GSACEP Lecture Series: Soft Power and Military Emergency Medicine By CAPT John Devlin, MD

CAPT John Devlin, MD shares lessons learned from USNS Comfort.

Watch the full episode and join the conversation at https://gsacep.tradewing.com/event/uw7Q78sJ6Yv7sADbh

Transcript

John Devlin: 1:04

All right. Good morning. I'm Captain John Devlin on the Emergency Medicine Residency Program Director here at Naval Medical Center Portsmouth, and I just want to thank the planning committee for inviting me to speak. And today I'll be talking about us soft power and the role of military emergency medicine in those missions. And I'll be drawing from lessons learned from recent Navy hospital ship missions, specifically the 2015 continuing promise mission and the SOUTHCOM AOR, as well as the 2017 hurricane relief operations in Puerto Rico.

Unknown: 1:35

So first, the DoD disclaimer, I just want to say that these opinions are my own opinions, they do not represent the United States Navy, or the Department of Defense, that these slides were prepared in the course of my normal official duties. And then just one quick comment on images. So unless the images contain an annotation, they are available in the public domain. Most of these were taken from the hospital ship comfort and the Public Affairs Office. And they are available through the defense visual information distribution services, which is available online. Another note is this is pre recorded recording from our residency spaces on in the hospital. So you may hear some overhead responses, those kinds of things. I apologize, I can't filter that out. All right. So just for today, I want to start off with just describing what Soft power is, and its role in international diplomacy, how they both the US and some of our adversaries utilize that. And then we'll talk about specifically how Navy hospital ship missions fit into that. But that can these lessons can be applied to any kind of humanitarian assistance type of mission, whether it be Army, Air Force, or navy. And then lastly, we'll talk about lessons learned. And then I'll identify some pearls that I think that if you are ever in charge of one of these missions, you can generalize these to your mission, things you need to consider before you step off, to ensure mission success. Alright, so we're gonna start off with a story, The Tale of Two admirals and so I think everybody probably recognizes the individual on the far right, that's Vice Admiral Mike Mullen. He's the former Chairman of the Joint Chiefs of Staff from 2007 to 2011. But probably very few of you, including those in the audience that are Navy recognize Admiral John nappin. So at the time of 2000 or so the title of 911 Admiral Nathanson was the commander for Naval Air Force's US Pacific fleet, and so he's in charge of the South Pacific right are in charge of the South China Sea. We know that there has been an increase in I guess, the boldness of our Chinese adversary there, they are expanding to the nine dash line there are claiming territorial rights for various islands that are disputed by other nations in that region. And they are starting to militarize those islands. So specifically, the Spratlys. And the Paracel Islands are becoming a home ports for military bases, right. And so that's going to inform all of Admiral Nachman strategic decision making, right so when you think about what he is most interested in, he is more interested in building the Navy up so that he can counter this increase in aggression in the South China Sea, right. So when he moves on to become the Deputy Chief of Naval Operations for warfare requirements and programs, he wants to build more ships and grow the US Navy. And this is in direct contrast with Admiral Mullens perspective. So Admiral Mullen and the early 2000s, he is the commander for Navy forces Europe, and so they don't have a numbered fleet. He is very aware of what's going on in CENTCOM and the counterinsurgency war. And what he recognizes is that globalization has reshaped the battlefield and that with international trade, with international information sharing, that you really have to have a much more thoughtful, I guess, all encompassing response in order to fight this new threat. And so he recognizes that the future of naval operations needs to keep all this in mind. And that's the only way we're going to be successful. And so he comes up with a document or I guess his camp is or the intellectuals that come up with this document. He's already retired at this point, but the 2015 Cooperative strategy for 21st century seapower incorporates an operating concept called the 1000. Ship navy. So if you were to take Admiral Nathans perspective, you'd want to build more ships, there's no way the United States can afford 1000 naval vessels and we can't afford the upkeep and there's a lot of reasons why that's not a cost effective strategy. However, if you incorporate Admiral Mullens perspective, we could through building partnerships have access to 1000 ship fleet, it won't be all us but with our partners and our allied nations, we could eventually have this group of cooperative countries that could number 1000 ships and that's what the 1000 ship Navy concept comes from. It's not a physical 1000 US ships, but it's 1000 ships at our, I guess that are willing to react in a quantity profession, right? And so what would they be responding to? Well, we want to keep all of the maritime sea trade open. Because if you look at Commerce 90% of that is conducted by sea. So it's not just a, we need the Navy to fight wars, but we need the Navy to keep these commerce and shipping lanes open. So it doesn't affect us from an economic standpoint. And so this is that broader, global look at the Navy's mission. And you could extrapolate that out to the Army, the Air Force as well, that we need to have a role in maintaining the status quo with economic trade, as well as being able to fight wars. And so this comes into the concept or informs the concept of all domain access, right? So if we need to keep all these shipping lanes open, we need to respond to them, anytime, anywhere. And that's a access to that domain. And we do that through our cooperative agreements with other countries. We can't do it all ourselves, we have to rely on some of our partner nations as well. Okay. So that's kind of the military piece of it, right? And that's how, how are we going to get to that place? Well, that's how US soft power comes in. And before we get into soft power, I want to talk about the other half of this. So this is how so the 1000 ship Navy, and the all domain access is how we're going to respond to a threat. But what about just reducing the threat to begin with? Well, that is where we get into the other part of soft