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

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

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Episode Transcript

John Devlin (00:03):
All right. Good morning. I'm Captain John Devlin
on the Emergency MedicineResidency Program Director here
at Naval Medical CenterPortsmouth, and I just want to
thank the planning committee forinviting me to speak. And today
I'll be talking about us softpower and the role of military
emergency medicine in thosemissions. And I'll be drawing
from lessons learned from recentNavy hospital ship missions,
specifically the 2015 continuingpromise mission and the SOUTHCOM

(00:26):
AOR, as well as the 2017hurricane relief operations in
Puerto Rico.

Unknown (00:34):
So first, the DoD disclaimer, I just want to say
that these opinions are my ownopinions, they do not represent
the United States Navy, or theDepartment of Defense, that
these slides were prepared inthe course of my normal official
duties. And then just one quickcomment on images. So unless the
images contain an annotation,they are available in the public
domain. Most of these weretaken from the hospital ship

(00:55):
comfort and the Public AffairsOffice. And they are available
through the defense visualinformation distribution
services, which is availableonline. Another note is this is
pre recorded recording from ourresidency spaces on in the
hospital. So you may hear someoverhead responses, those kinds
of things. I apologize, I can'tfilter that out. All right. So
just for today, I want to startoff with just describing what

(01:18):
Soft power is, and its role ininternational diplomacy, how
they both the US and some of ouradversaries utilize that. And
then we'll talk aboutspecifically how Navy hospital
ship missions fit into that. Butthat can these lessons can be
applied to any kind ofhumanitarian assistance type of
mission, whether it be Army, AirForce, or navy. And then lastly,
we'll talk about lessonslearned. And then I'll identify
some pearls that I think that ifyou are ever in charge of one of

(01:41):
these missions, you cangeneralize these to your
mission, things you need toconsider before you step off, to
ensure mission success.
Alright, so we're gonna startoff with a story, The Tale of
Two admirals and so I thinkeverybody probably recognizes
the individual on the far right,that's Vice Admiral Mike Mullen.

(02:01):
He's the former Chairman of theJoint Chiefs of Staff from 2007
to 2011. But probably very fewof you, including those in the
audience that are Navy recognizeAdmiral John nappin. So at the
time of 2000 or so the title of911 Admiral Nathanson was the
commander for Naval Air Force'sUS Pacific fleet, and so he's in

(02:21):
charge of the South Pacificright are in charge of the South
China Sea. We know that therehas been an increase in I guess,
the boldness of our Chineseadversary there, they are
expanding to the nine dash linethere are claiming territorial
rights for various islands thatare disputed by other nations in
that region. And they arestarting to militarize those

(02:44):
islands. So specifically, theSpratlys. And the Paracel
Islands are becoming a homeports for military bases, right.
And so that's going to informall of Admiral Nachman strategic
decision making, right so whenyou think about what he is most
interested in, he is moreinterested in building the Navy
up so that he can counter thisincrease in aggression in the

(03:06):
South China Sea, right. So whenhe moves on to become the Deputy
Chief of Naval Operations forwarfare requirements and
programs, he wants to build moreships and grow the US Navy. And
this is in direct contrast withAdmiral Mullens perspective. So
Admiral Mullen and the early2000s, he is the commander for
Navy forces Europe, and so theydon't have a numbered fleet. He

(03:29):
is very aware of what's going onin CENTCOM and the
counterinsurgency war. And whathe recognizes is that
globalization has reshaped thebattlefield and that with
international trade, withinternational information
sharing, that you really have tohave a much more thoughtful, I
guess, all encompassing responsein order to fight this new

(03:50):
threat. And so he recognizesthat the future of naval
operations needs to keep allthis in mind. And that's the
only way we're going to besuccessful. And so he comes up
with a document or I guess hiscamp is or the intellectuals
that come up with this document.
He's already retired at thispoint, but the 2015 Cooperative
strategy for 21st centuryseapower incorporates an

(04:11):
operating concept called the1000. Ship navy. So if you were
to take Admiral Nathansperspective, you'd want to build
more ships, there's no way theUnited States can afford 1000
naval vessels and we can'tafford the upkeep and there's a
lot of reasons why that's not acost effective strategy.
However, if you incorporateAdmiral Mullens perspective, we
could through buildingpartnerships have access to 1000

(04:35):
ship fleet, it won't be all usbut with our partners and our
allied nations, we couldeventually have this group of
cooperative countries that couldnumber 1000 ships and that's
what the 1000 ship Navy conceptcomes from. It's not a physical
1000 US ships, but it's 1000ships at our, I guess that are

(04:55):
willing to react in a quantityprofession, right? And so what
would they be responding to?
Well, we want to keep all of themaritime sea trade open. Because
if you look at Commerce 90% ofthat is conducted by sea. So
it's not just a, we need theNavy to fight wars, but we need
the Navy to keep these commerceand shipping lanes open. So it

(05:17):
doesn't affect us from aneconomic standpoint. And so this
is that broader, global look atthe Navy's mission. And you
could extrapolate that out tothe Army, the Air Force as well,
that we need to have a role inmaintaining the status quo with
economic trade, as well as beingable to fight wars. And so this
comes into the concept orinforms the concept of all

(05:39):
domain access, right? So if weneed to keep all these shipping
lanes open, we need to respondto them, anytime, anywhere. And
that's a access to that domain.
And we do that through ourcooperative agreements with
other countries. We can't do itall ourselves, we have to rely
on some of our partner nationsas well. Okay. So that's kind of
the military piece of it, right?

