP should clearly explain the C2 structure on all levels and must include the tasks, responsibilities and authorities followed by the overarching procedures and battle rhythm.
Suitable communication equipment is really essential and appointing a Role Specialist Nation for this task prevents interoperability problems and will simplify technical assistance and support. Timely and intensive training of the international staff on the use of the equipment and its functionality is a definite must.
The use of forms in a national language especially related to patient information and the distribution and use of drugs and blood products should be prevented. National forms can be used locally or nationally only but it will hamper interoperability and the exchange of information from international staff.
Standardization of equipment will not be achieved soon. By identifying what is in use and to ensure the physical or procedural connection the lack of standardization of equipment should not hamper interoperability.
Cultural differences will always exist. These differences should be recognized and need to be dealt with. Communication and acceptance is the key. It is already not uncommon in the medical community that skills should prevail over rank but it is not commonly accepted or understood.
To sum up what we have experienced and learned we can say that the flexibility and willingness to get the job done demonstrated by the participants largely contributed to the success of Exercise VW13. Many lessons are identified and the solutions to problems are within reach. There is still a lot of work to be done. We must realize that, when working so close together, the effect of missing procedures, failure to communicate, misunderstandings etc. can or will have severe consequences.