power, right? So building relationships, building infrastructure, if you look at the relationship between poverty and radicalization, it's actually pretty strong outside of predominantly Muslim countries. So if you look at Muslim countries and Islamic radicals, there's really not a great relationship between socio economic resources and education. In fact, there's some incredibly highly trained individuals in those regions who are very radicalized. When you look at the Western Hemisphere, and you look at our poor nations, there is a great relationship between poverty and radicalization. So if you can help to pull our partners out of poverty, they're less likely to have the night as a radicalization forming in their countries and less likely to create a threat that we have to respond to militarily. So that's the other half of global power, it will help us very soft power, and that it will allow us to better respond to threats and also prevent strip threats from forming. When it comes to radicalization in the Western Hemisphere, we often are very preoccupied with al Qaeda, with ISIS. But if you can think back and some of you guys weren't even born yet, but think back before 911, we really didn't, you know, the, the biggest problem from a radicalized religious standpoint was from Hezbollah. And we know for a fact that Hezbollah has roots in the Western Hemisphere, both from a financing standpoint, and also from an operating standpoint, particularly in Honduras, there is a Honduran Hezbollah group there that is very active. And it's probably no surprise to anybody. That's why JTF Bravo is headquartered in Honduras. So these are things that we have to pay attention to, because if we ignore them, they're gonna become bigger threats that are going to force a military solution, which is what we want to try to avoid. Alright, so what is the definition of soft power? Well, this is a term that was coined by Joseph Nye back in the the end of the Cold War. And that's the ability of a country to persuade others to do what it wants without force or coercion. If you put that into department defense terms, what it really means is the ability for us to either engender goodwill with nations that we can pre position forces or create favorable conditions. So when we do have to engage in combat operations or in lieu of combat operations, we are more likely to succeed in our mission. And so this is really battlespace shaping. And so it's a term that we use and JP me that we've talked about for decades. This is helping to shape the environment so that we're more likely to win. And so if you think if you remember nothing else from this presentation, what I want you to take home from this presentation is that these soft power missions, these global health engagement missions are really helping to battlespace shape, and that's one of the the roles and responsibilities that military medicine has is to use what we can to help ensure victory, should we have to engage in combat operations. And this is one way we do it. To kind of put it differently. Admiral Mullen said preventing Wars is as important as winning them, and far less costly, and that's cost in terms of human life, as well as material and capital. Wars are incredibly expensive, result in a lot of civilian deaths. And if you look at any of the disaster response and complex disaster scenarios, the civilian death toll is getting higher and higher, with every one of these conflicts. Another way to put it the Chief of Naval Operations, Mr. Richardson said, I want to be the best at not fighting Russia and China. So if we're successful from a soft power standpoint, we never have to go to war. Alright, so how do we measure soft power? Well, there's lots of different metrics out there, but probably the one that's most routinely appointed to as the authority is the Brand Finance brand directory and their global soft power index. And so I'm going to give you the data from the 2020. White Paper. But we're first talk about the inputs that go into it. So there's seven different pillars that are used to provide a measure of how successful a country is, and getting its brand out there and also goes into how familiar countries are, with your brand, the influence that a country has, and its reputation for being a global source of goodness, as opposed to just following its own self interests. So what goes into this? Well, there's really two lines of effort. A brand has a general audiences line of effort, which is for the 2020 power index, it involved 54,000 online surveys in 87 countries. And then the other half of that is the specialist audience, which is interviews, personal interviews with over 1000 Subject Matter Experts among 71 countries, and all that gets rolled in to a numeric score. And here's how we did in 2020. So this is available online, anybody can look it up, you can see that the United States is at the top. And this is again, this is March of 2020. We're in a little bit different place now. But here's an exact quote from the executive summary. Soft power cannot be rapidly achieved nor lost. The United States has shown that ultimately, despite the reputational challenges and impeachment in the unpredictable foreign policy, its position as the rule maker and international system, and the world's only soft power superpower is unrivaled. So I will say that that is not necessarily the case today, and we'll talk about that. But what they also identified is that China has invested a lot into soft power, and it's working for them. And that China and Russia are kind of dictating global change right now. So let's get into the specifics of what China has done from a soft power standpoint. So some of you may have heard about the Belt and Road Initiative. It's a gigantic, colossal infrastructure building project. And so belt refers to any kind of overland route, which really is to is designed to recreate and expand upon the old Silk Road concepts. This is really connecting metropolitan areas in Europe, Eurasia with the metropolitan areas in China, so that you have international trade or facilitates international trade and potentially reducing shipping costs, and maybe making China the preferred partner. The road refers to maritime networks, and these are primarily connecting the Pacific nations with China, as well as Africa with China and Africa is incredibly important from a strategic standpoint for the Chinese. So the Chinese are a gigantic economy, and they are a huge consumer of oil. And some of the largest energy reserves are available on the continent of Africa. Right now, China spends about $285 billion a year on oil imported from Africa, which represents about 18% of its consumption. Now, the reserves there are pretty substantial. So the future for the