(06:00):
And that's how, how are we goingto get to that place? Well,
that's how US soft power comesin. And before we get into soft
power, I want to talk about theother half of this. So this is
how so the 1000 ship Navy, andthe all domain access is how
we're going to respond to athreat. But what about just
reducing the threat to beginwith? Well, that is where we get

(06:20):
into the other part of softpower, right? So building
relationships, buildinginfrastructure, if you look at
the relationship between povertyand radicalization, it's
actually pretty strong outsideof predominantly Muslim
countries. So if you look atMuslim countries and Islamic
radicals, there's really not agreat relationship between socio
economic resources andeducation. In fact, there's some

(06:42):
incredibly highly trainedindividuals in those regions who
are very radicalized. When youlook at the Western Hemisphere,
and you look at our poornations, there is a great
relationship between poverty andradicalization. So if you can
help to pull our partners out ofpoverty, they're less likely to
have the night as aradicalization forming in their

(07:04):
countries and less likely tocreate a threat that we have to
respond to militarily. So that'sthe other half of global power,
it will help us verysoft power, and that it will
allow us to better respond tothreats and also prevent strip
threats from forming.
When it comes to radicalizationin the Western Hemisphere, we
often are very preoccupied withal Qaeda, with ISIS. But if you

(07:27):
can think back and some of youguys weren't even born yet, but
think back before 911, we reallydidn't, you know, the, the
biggest problem from aradicalized religious standpoint
was from Hezbollah. And we knowfor a fact that Hezbollah has
roots in the Western Hemisphere,both from a financing
standpoint, and also from anoperating standpoint,
particularly in Honduras, thereis a Honduran Hezbollah group

(07:50):
there that is very active. Andit's probably no surprise to
anybody. That's why JTF Bravo isheadquartered in Honduras. So
these are things that we have topay attention to, because if we
ignore them, they're gonnabecome bigger threats that are
going to force a militarysolution, which is what we want
to try to avoid.
Alright, so what is thedefinition of soft power? Well,
this is a term that was coinedby Joseph Nye back in the the

(08:12):
end of the Cold War. And that'sthe ability of a country to
persuade others to do what itwants without force or coercion.
If you put that into departmentdefense terms, what it really
means is the ability for us toeither engender goodwill with
nations that we can pre positionforces or create favorable
conditions. So when we do haveto engage in combat operations

(08:34):
or in lieu of combat operations,we are more likely to succeed in
our mission. And so this isreally battlespace shaping. And
so it's a term that we use andJP me that we've talked about
for decades. This is helping toshape the environment so that
we're more likely to win. And soif you think if you remember
nothing else from thispresentation, what I want you to

(08:54):
take home from this presentationis that these soft power
missions, these global healthengagement missions are really
helping to battlespace shape,and that's one of the the roles
and responsibilities thatmilitary medicine has is to use
what we can to help ensurevictory, should we have to
engage in combat operations. Andthis is one way we do it. To
kind of put it differently.
Admiral Mullen said preventingWars is as important as winning

(09:17):
them, and far less costly, andthat's cost in terms of human
life, as well as material andcapital. Wars are incredibly
expensive, result in a lot ofcivilian deaths. And if you look
at any of the disaster responseand complex
disaster scenarios, the civiliandeath toll is getting higher and

(09:38):
higher, with every one of theseconflicts. Another way to put it
the Chief of Naval Operations,Mr. Richardson said, I want to
be the best at not fightingRussia and China. So if we're
successful from a soft powerstandpoint, we never have to go
to war.
Alright, so how do we measuresoft power? Well, there's lots
of different metrics out there,but probably the one that's most

(09:59):
routinelyappointed to as the authority is
the Brand Finance branddirectory and their global soft
power index. And so I'm going togive you the data from the 2020.
White Paper. But we're firsttalk about the inputs that go
into it. So there's sevendifferent pillars that are used
to provide a measure of howsuccessful a country is, and
getting its brand out there andalso

(10:24):
goes into how familiar countriesare, with your brand, the
influence that a country has,and its reputation for being a
global source of goodness, asopposed to just following its
own self interests. So what goesinto this? Well, there's really
two lines of effort. A brand hasa general audiences line of
effort, which is for the 2020power index, it involved 54,000

(10:47):
online surveys in 87 countries.
And then the other half of thatis the specialist audience,
which is interviews, personalinterviews with over 1000
Subject Matter Experts among 71countries, 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,

(11:08):
you can see that the UnitedStates is at the top. And this
is again, this is March of 2020.
We're in a little bit differentplace now. But here's an exact
quote from the executivesummary. Soft power cannot be
rapidly achieved nor lost. TheUnited States has shown that
ultimately, despite thereputational challenges and
impeachment in the unpredictableforeign policy, its position as
the rule maker and internationalsystem, and the world's only

(11:30):
soft power superpower isunrivaled. So I will say that
that is not necessarily the casetoday, and we'll talk about
that. But what they alsoidentified is that China has
invested a lot into soft power,and it's working for them. And
that China and Russia are kindof dictating global change right
now. So let's get into thespecifics of what China has done

(11:51):
from a soft power standpoint. Sosome of you may have heard about
the Belt and Road Initiative.
It's a gigantic, colossalinfrastructure building project.
And so belt refers to any kindof overland route, which really
is to is designed to recreateand expand upon the old Silk
Road concepts. This is reallyconnecting metropolitan areas in

(12:16):
Europe, Eurasia with themetropolitan areas in China, so
that you have internationaltrade or facilitates
international trade andpotentially reducing shipping
costs, and maybe making Chinathe preferred partner. The road
refers to maritime networks, andthese are primarily connecting
the Pacific nations with China,as well as Africa with China and

(12:39):
Africa is incredibly importantfrom a strategic standpoint for
the Chinese. So the Chinese area gigantic economy, and they are
a huge consumer of oil. And someof the largest energy reserves
are available on the continentof Africa. Right now, China
spends about $285 billion a yearon oil imported from Africa,

(12:59):
which represents about 18% ofits consumption. Now, the
reserves there are prettysubstantial. So the future for
the future. Africa is essentialto China, and their ability to
keep their economy and theirmilitary on track. Alright, so I
want you to briefly just take amoment to look at that picture.