future. Africa is essential to China, and their ability to keep their economy and their military on track. Alright, so I want you to briefly just take a moment to look at that picture. And then it's super superimposed another picture on it. And this is a military operation, a Chinese military operation, you can see it's a naval operation that takes off from China from the mainland, stops at a port in Sri Lanka. And that port is a is a part of the the Belton Road initiative. It's a little bit of a controversial project in that the Chinese have are essentially running it. But it is based in Sri Lanka, then stops in Djibouti and other logistical stop in Spain and then comes around the western coast of Africa. And particularly in stops three, four and five, those are huge oil exporting countries and comes around two stops five and six and then ends up in timber. Okay, so this is a military operation. But it is not a gray hole operation. This is a medical Humanitarian Assistance Mission by Peace Ark, which is China's only operating hospital ship and as equivalent to USNS comfort and us as mercy in the US inventory. And so you can see that the Chinese recognize that the US missions with comfort and mercy have been very successful in cultivating soft power. So China has kind of taken a page from our playbook and using it to further their economic ambitions. So one of the other concerns about the Belt and Road Initiative is not just its geopolitical positioning, but also something called the debt trap diplomacy. So if you look at these projects, and here's an example of from the Western Hemisphere, it's not just the eastern hemisphere, of countries that are signatories to the Belton Road initiative. And you can see that they've taken on huge loans from the Chinese. So if these were, you know, free grants or international aid that wasn't expect to be paid back, that'd be one thing. But these are low interest loans are expected to be paid back. And we all recognize that Venezuela's government is pretty chaotic. Their healthcare infrastructure is almost non existent. They've taken on gigantic loans from the Chinese, a lot of watchdog groups have coined this phrase that debt trap diplomacy, because there are multiple countries whose debt that they have incurred from the Chinese does not match up with the requisite increase in their, what he called gross domestic product, there's a concern, they will never be able to pay those back. Or that the Chinese might use course of methods, when they go to repack, repay these loans, that it might ask for certain concessions. So it's a big concern among along the, I guess, in the international diplomatic community. So those countries are not the only ones who have signed on for the Belton Road initiative. These are other countries in the Western Hemisphere that have done so. And you can see some of those are neighbors that are pretty darn close to the United States. And so it is on our best interest to keep this in check. And there's a lot of concerns about the Belton Road initiative. One is that debt trap diplomacy, there's a lot of promises, transparency, Where does this money actually coming from? It's certainly a huge project of President sieging pains. However, a lot of these things are tied to corporations in China. And there are some concerns that there are certain stipulations with these contracts between the two governments that really bring in Chinese, the private sector from China to to build this infrastructure. And so this, these loans are being provided to these countries, and then have to give that money back to Chinese companies. So it never actually stimulates their economies, it just goes back to China. Obviously, that's a concern. So the last concern is that this is moving beyond just infrastructure. And that's where we get into some of the contractual things with the Chinese government and Chinese corporations. So as Chinese corporations are building more and more of these projects, you have to be aware of that to be a corporation in China. And if you're involved in these projects, there is a stipulation in Chinese law, that it's built for the private sector. But everything has to have the caveat that it can be used for the People's Liberation Army. And so the PLA is allowed to utilize these ports, it's allowed, you're allowed to utilize these rail systems. That's a stipulation with the building projects. So you can see as we start to kind of put all the pieces here, they're really see basic, right. So they are putting logistics hubs all around the world where they could use for follow up military operations. And obviously, this has US Defense planners, very concerned. And the last thing is, it's kind of going beyond the the sector of infrastructure building and into other things such as information technology that's been in the news a lot lately about corporate espionage. And the concern that some of our Western Hemisphere partners might be engaging in contracts with Chinese information technology companies, and some of our trade secrets and wells, our military defense secrets might slip away. So those are concerns that were raised about the Belt and Road Initiative. And because of that, China has dropped from the fifth position to the eighth position in 2021. But what's even more concerning, is we've dropped from number one to number six. And so this was just released last month, for the first time ever, we're not on top in soft power, which is a huge concern. And that's why everyone who's listening to this lecture needs to be aware of this, and that our ability to export our soft power and our brand is more important today than it was five years ago, which kind of leads us to our humanitarian assistance missions. So in 2015, I was tasked with being a member of the comfort crew and executing the CP 15 mission. That was a plan to visit 11 mission or 11 countries as mission stops and a couple other countries as port calls and logistic stops. And I was one of two emergency physicians was myself and Luton commander Lawrence Decker, now commander Lawrence Decker. And so, when we got the initial order, here's what the commander's intent was only to read this word for works, I think it's important. So the purpose of continuing promise is to positively shape the strategic environment in the US SOUTHCOM AOR from the sea and build us, partner, nation, host nation, interagency and non government organization capacity and interoperability to conduct foreign humanitarian assistance, disaster relief operations. Okay. So it's really important capacity and interoperability. Nowhere in there, does it say medical, and I think it's the first I guess things that are new ones that every has to be aware of that medical is not the top priority, even though it's a hospital ship mission. And this is true of all soft power projection missions, they are not necessarily primarily medical. And I will tell you that on the comfort, we brought CBS that built infrastructure as well. There was diplomats we had, visitors come from all sectors of the economy. So there's really much more than medical. And sometimes as a leader, you have to communicate that to your people, because they don't necessarily understand it, especially if they're very junior. So here is the port of call for the CP mission, there's 11 countries in Central and South America with various mission stops. Here is the historical is protocol for the CP missions. And you can see when you put these two next to each other, there's a little bit of a trend here that I think everybody can identify. Alright, so what are the capabilities of the comfort? Well, you often hear that it's 1000 bed hospital ship, which is true, there are 1000 beds on the ship, but you only gonna utilize 1000 of those beds for the medical mission. If you displace all of your crew, so the crew sleeping on the deck, yep, you can put 1000 patients on board. But in general, it's really 40 Bed ICU, a 200 bed Ward, with 12 hours, we have a CT scanner, one of the big things that comfort can do that some people don't think about is it can make its own oxygen, and it can make its own freshwater, which is huge for a disaster response or for responding to a complex emergency, like a conflict. So what do emergency physicians do on board. So they're really for a humanitarian assistance mission, there's not a huge need for emergency medicine. There might be some crew members who need some emergency care, but you're not going to go ashore and deliver emergency care in general. So we're really there for contingencies. So if we have to divert the hospital ship to respond to a hurricane disaster or an earthquake disaster, that's what the emergency physicians are there for. But in the interim, if that doesn't happen, what do you do? Well, you see patients just like any other generalist, and we'll talk a little bit about that. You also are going to participate in subject matter expert exchanges. So you're going to help to meet with your counterpart in the host nation and talk about best practices. And then lastly, and I would say that this is really where we're ideally suited is to lead these medical engagement sites. And we'll talk a lot about that here in a moment. So what services are provided on these missions? Well, there's four main service lines, there's adult medicine, pediatric medicine, Optometry, which is primarily making classes for folks and then dentistry. So this is a picture of Dr. Jill dorsum. She was one of our residents at the time. And she came along as a for an elective rotation on a hospital ship. And the patients we saw are pretty much just like the patients we see in the emergency department. These are our top four chief complaints. So musculoskeletal complaints, obviously, we see tons of those in the US military, women's health, dermatology, and abdominal pain. So not a whole lot different from what we see back home and a garrison environment. What is different though, is your testing and diagnostic capability. So from a laboratory standpoint, we don't have a lot of resources, you can do a urine dipstick, you can check for diabetes, check for anemia, and then for whatever reason we could test for H. Pylori as the was something was requested from our host nations. And then we have very limited radiography. With the bedside ultrasound only being available on the ship, we did not bring that to the medical engagement sites unless it was absolutely necessary. So what happened was you got really good at using your exam to pare down your diagnostic workups. And this is a patient I saw on Haiti who has pre impressive conjunctival power, did confirm her medical written or hemoglobin with diagnostic testing, it was down at five, she had suspected malaria for which should we treated her. So the formulary is also very limited. We had antibiotics and had anti health metrics. And this is a picture from one of our interpreters who vomited up this new world worm. But there's not a lot of medication options, obviously, treatment for musculoskeletal diseases, treatment for reflux, antibiotics for infections, and then hypertensives, we didn't use a lot of antihypertensives, we ended up giving those to the host nation just because we didn't think it was appropriate to start that and not have proper follow up, and a lot of topical steroids and fumbles and tons of vitamins Of course. So one of the things that you have to be aware of your leading one of these missions is your provider mix and where that provider mix is on any given day. We found out very early in the mission, that oftentimes we'd have a patient who would definitely benefit from a certain sub specialist, but that certain sub specialist may not be at the site at that given day. So we had to come up with a provider matrix. And you can see we have lots of different sub specialists. We have cardiologists dermatologist nephrologist. There's dialysis available on the ship, although obviously not the engagement site, and there was a huge mental health need. So we had psychiatrists, and we just rotate those individuals and so if a person was there who needed those services We would just had them come back on the day when that service was available. I'm saying long term follow up is a little bit of a challenge. Sometimes it really depends on what resources are available in the host nation. This is a picture of Jamaica, one of the engagement sites there. And you can see that they have a pretty robust health care system as well as public health system. And here our volunteers are being recorded, so they can be followed up with in the Jamaican healthcare system. However, if the country was maybe had less resources, we were really dependent on external or outside forces to help get their follow on care. And so the non governmental organization volunteers, the NGO volunteers, were a huge resource. And this is a picture with Dr. Harry Owens, who was the chief medical officer on board, you are the hospital ship, hope, Project Hope, excuse me. And he was the CMO back in the 70s. Now that hospital ship doesn't exist anymore. However, Harry was a volunteer on our mission. And he was a great resource and helping us plug into the local NGO resources to get that follow on care. Another thing you should be aware of is your the complexity of the patients, the richer a country, the more complex, the patients would show up these engagement sites, because they obviously have had more resources or have more resources and had more of a workup before they got there. And so sometimes