(13:19):
And then it's super superimposedanother picture on it.
And this is a militaryoperation, a Chinese military
operation, you can see it's anaval operation that takes off
from China from the mainland,stops at a port in Sri Lanka.
And that port is a is a part ofthe the Belton Road initiative.
It's a little bit of acontroversial project in that

(13:41):
the Chinese have are essentiallyrunning it. But it is based in
Sri Lanka, then stops inDjibouti and other logistical
stop in Spain and then comesaround the western coast of
Africa. And particularly instops three, four and five,
those are huge oil exportingcountries and comes around two
stops five and six and then endsup in timber. Okay, so this is a

(14:02):
military operation. But it isnot a gray hole operation. This
is a medical HumanitarianAssistance Mission by Peace Ark,
which is China's only operatinghospital ship and as equivalent
to USNS comfort and us as mercyin the US inventory. And so you
can see that the Chineserecognize that the US missions

(14:24):
with comfort and mercy have beenvery successful in cultivating
soft power. So China has kind oftaken a page from our playbook
and using it to further theireconomic ambitions. So one of
the other concerns about theBelt and Road Initiative is not
just its geopoliticalpositioning, but also something

(14:47):
called the debt trap diplomacy.
So if you look at theseprojects, and here's an example
of from the Western Hemisphere,it's not just the eastern
hemisphere, of countries thatare signatories to the
Belton Road initiative. And youcan see that they've taken on
huge loans from the Chinese. Soif these were,

(15:07):
you know, free grants orinternational aid that wasn't
expect to be paid back, that'dbe one thing. But these are low
interest loans are expected tobe paid back. And we all
recognize that Venezuela'sgovernment is pretty chaotic.
Their healthcare infrastructureis almost non existent. They've
taken on gigantic loans from theChinese, a lot of watchdog
groups have coined this phrasethat debt trap diplomacy,

(15:30):
because there are multiplecountries whose debt that they
have incurred from the Chinesedoes not match up with the
requisite increase in their,what he called gross domestic
product, there's a concern, theywill never be able to pay those
back. Or that the Chinese mightuse course of methods, when they
go to repack, repay these loans,that it might ask for certain

(15:51):
concessions. So it's a bigconcern among along the, I
guess, in the internationaldiplomatic community.
So those countries are not theonly ones who have signed on for
the Belton Road initiative.
These are other countries in theWestern Hemisphere that have
done so. And you can see some ofthose are neighbors that are
pretty darn close to the UnitedStates. And so it is on our best
interest to keep this in check.

(16:15):
And there's a lot of concernsabout the Belton Road
initiative. One is that debttrap diplomacy, there's a lot of
promises, transparency, Wheredoes this money actually coming
from? It's certainly a hugeproject of President sieging
pains. However, a lot of thesethings are tied to corporations
in China. And there are someconcerns that there are certain

(16:36):
stipulations with thesecontracts between the two
governments that really bring inChinese, the private sector from
China to to build thisinfrastructure. And so this,
these loans are being providedto these countries, and then
have to give that money back toChinese companies. So it never
actually stimulates theireconomies, it just goes back to

(16:56):
China. Obviously, that's aconcern.
So the last concern is that thisis moving beyond just
infrastructure. And that's wherewe get into some of the
contractual things with theChinese government and Chinese
corporations. So as Chinesecorporations are building more
and more of these projects, youhave to be aware of that to be a

(17:18):
corporation in China. And ifyou're involved in these
projects, there is a stipulationin Chinese law, that it's built
for the private sector. Buteverything has to have the
caveat that it can be used forthe People's Liberation Army.
And so the PLA is allowed toutilize these ports, it's
allowed, you're allowed toutilize these rail systems.
That's a stipulation with thebuilding projects. So you can

(17:41):
see as we start to kind of putall the pieces here, they're
really see basic, right. So theyare putting logistics hubs all
around the world where theycould use for follow up military
operations. And obviously, thishas US Defense planners, very
concerned. And the last thingis, it's kind of going beyond
the the sector of infrastructurebuilding and into other things
such as information technologythat's been in the news a lot

(18:03):
lately about corporateespionage. And the concern that
some of our Western Hemispherepartners might be engaging in
contracts with Chineseinformation technology
companies, and some of our tradesecrets and wells, our military
defense secrets might slip away.
So those are concerns that wereraised about the Belt and Road
Initiative. And because of that,China has dropped from the fifth

(18:24):
position to the eighth positionin 2021. But what's even more
concerning, is we've droppedfrom number one to number six.
And so this was just releasedlast month, for the first time
ever, we're not on top in softpower, which is a huge concern.
And that's why everyone who'slistening to this lecture needs

(18:44):
to be aware of this, and thatour ability to export our soft
power and our brand is moreimportant today than it was five
years ago, which kind of leadsus to our humanitarian
assistance missions. So in 2015,I was tasked with being a member
of the comfort crew andexecuting the CP 15 mission.

(19:05):
That was a plan to visit 11mission or 11 countries as
mission stops and a couple othercountries as port calls and
logistic stops. And I was one oftwo emergency physicians was
myself and Luton commanderLawrence Decker, now commander
Lawrence Decker. And so, when wegot the initial order, here's
what the commander's intent wasonly to read this word for

(19:28):
works, I think it's important.
So the purpose of continuingpromise is to positively shape
the strategic environment in theUS SOUTHCOM AOR from the sea and
build us, partner, nation, hostnation, interagency and non
government organization capacityand interoperability to conduct
foreign humanitarian assistance,disaster relief operations.