it was pretty difficult to come up with a plan that you could implement there at the engagement site that hadn't already been started or thought of by the outside providers in the host nation. As far as volumes are concerned, it really varied. I would say some of our providers could see 20 patients a day, that would be our sub specialists who are used to an hour long appointment back home, and then the emergency physicians could get up there to about 100. And that's an eight hour workday. So you're definitely moving. And one of the big benefits of one of these missions is very little medical documentation, nothing about the facts. So that's patient care. The next thing I want to talk about are subject matter experts exchanges. And this is really where you have a chance to probably build more healthcare infrastructure from a policy standpoint. And so if you look at emergency physicians in the military, we are the disaster experts, right. So if you look at health care system in the US, most of our emergency departments are functioning at disaster, mass casualty levels on a daily basis. If you look around at the provider mix in the military, they're always gonna look back at the emergency physicians as being the disaster experts. So regardless of how comfortable you are with that, just be aware that on these missions, you are the expert. And so when you go to talk to some of your counterparts in these hosting partner nations, you'll be talking about things that are probably pretty easy, from a day to day standpoint. So I'm a former diving medical officer, I feel very comfortable talking about diving injury. Obviously, as an emergency physician talking about ultrasound, I borrowed this from one of our ultrasound fellows. And her presentation was fantastic, I have no problems develop or delivering that. And then as a medical toxicologist talking about snake envenomation, was easy as well, although remember that the snakes are original, so a little bit more challenging, a little bit uncomfortable talking to a host nation physician about how they should manage their snake and animation. But that's a little bit easy by comparison, when you compare it to these type of lectures. So you're lecturing on disaster response for hurricanes and floods, and you've never really done it can be a little bit of a challenge. And I think as long as you are just straightforward about that with your host nation counterpart, that you have, you are speaking as the Navy's expert, but you have not routinely engaged in this can be a little bit disconcerting, but it's probably the best is going to get. Oftentimes you have to lecture in the host nations language. So it may not be in English, lecturing through an interpreter is a little bit of a challenge. And the only real caveat or Pro I can give you there is to keep your slides as simple as possible. And make sure whoever is interpreting for you has a very good working knowledge of medical, English and medical, the host nations language. And so we typically use one of our nurses who was bilingual. So moving on to leading medical engagement sites. So I would say that this is one of the more rewarding experiences that you will get during one of these missions, there are a couple things you're responsible for the command is going to expect you to optimize patient flow. So you can see that these are some of the countries that we go to there is a huge healthcare disparity and an overwhelming need for these this population. And so the more efficient you can become, the more people benefit from your presence there. And that's why I think that emergency physicians play a huge role because we just see inefficiency in all systems. The only thing that you're responsible for is crowd control, which can be a little bit of a challenge, particularly as medical officers, we don't deal with crowd control very often. But if you look at all the different specialties available, who's going to be more likely to understand crowd control and dealing with a socio economically impoverished population? It's gonna be the emergency physicians. And so that's I think we're better at this than most. And then trying to enable your providers to remove barriers so they can get to the patients and provide the best care is a challenge and again, it's a world Working within a system that's flawed and imperfect, and we do that better than most. So gave you the first mission stop at the CP mission was Billy's, which is a former British colony, they have a decent health care system. The first site that I was leading was the medical engagement site at the Hatfield public school. And you can see what this is what the exam rooms look like, there are essentially classrooms, which make it a little bit challenging to create some privacy for your patients, one of the first things you'll need to do as an officer in charge of one of these missions is to create the patient flow to make it as efficient as possible. And you can see here from the top of the screen there, that red around the red border around the site is a fence. And so there was a gate at the top and a gate off to the left hand side. And that was our patient flow, light. So that was an efficient way. So you don't have to looping back around on each other. But other things that we noticed, and this is a a diagram from Guatemala, that wasn't necessarily led by emergency physician, we were working in this area. And we noticed that there is a a corpsman or equivalent of a medic, who was directing traffic, and actually there was two of them for this area. And it seemed like just a big waste of manpower. So all we did that our Decker and I, we took that last row of seeds and just made shoots, the patients would just hop to the next seat and then getting into the the examination Bay, and then they would after they dumped the patient counter, they would just go over the pharmacy is that remove the two coordinate required for ushering and let them be used elsewhere. And that resulted in an increase in productivity of 27%. And when you're seeing 1000 patients a day, that's 270 patients more you can see. And so it might not seem like a huge increase in capability or productivity. But it really does translate to a lot more people getting the care they need. But I would say that one of the biggest lessons learned in that first mission stop was the hosting of VIPs. And here I'm hosting the Ministry of Health, the Minister of Health and her entourage. And I would say that this is definitely a little bit of an art that you don't necessarily feel prepared for with a general medical education. Also, this is hosting the ambassador to Belize and the United States and the deputy commander for SOUTHCOM. And this is the Navy Surgeon General. And then later on in the mission, went on to attend a state dinner with the President of Panama, as well as engage with the some physicians from a delegation from Cuba in Haiti. And this is the first time that US military physicians met Cuban military physicians in 60 years. So these are huge public relations events, that you can do a lot of harm if you don't know what you're doing, and don't recognize that. The first lesson is that these are public relations missions, not necessarily medical missions. And you have to understand that right up front, and you have to get your people to understand that as well. So moving on to Jamaica, this is actually our third mission stop, but the second one for me as a officer in charge, and this is a giant mission. So we are going to be setting up in the capitol in Kingston. And this is the use one of their indoor arenas to set up our medical engagement site. And this is me briefing the troops. And so on day three, we found out that CNN was coming, and we had already given tours to some of the members of the Jamaican Senate, other members of their government, but CNN was gonna be a big deal, right. So we're gonna broadcast this back home. Very important event, we already had some problems with some unrest outside the gates. And it was incredibly important to command this go off without a hitch. And so he heard that Dr. Gupta was coming to visit. He was going to set up here and that blue 10 Off to the left hand of the of the picture. And that was the entrance to the coming into the engagement site from the outside and he was going to do the interview there. And about that time, my senior chief comes up to me and says, Hey, Doc, they want to set up the Jamaica Ministry of Health wants to set up a safe sex display and do some public health teaching. Is that okay? Sure. Go ahead. Well, they want to set up in front of the blue tennis That sounds fantastic. Go ahead and do it'd be a great backdrop for Dr. Gupta. So that is what they set up. And I put this in there intentionally. That is what you think it is. And as you might imagine, that could be potentially something unsavory in the eyes of the US military. So try to be as diplomatic as possible. Talk to the individuals who are setting that up and say, hey, you know, you're sitting up in the front of the engagement site, most patients want to get right to their provider encounter, they're not going to be very patient with you, you might want to set up in front of the pharmacy, which is on the other side of that little blue tent, which will be a captive audience as they wait for their medications. And they thought it was a fantastic idea. They move that over there and the interview is conducted without that in the background. So it's a win win for everybody. But that's kind of brings me to my second lesson, and that the soft power missions. There is a huge need for media training. And you don't usually get that in medical school or residency as something you need to think about. We had mock interviews that were conducted with our public affairs officer, as well as Doing going through some talking points and doing some rehearsals. We were on a Nicaragua, we had some unique challenges to overcome there, primarily with transportation. So this is the hospital ship. And you'll see that there are some challenges with getting onto a tender when you're at seas, this is relatively calm seas, here, we can see that platform and that orange tender, sometimes they are rocking this way, it can kill them a little bit dangerous trying to step off into that thing. And so we actually had to hire some commercial tenders when we were in Colombia. That's that flat deck one you see there in the bottom, and you had to jump from the platform into the ship, which makes it a little bit of a challenge, right. So the other way that you can move yourself in patients is via air, right. So when we got to Nicaragua, it was determined that we were going to fly everybody to the engagement sites, which can be a little bit of a problem when you're talking about moving 200 People ashore in sticks of seven, right. But we're able to do that. There's definitely a trade off there. Some of them are folks who are arriving last and leaving first, we're only working for about four hours a day. But it did, let us do a couple of things. And so when you get good at moving 200 People ashore every day by Hilo, it's a that is a learning curve right there. And what I want you to focus on is that picture in the upper right hand corner, that looks a lot like these pictures here, which are embassy evacuation missions over the last 25 years. And so what I want to tell you is that these global health engagement missions are not just PR missions, but they're also rehearsals, which kind of leads us to what confers primary mission is its primary mission. The reason that the United States Navy has an inventory of hospital ships, is not to conduct humanitarian civil assistance missions, it's to support combat operations. Now, the ship's have not been used in that role since Desert Storm Desert Shield when I was in high school. But we certainly have used them in the humanitarian and civil assistance realm, as well as disaster response. We've done that quite effectively. But just keep in mind that you might be asked to do some things that don't make a whole lot of sense from a medical standpoint, because the commanding officer needs to stretch out the capabilities of the ship and figure out what the upper operating limits are. All right. So getting to our last mission stop, which was Haiti, which is the most impoverished country in the Western Hemisphere. And these are just two pictures that are, I'm trying to encapsulate that sentiment. So if you look at that first one in the upper left hand side, that is a market that we drove by, on the way from the ports to St. Luke's which are medical and gear, which was our medical engagement site. And what I want you to see is that, you know, that is a market that things are laid out in the tarp or for sale. And the rest of that is trashed some places, it's hard to determine what's what, but that just really is a reflection of their lack of resources. That second picture in their right lower corner is it's hard to see because it's a bit blurry, and we took it from a moving vehicle. But that is the basis of a river at low tide, right. So it's a little creek coming into the city, and low tide, that is trash that fills the bottom of the basin. In fact, that's how we kind of would know how close we're getting to shore we came from the tenders from the ship is the density of trash that was floating in the water. We also had a flight divers out to clean out the intakes because the saltwater intake is getting clogged with trash. And that's how