(19:51):
Okay. So it's really importantcapacity and interoperability.
Nowhere in there, does it saymedical, and I think it's the
firstI guess things that are new ones
that every has to be aware ofthat medical is not the top
priority, even though it's ahospital ship mission. And this
is true of all soft powerprojection missions, they are
not necessarily primarilymedical. And I will tell you

(20:12):
that on the comfort, we broughtCBS that built infrastructure as
well. There was diplomats wehad, visitors come from all
sectors of the economy. Sothere's really much more than
medical. And sometimes as aleader, you have to communicate
that to your people, becausethey don't necessarily
understand it, especially ifthey're very junior. So here is
the port of call for the CPmission, there's 11 countries in

(20:36):
Central and South America withvarious mission stops. Here is
the historical is protocol forthe CP missions.
And you can see when you putthese two next to each other,
there's a little bit of a trendhere that I think everybody can
identify.

(20:57):
Alright, so what are thecapabilities of the comfort?
Well, you often hear that it's1000 bed hospital ship, which is
true, there are 1000 beds on theship, but you only gonna utilize
1000 of those beds for themedical mission. If you displace
all of your crew, so the crewsleeping on the deck, yep, you
can put 1000 patients on board.
But in general, it's really 40Bed ICU, a 200 bed Ward, with 12
hours, we have a CT scanner, oneof the big things that comfort

(21:20):
can do that some people don'tthink about is it can make its
own oxygen, and it can make itsown freshwater, which is huge
for a disaster response or forresponding to a complex
emergency, like a conflict. Sowhat do emergency physicians do
on board. So they're really fora humanitarian assistance
mission, there's not a huge needfor emergency medicine. There

(21:40):
might be some crew members whoneed some emergency care, but
you're not going to go ashoreand deliver emergency care in
general. So we're really therefor contingencies. So if we have
to divert the hospital ship torespond to a hurricane disaster
or an earthquake disaster,that's what the emergency
physicians are there for.
But in the interim, if thatdoesn't happen, what do you do?

(22:02):
Well, you see patients just likeany other generalist, and we'll
talk a little bit about that.
You also are going toparticipate in subject matter
expert exchanges. So you'regoing to help to meet with your
counterpart in the host nationand talk about best practices.
And then lastly, and I would saythat this is really where we're
ideally suited is to lead thesemedical engagement sites. And
we'll talk a lot about that herein a moment.

(22:23):
So what services are provided onthese missions? Well, there's
four main service lines, there'sadult medicine, pediatric
medicine, Optometry, which isprimarily making classes for
folks and then dentistry.
So this is a picture of Dr. Jilldorsum. She was one of our
residents at the time. And shecame along as a for an elective
rotation on a hospital ship. Andthe patients we saw are pretty

(22:45):
much just like the patients wesee in the emergency department.
These are our top four chiefcomplaints. So musculoskeletal
complaints, obviously, we seetons of those in the US
military, women's health,dermatology, and abdominal pain.
So not a whole lot differentfrom what we see back home and a
garrison environment. What isdifferent though, is your
testing and diagnosticcapability. So from a laboratory

(23:06):
standpoint, we don't have a lotof resources, you can do a urine
dipstick, you can check fordiabetes, check for anemia, and
then for whatever reason wecould test for H. Pylori as the
was something was requested fromour host nations. And then we
have very limited radiography.
With the bedside ultrasound onlybeing available on the ship, we
did not bring that to themedical engagement sites unless

(23:26):
it was absolutely necessary. Sowhat happened was you got really
good at using your exam to paredown your diagnostic workups.
And this is a patient I saw onHaiti who has pre impressive
conjunctival power, did confirmher medical written or
hemoglobin with diagnostictesting, it was down at five,
she had suspected malaria forwhich should we treated her.

(23:50):
So the formulary is also verylimited. We had antibiotics and
had anti health metrics. Andthis is a picture from one of
our interpreters who vomited upthis
new world worm. But there's nota lot of medication options,
obviously, treatment formusculoskeletal diseases,
treatment for reflux,antibiotics for infections, and

(24:11):
then hypertensives, we didn'tuse a lot of antihypertensives,
we ended up giving those to thehost nation just because we
didn't think it was appropriateto start that and not have
proper follow up, and a lot oftopical steroids and fumbles and
tons of vitamins Of course.
So one of the things that youhave to be aware of your leading
one of these missions is yourprovider mix and where that
provider mix is on any givenday. We found out very early in

(24:33):
the mission, that oftentimeswe'd have a patient who would
definitely benefit from acertain sub specialist, but that
certain sub specialist may notbe at the site at that given
day. So we had to come up with aprovider matrix. And you can see
we have lots of different subspecialists. We have
cardiologists dermatologistnephrologist. There's dialysis
available on the ship, althoughobviously not the engagement
site, and there was a hugemental health need. So we had

(24:54):
psychiatrists, and we justrotate those individuals and so
if a person was there who neededthose services
We would just had them come backon the day when that service was
available.
I'm saying long term follow upis a little bit of a challenge.
Sometimes it really depends onwhat resources are available in
the host nation. This is apicture of Jamaica, one of the
engagement sites there. And youcan see that they have a pretty

(25:14):
robust health care system aswell as public health system.
And here our volunteers arebeing recorded, so they can be
followed up with in the Jamaicanhealthcare system. However, if
the country was maybe had lessresources, we were really
dependent on external or outsideforces to help get their follow
on care. And so the nongovernmental organization
volunteers, the NGO volunteers,were a huge resource. And this