we cool the ship. And so it was becoming pretty uncomfortable on board the ship. So just need to be aware of that. These countries are super impoverished, and the need is huge, which is why they have these giant crowds waiting for care. Now the 2011 mission, the Haitian crowd actually pushed down the walls, the engagement site. So crowd control is going to be incredibly important during this mission. So one of the novel ways we solve that problem is bringing the Fleet Forces band. So obviously music crosses all cultures, you know, it definitely helps people that are waiting for sometimes hours in the Caribbean heat to just kind of relax and not get too worked up and anxious. And so the fleet force is banned was a huge force multiplier. But every now and then the crowd does get a little bit worked up. And that's what we brought in some New York City police officers who are of Haitian descent, and they did a fantastic job engaging with the, you know, with the crowd at their level having been, you know, groomed and reared in that population. They knew exactly how to be culturally sensitive, but still be firm. And we didn't have any, I would say negative interactions with the crowd during that engagement site. And these are the individuals that helped make that happen. This is me with our our US Army JTF Bravo counterparts as well as those New York City police officers. So I know I've talked a lot about operations and one of the things I want to end with before I stop talking about the mission is that some of the kind of interesting cases and this is really what makes the mission that gratifying his deal is is kind of dealt with these medical problems that there's really not a lot of resources for the host nation, but doing it at the individual level with the patients. So this is an individual who has struck in the back by high power, what he called electrical lines and had the current shoot out the top of his head, and it burned off his scalp. And that's exposed calvarium that you're seeing right there. Now, obviously, we had antibiotics that we could give him to treat that that small infection that's kind of in the lower anterior part there of his scalp, but that's not gonna be the long term solution. So we had to work through an NGO to get him linked up with a plastic surgeons that could do a graft and cover that, so that he didn't have repeated problems with infection. This is a patient from Dominika that was referred for a broken leg and a lay limb length discrepancy, you can see the fracture in the middle of the heel fracture the middle of the femur. What you also see at the bottom are dents, Metastasio lines, which are consistent with heavy metal poisoning. And when you did an exam on this child, you would see what are called Burton lines and the gum there. And this is a six year old, whose mother reported to us that he liked to peel pain and chew on it. And so this is a child who, if not treated, could have a long term consequences with his neurologic development affect his, his schoolwork and his intelligence as an adult. And so we were able to link up with the Ministry of Health and get him plugged in for testing, and hopefully, correlation. And this last one is a great story. So this individual in El Salvador, that family brought this, this gentleman here to us, and he had a license driver's license and said that he was 100 years old. And he had just stopped walking, the family didn't understand why he was pretty much nonverbal at the time. And the grandson who's pictured to my left, you actually was carrying him around the village. And all they asked for was the solution to help him get around. At that time, it came at the end of the engagement site mission, we were out of, what do you call it out of wheelchairs. And so we got one from the ship, cost us a couple$100 gave it to the family and the whole family wept when we gave it to him. And I think that's really kind of helps to emphasize the point that you know, an individual level, your ability have an impact for an individual or a family comes down to your willingness to go the extra mile, we could have easily turned them away and said, Sorry, we don't have anything to help you out with. Making that connection with an NGO, or the Minister of Health or providing some kind of durable medical equipment is really what's going to make the difference and sway these individuals, you know, to our side. Okay, so the bottom line is, although these are PR missions, there are also medical admissions to these individuals, and you'll have the impact that you have really comes down to your willingness to go the extra mile. All right, so we're gonna quickly review those lessons learned that are up on the screen, I'm going to move into the last piece of this presentation, which is the Puerto Rico mission. So 2017 On September 20, Hurricane Maria slammed into Puerto Rico and pretty much destroyed the island. You know, leading up into that point, it was thought that it would if hurricane Maria, or tropical storm Maria formed a hurricane, it wouldn't do so until was in the mid Atlantic. That obviously was not the case. It hit Puerto Rico on the 20th. We activate on the 26th. And we are underway by the 28th. If you look at the path of Maria, it hit just south of a city called Macau and then attract along the spine of the island, gathered up strength and exited. And so it really perfectly hit and then went across the island and exited, destroying everything in its path. And I think this picture really illustrates that you can see the blue Tyvek, where the shingles of roofing have been torn apart for several buildings and have no roof at all. And that's what most of the island looked like. So we arrived on the second of October. And we immediately sent a team ashore I was a part of that team, I was the only medical representative to do a site survey to figure out where the greatest need was and to figure how to get them to the ship. So it was a bit of a challenge, we could move into the interior of the island because all of the roads were impassable. And even going around the outside of the island, Macau, here's what the roads look like, still pretty difficult to get there. On the far right there. That's a three foot concrete reinforced pylon that was snapped in multiple places. That's pretty indicative of what the island looked like. So everything in the center part of the island had been hit pretty hard, but there was no way to reach them. And so the the ship looked like this, which was from a medical mission, and a PR mission is less than ideal. And so we had to figure out a way to get the patients to the ship. And the only way to do that, because you can't fly patients on board the ship and it's important. It's a Coast Guard