(25:37):
is a picture with Dr. HarryOwens, who was the chief medical
officer on board, you are thehospital ship, hope, Project
Hope, excuse me. And he was theCMO back in the 70s. Now that
hospital ship doesn't existanymore. However, Harry was a
volunteer on our mission. And hewas a great resource and helping

(25:57):
us plug into the local NGOresources to get that follow on
care. Another thing you shouldbe aware of is your the
complexity of the patients, thericher a country, the more
complex, the patients would showup these engagement sites,
because they obviously have hadmore resources or have more
resources and had more of aworkup before they got there.
And so sometimes it was prettydifficult to come up with a plan

(26:20):
that you could implement thereat the engagement site that
hadn't already been started orthought of by the outside
providers in the host nation. Asfar as volumes are concerned, it
really varied. I would say someof our providers could see 20
patients a day, that would beour sub specialists who are used
to an hour long appointment backhome, and then the emergency
physicians could get up there toabout 100. And that's an eight
hour workday. So you'redefinitely moving. And one of

(26:42):
the big benefits of one of thesemissions is very little medical
documentation, nothing about thefacts. So that's patient care.
The next thing I want to talkabout are subject matter experts
exchanges. And this is reallywhere you have a chance to
probably build more healthcareinfrastructure from a policy
standpoint. And so if you lookat emergency physicians in the
military, we are the disasterexperts, right. So if you look

(27:04):
at health care system in the US,most of our emergency
departments are functioning atdisaster, mass casualty levels
on a daily basis. If you lookaround at the provider mix in
the military, they're alwaysgonna look back at the emergency
physicians as being the disasterexperts. 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 tosome of your counterparts in

(27:24):
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 medicalofficer, I feel very comfortable
talking about diving injury.
Obviously, as an emergencyphysician talking about
ultrasound, I borrowed this fromone of our ultrasound fellows.
And her presentation wasfantastic, I have no problems

(27:46):
develop or delivering that. Andthen as a medical toxicologist
talking about snakeenvenomation, was easy as well,
although remember that thesnakes are original, so a little
bit more challenging, a littlebit uncomfortable talking to a
host nation physician about howthey should manage their snake
and animation. But that's alittle bit easy by comparison,
when you compare it to thesetype of lectures. So you're

(28:09):
lecturing on disaster responsefor hurricanes and floods, and
you've never really done it canbe a little bit of a challenge.
And I think as long as you arejust straightforward about that
with your host nationcounterpart, that you have, you
are speaking as the Navy'sexpert, but you have not
routinely engaged in this can bea little bit disconcerting, but
it's probably the best is goingto get. Oftentimes you have to

(28:31):
lecture in the host nationslanguage. So it may not be in
English, lecturing through aninterpreter is a little bit of a
challenge. And the only realcaveat or Pro I can give you
there is to keep your slides assimple as possible. And make
sure whoever is interpreting foryou has a very good working
knowledge of medical, Englishand medical, the host nations

(28:52):
language. And so we typicallyuse one of our nurses who was
bilingual.
So moving on to leading medicalengagement sites. So I would say
that this is one of the morerewarding experiences that you
will get during one of thesemissions, there are a couple
things you're responsible forthe command is going to expect
you to optimize patient flow. Soyou can see that these are some

(29:14):
of the countries that we go tothere is a huge healthcare
disparity and an overwhelmingneed for these this population.
And so the more efficient youcan become, the more people
benefit from your presencethere. And that's why I think
that emergency physicians play ahuge role because we just see
inefficiency in all systems. Theonly thing that you're
responsible for is crowdcontrol, which can be a little
bit of a challenge, particularlyas medical officers, we don't

(29:35):
deal with crowd control veryoften. But if you look at all
the different specialtiesavailable, who's going to be
more likely to understand crowdcontrol and dealing with a socio
economically impoverishedpopulation? It's gonna be the
emergency physicians. And sothat's I think we're better at
this than most. And then tryingto enable your providers to
remove barriers so they can getto the patients and provide the

(29:57):
best care is a challenge andagain, it's a world
Working within a system that'sflawed and imperfect, and we do
that better than most.
So gave you the first missionstop at the CP mission was
Billy's, which is a formerBritish colony, they have a
decent health care system. Thefirst site that I was leading
was the medical engagement siteat the Hatfield public school.

(30:18):
And you can see what this iswhat the exam rooms look like,
there are essentiallyclassrooms, which make it a
little bit challenging to createsome privacy for your patients,
one of the first things you'llneed to do as an officer in
charge of one of these missionsis to create the patient flow to
make it as efficient aspossible. And you can see here
from the top of the screenthere, that red around the red
border around the site is afence. And so there was a gate

(30:40):
at the top and a gate off to theleft hand side. And that was our
patient flow, light. So that wasan efficient way. So you don't
have to looping back around oneach other. But other things
that we noticed, and this is a adiagram from Guatemala, that
wasn't necessarily led byemergency physician, we were
working in this area. And wenoticed that there is a a
corpsman or equivalent of amedic, who was directing

(31:02):
traffic, and actually there wastwo of them for this area. And
it seemed like just a big wasteof manpower. So all we did that
our Decker and I, we took thatlast row of seeds and just made
shoots, the patients would justhop to the next seat and then
getting into the the examinationBay, and then they would after
they dumped the patient counter,they would just go over the
pharmacy is that remove the twocoordinate required for ushering

(31:24):
and let them be used elsewhere.
And that resulted in an increasein productivity of 27%. And when
you're seeing 1000 patients aday, that's 270 patients more
you can see. And so it might notseem like a huge
increase in capability orproductivity. But it really does
translate to a lot more peoplegetting the care they need.
But I would say that one of thebiggest lessons learned in that

(31:46):
first mission stop was thehosting of VIPs. And here I'm
hosting the Ministry of Health,the Minister of Health and her
entourage. And I would say thatthis is definitely a little bit
of an art that you don'tnecessarily feel prepared for
with a general medicaleducation. Also, this is hosting
the ambassador to Belize and theUnited States and the deputy

(32:09):
commander for SOUTHCOM. And thisis the Navy Surgeon General. And
then later on in the mission,went on to attend a state dinner
with the President of Panama, aswell as engage with the some
physicians from a delegationfrom Cuba in Haiti. And this is
the first time that US militaryphysicians met Cuban military
physicians in 60 years. So theseare huge public relations

(32:33):
events, that you can do a lot ofharm if you don't know what
you're doing, and don'trecognize that. The first lesson
is that these are publicrelations missions, not
necessarily medical missions.
And you have to understand thatright up front, and you have to
get your people to understandthat as well.
So moving on to Jamaica, this isactually our third mission stop,
but the second one for me as aofficer in charge, and this is a

(32:55):
giantmission. So we are going to be
setting up in the capitol inKingston. And this is the use
one of their indoor arenas toset up our medical engagement
site. And this is me briefingthe troops. And so on day three,
we found out that CNN wascoming, and we had already given
tours to some of the members ofthe Jamaican Senate, other
members of theirgovernment, but CNN was gonna be

(33:18):
a big deal, right. So we'regonna broadcast this back home.
Very important event, we alreadyhad some problems with some
unrest outside the gates. And itwas incredibly important to
command this go off without ahitch. And so he heard that Dr.
Gupta was coming to visit.
He was going to set up here andthat blue 10 Off to the left
hand of the of the picture. Andthat was the entrance to the

(33:41):
coming into the engagement sitefrom the outside and he was
going to do the interview there.
And about that time, my seniorchief comes up to me and says,
Hey, Doc, they want to set upthe Jamaica Ministry of Health
wants to set up a safe sexdisplay and do some public
health teaching. Is that okay?
Sure. Go ahead. Well, they wantto set up in front of the blue
tennis That sounds fantastic. Goahead and do it'd be a great
backdrop for Dr. Gupta. So thatis what they set up. And I put

(34:06):
this in there intentionally.
That is what you think it is.
And as you might imagine, thatcould be potentially something
unsavory in the eyes of the USmilitary. So try to be as
diplomatic as possible. Talk tothe individuals who are setting
that up and say, hey, you know,you're sitting up in the front
of the engagement site, mostpatients want to get right to
their provider encounter,they're not going to be very

(34:28):
patient with you, you might wantto set up in front of the
pharmacy, which is on the otherside of that little blue tent,
which will be a captive audienceas they wait for their
medications. And they thought itwas a fantastic idea. They move
that over there and theinterview is conducted without
that in the background. So it'sa win win for everybody. But
that's kind of brings me to mysecond lesson, and that the soft
power missions. There is a hugeneed for media training. And you

(34:49):
don't usually get that inmedical school or residency as
something you need to thinkabout. We had mock interviews
that were conducted with ourpublic affairs officer, as well
asDoing going through some talking
points and doing somerehearsals.
We were on a Nicaragua, we hadsome unique challenges to
overcome there, primarily withtransportation. So this is the

(35:14):
hospital ship. And you'll seethat there are some
challenges with getting onto atender when you're at seas, this
is relatively calm seas, here,we can see that platform and
that orange tender, sometimesthey are rocking this way, it
can kill them a little bitdangerous trying to step off
into that thing. And so weactually had to hire some
commercial tenders when we werein Colombia. That's that flat

(35:37):
deck one you see there in thebottom, and you had to jump from
the platform into the ship,which makes it a little bit of a
challenge, right. So the otherway that you can move yourself
in patients is via air, right.
So when we got to Nicaragua, itwas determined that we were
going to fly everybody to theengagement sites, which can be a
little bit of a problem whenyou're talking about moving 200
People ashore in sticks ofseven, right. But we're able to

(36:00):
do that. There's definitely atrade off there. Some of them
are folks who are arriving lastand leaving first, we're only
working for about four hours aday. But it did, let us do a
couple of things. And so whenyou 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 youto focus on is that picture in

(36:21):
the upper right hand corner,that looks a lot like these
pictures here, which are embassyevacuation missions over the
last 25 years. And so what Iwant to tell you is that these
global health engagementmissions are not just PR
missions, but they're alsorehearsals, which kind of leads
us to what confers primarymission is its primary mission.
The reason that the UnitedStates Navy has an inventory of

(36:44):
hospital ships, is not toconduct humanitarian civil
assistance missions, it's tosupport combat operations. Now,
the ship's have not been used inthat role since Desert Storm
Desert Shield when I was in highschool. But we certainly have
used them in the humanitarianand civil assistance realm, as
well as disaster response. We'vedone that quite effectively. But
just keep in mind that you mightbe asked to do some things that

(37:04):
don't make a whole lot of sensefrom a medical standpoint,
because the commanding officerneeds to stretch out the
capabilities of the ship andfigure out what the upper
operating limits are.
All right. So getting to ourlast mission stop, which was
Haiti, which is the mostimpoverished country in the
Western Hemisphere. And theseare just two pictures that are,

(37:25):
I'm trying to encapsulate thatsentiment. So if you look at
that first one in the upper lefthand side, that is a market that
we drove by, on the way from theports to St. Luke's which are
medical and gear, which was ourmedical engagement site. And
what I want you to see is that,you know, that is a market that
things are laid out in the tarpor for sale. And the rest of
that is trashed some places,it's hard to determine what's