regulation, we had to go out to sea. So we pushed out to sea and in the interim, we were waiting to start receiving patients. We started rehearsing what we would do in the back of the MH 60 By making a mock up there in our cache and receiving which the er the ship here our positions, the first part of that mission. And so we actually went all the way around the island down to Ponce and then came back picking up critical care patients by air evac, and so are in route care teams were composed of two providers one had to be a board certified physicians so we paired board certified emergency physicians with CRNAs. And board certified anesthesiologist with emergency medicine residents. We ended up flying about 127 missions or so we bring 127 patients to the ship. And here are some of the sticking points that we ran into. Oftentimes, we couldn't identify the LLC when we got there, because of all the debris, sometimes we would land we get to the hospital, and the hospital would have either, you know, transferred the patients somewhere else. Or sometimes they held on to the patients, especially if they were paying customers. And I'll talk about that in a moment here. Because most people with means left the island. And so if you had a paying customer, you want to keep your hospital afloat, you kept those patients didn't transfer them to comfort. Alright, oftentimes we get there, they're being escort with the patient we weren't accounting for, we had to troubleshoot all these things kind of in the mission. Now some of the patients we picked up were pretty darn sick on pressors, or on anti dust Rhythmix we had to do push those pressors in the field in order to prevent Peri intubation arrest twice, we publish those results in the Journal of pre hospital disaster medicine. But eventually, they were able to clear the roads after about two to three weeks, and we were able to start taking patients via land. So we went back to Puerto Rico and started the second phase, which is the Pierside phase of the mission. So here's a schematic of what the ER casually receiving looks like on board the ship. It's a 47 bed facility. And this is a schematic of the patient flow or the diagram for patient flow getting to the resuscitation area. However, I do want to point out that those green areas were actually staffed by generalist pediatricians, internists, and family practitioners. And our surgeons were staffing the wound care area, the ones that weren't in the O R, and we were staffing the red area, the resuscitation area, which is staffed by one emergency physician, and one emergency medicine resident, per shift. And so it was very interesting is that our model was kind of takes the US model flips it on its head, and that we have generalist seeing majority of patients then making a console to emergency medicine for patients that require resuscitation. So it worked out really well. It was very gratifying. And it really leveraged our manpower in such a way that we provide the most care to the most people. However, there was also plenty of VIPs to hosts so and media engagements to participate in. So that on the left hand side is us briefing, the US Surgeon General on the right side is taking an interview from one of the new stations. All right, so I've kind of already mentioned this, but um, I talked about this briefly. And this was an orthopedic patient that was referred to us during the Pierside phase of the mission. And I'm just gonna read the bottom as a patient who's going to tibial plateau fracture, but no compartment syndrome, no vascular injury. And it says the patient does not have medical insurance and does not qualify for reform, which is their version of Medicaid. We're currently completing paperwork for the patient, we transferred to the comfort for further management, I tell this patient got there, there was a big uproar about how they would turf this patient in the middle of a disaster because they couldn't pay. And that was my initial reaction as well. And I guess I'm a little bit embarrassed to say that in retrospect, but I will say that the more I thought about it, I would say the more all of us thought about we realized that, hey, you know, whenever you are conducting one of these missions, you need to make sure that when you leave that the medical resources in place, can manage the medical mission after you're gone. And so for these hospitals to retain the paying patients and send us the indigent care patient makes complete sense in that regard and that big picture. So we would have, you know, there was a bunch of talk about whether or not that's ethical, I think it's completely ethical. If you look at it from a system standpoint, and a disaster response standpoint, that was the right call by that hospital, and we should not second guess, what they're doing to keep their healthcare infrastructure sustained. So, and like I said, the bottom line at the individual level, these are medical missions, regardless of what the other possible gains are. And that is where you're gonna have the biggest impact in the care you provide to these patients. So where do emergency physicians, physicians belong in this type of operation? So there was a article published in the emergency medicine clinics in North America in 2005. And they created a huge laundry list of reasons why emergency physicians should be involved in these missions, we tend to do well in high stress environments. We can make decisions with limited or no information. We have a broad knowledge base. We're used to dysfunctional healthcare systems, and certainly are no strangers to social emergencies. But I would argue that we're not just we should not just be a part of this. We should be leading these missions for all the reasons I already described. We tend to make make the best decisions under pressure, we tend to understand the dynamics that are involved, we tend to not get so zeroed in on the medicine that we lose the big picture. And so I would tell everybody who's listening today, that if you are planning on making the career or a career of the US military, in the medical corps, that you should, without a doubt, try to be involved in one of these missions during the course of your career. And if you're a senior leader or a senior officer, you should try to lead one of these missions. I will say that for my personal career, it was incredibly gratifying. I learned a ton about myself and learned a ton about my role kind of in the bigger picture. And I thought it was very professionally gratifying, one of the best experiences of my career. And so I would highly encourage everyone to take a part of one of these missions. And so that's all I have. I appreciate everybody's time. If you have any questions, I'd be happy to feel those at this time.