(37:47):
what, but that just really is areflection of their lack of
resources. That second picturein their right lower corner is
it's hard to see because it's abit blurry, and we took it from
a moving vehicle. But that isthe basis of a river at low
tide, right. So it's a littlecreek coming into the city, and
low tide, that is trash thatfills the bottom of the basin.
In fact, that's how we kind ofwould know how close we're

(38:09):
getting to shore we came fromthe tenders from the ship is the
density of trash that wasfloating in the water. We also
had a flight divers out to cleanout the intakes because the
saltwater intake is gettingclogged with trash. And that's
how we cool the ship. And so itwas becoming pretty
uncomfortable on board the ship.
So just need to be aware ofthat. These countries are super
impoverished, and the need ishuge, which is why they have

(38:29):
these giant crowds waiting forcare. Now the 2011 mission, the
Haitian crowd actually pusheddown the walls, the engagement
site. So crowd control is goingto be incredibly important
during this mission. So one ofthe novel ways we solve that
problem is bringing the FleetForces band. So obviously music
crosses all cultures, you know,it definitely helps people that
are waiting for sometimes hoursin the Caribbean heat

(38:54):
to just kind of relax and notget too worked up and anxious.
And so the fleet force is bannedwas a huge force multiplier. But
every now and then the crowddoes get a little bit worked up.
And that's what we brought insome New York City police
officers who are of Haitiandescent, and they did a
fantastic job engaging with the,you know, with the crowd at
their level having been, youknow, groomed and reared in that

(39:18):
population. They knew exactlyhow to be culturally sensitive,
but still be firm. And we didn'thave any, I would say negative
interactions with the crowdduring that engagement site. And
these are the individuals thathelped make that happen. This is
me with our our US Army JTFBravo counterparts as well as
those New York City policeofficers. So

(39:40):
I know I've talked a lot aboutoperations and one of the things
I want to end with before I stoptalking about the mission is
that some of the kind ofinteresting cases and this is
really what makes the missionthat gratifying his deal is is
kind of dealt with these medicalproblems that there's really not
a lot of resources for the hostnation, but doing it at the
individual level with thepatients. So this is an
individual who hasstruck in the back by high
power, what he called electricallines and had the current shoot

(40:03):
out the top of his head, and itburned off his scalp. And that's
exposed calvarium that you'reseeing right there. Now,
obviously, we had antibioticsthat we could give him to treat
that that small infection that'skind of in the lower anterior
part there of his scalp, butthat's not gonna be the long
term solution. So we had to workthrough an NGO to get him linked
up with a plastic surgeons thatcould do a graft and cover that,

(40:25):
so that he didn't have repeatedproblems with infection.
This is a patient from Dominikathat was referred for a broken
leg and a lay limb lengthdiscrepancy, you can see the
fracture in the middle of theheel fracture the middle of the
femur. What you also see at thebottom are dents, Metastasio
lines, which are consistent withheavy metal poisoning. And when

(40:46):
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 chewon it. And so this is a child
who, if not treated, could havea long term consequences with
his neurologic developmentaffect his, his schoolwork and
his intelligence as an adult.
And so we were able to link upwith the Ministry of Health and

(41:09):
get him plugged in for testing,and hopefully, correlation.
And this last one is a greatstory. So this individual in El
Salvador, that family broughtthis, this gentleman here to us,
and he had a license driver'slicense and said that he was 100
years old. And he had juststopped walking, the family
didn't understand why he waspretty much nonverbal at the

(41:31):
time. And the grandson who'spictured to my left, you
actually was carrying him aroundthe village. And all they asked
for was the solution to help himget around. At that time, it
came at the end of theengagement site mission, we were
out of,what do you call it out of
wheelchairs. And so we got onefrom the ship, cost us a couple
$100 gave it to the family andthe whole family wept when we

(41:51):
gave it to him. And I thinkthat's really kind of helps to
emphasize the point that youknow, an individual level, your
ability have an impact for anindividual or a family comes
down to your willingness to gothe extra mile, we could have
easily turned them away andsaid, Sorry, we don't have
anything to help you out with.
Making that connection with anNGO, or the Minister of Health

(42:11):
or providing some kind ofdurable medical equipment is
really what's going to make thedifference and sway these
individuals, you know, to ourside.
Okay, so the bottom line is,although these are PR missions,
there are also medicaladmissions to these individuals,
and you'll have the impact thatyou have really comes down to
your willingness to go the extramile.

(42:34):
All right, so we're gonnaquickly review those lessons
learned that are up on thescreen, I'm going to move into
the last piece of thispresentation, which is the
Puerto Rico mission.
So 2017 On September 20,Hurricane Maria slammed into
Puerto Rico and pretty muchdestroyed the island. You know,
leading up into that point, itwas thought that it would if

(42:55):
hurricane Maria, or tropicalstorm Maria formed a hurricane,
it wouldn't do so until was inthe mid Atlantic. That obviously
was not the case. It hit PuertoRico on the 20th. We activate on
the 26th. And we are underway bythe 28th.
If you look at the path ofMaria, it hit just south of a
city called Macau and thenattract along the spine of the

(43:16):
island, gathered up strength andexited. And so it really
perfectly hit and then wentacross the island and exited,
destroying everything in itspath. And I think this picture
really illustrates that you cansee the blue Tyvek, where the
shingles of roofing have beentorn apart for several buildings
and have no roof at all. Andthat's what most of the island
looked like.
So we arrived on the second ofOctober. And we immediately sent

(43:40):
a team ashore I was a part ofthat team, I was the only
medical representative to do asite survey to figure out where
the greatest need was and tofigure how to get them to the
ship. So it was a bit of achallenge, we could move into
the interior of the islandbecause all of the roads were
impassable. And even goingaround the outside of the
island, Macau, here's what theroads look like, still pretty
difficult to get there. On thefar right there. That's a three

(44:02):
foot concrete reinforced pylonthat was snapped in multiple
places. That's pretty indicativeof what the island looked like.
So everything in the center partof the island had been hit
pretty hard, but there was noway to reach them. And so the
the ship looked like this, whichwas from a medical mission, and
a PR mission is less than ideal.
And so we had to figure out away to get the patients to the
ship. And the only way to dothat, because you can't fly

(44:23):
patients on board the ship andit's important. It's a Coast
Guard regulation, we had to goout to sea. So we pushed out to
sea and in the interim, we werewaiting to start receiving
patients. We started rehearsingwhat we would do in the back of
the MH 60 By making a mock upthere in our cache and receiving
which the er the ship here ourpositions, the first part of
that mission. And so we actuallywent all the way around the

(44:46):
island down to Ponce and thencame back picking up critical
care patients by air evac, andso are in route care teams were
composed of two providers onehad to be a board certified
physicians so we paired boardcertified emergency physicians
with CRNAs. And board certifiedanesthesiologist with emergency

(45:08):
medicine residents.
We ended up flying about 127missions or so we bring 127
patients to the ship. And hereare some of the sticking points
that we ran into. Oftentimes, wecouldn't identify the LLC when
we got there, because of all thedebris, sometimes we would land
we get to the hospital, and thehospital would have either, you

(45:29):
know, transferred the patientssomewhere else. Or sometimes
they held on to the patients,especially if they were paying
customers. And I'll talk aboutthat in a moment here. Because
most people with means left theisland. And so if you had a
paying customer, you want tokeep your hospital afloat, you
kept those patients didn'ttransfer them to comfort.
Alright, oftentimes we getthere, they're being escort with

(45:50):
the patient we weren'taccounting for, we had to
troubleshoot all these thingskind of in the mission. Now some
of the patients we picked upwere pretty darn sick on
pressors, or on anti dustRhythmix we had to do push those
pressors in the field in orderto prevent Peri intubation
arrest twice, we publish thoseresults in the Journal of pre
hospital disaster medicine. Buteventually, they were able to

(46:12):
clear the roads after about twoto three weeks, and we were able
to start taking patients vialand. So we went back to Puerto
Rico and started the secondphase, which is the Pierside
phase of the mission.
So here's a schematic of whatthe ER casually receiving looks
like on board the ship. It's a47 bed facility. And this is a

(46:33):
schematic of the patient flow orthe diagram for patient flow
getting to the resuscitationarea. However, I do want to
point out that those green areaswere actually staffed by
generalist pediatricians,internists, and family
practitioners. And our surgeonswere staffing the wound care
area, the ones that weren't inthe O R, and we were staffing
the red area, the resuscitationarea, which is staffed by one

(46:54):
emergency physician, and oneemergency medicine resident, per
shift. And so it was veryinteresting is that our model
was kind of takes the US modelflips it on its head, and that
we have generalist seeingmajority of patients then making
a console to emergency medicinefor patients that require
resuscitation. So it worked outreally well. It was very

(47:15):
gratifying. And it reallyleveraged our manpower in such a
way that we provide the mostcare to the most people.
However, there was also plentyof VIPs to hosts so and media
engagements to participate in.
So that on the left hand side isus briefing, the US Surgeon
General on the right side istaking an interview from one of

(47:35):
the new stations.
All right, so I've kind ofalready mentioned this, but um,
I talked about this briefly. Andthis was an orthopedic patient
that was referred to us duringthe Pierside phase of the
mission. And I'm just gonna readthe bottom as a patient who's
going to tibial plateaufracture, but no compartment

(47:56):
syndrome, no vascular injury.
And it says the patient does nothave medical insurance and does
not qualify for reform, which istheir version of Medicaid. We're
currently completing paperworkfor the patient, we transferred
to the comfort for furthermanagement, I tell this patient
got there, there was a biguproar about how they would turf
this patient in the middle of adisaster because they couldn't
pay. And that was my initialreaction as well. And I guess
I'm a little bit embarrassed tosay that in retrospect, but I

(48:17):
will say that the more I thoughtabout it, I would say the more
all of us thought about werealized that, hey, you know,
whenever you are conducting oneof these missions, you need to
make sure that when you leavethat the medical resources in
place, can manage the medicalmission after you're gone. And
so for these hospitals to retainthe paying patients and send us

(48:38):
the indigent care patient makescomplete sense in that regard
and that big picture. So wewould have, you know, there was
a bunch of talk about whether ornot that's ethical, I think it's
completely ethical. If you lookat it from a system standpoint,
and a disaster responsestandpoint, that was the right
call by that hospital, and weshould not second guess, what
they're doing to keep theirhealthcare infrastructure

(48:59):
sustained. So, and like I said,the bottom line at the
individual level, these aremedical missions, regardless of
what the other possible gainsare. And that is where you're
gonna have the biggest impact inthe care you provide to these
patients.

(49:20):
So where do emergencyphysicians, physicians belong in
this type of operation? So therewas a article published in the
emergency medicine clinics inNorth America in 2005. And they
created a huge laundry list ofreasons why emergency physicians
should be involved in thesemissions, we tend to do well in
high stress environments. We canmake decisions with limited or

(49:41):
no information. We have a broadknowledge base. We're used to
dysfunctional healthcaresystems, and certainly are no
strangers to social emergencies.
But I would argue that we're notjust we should not just be a
part of this. We should beleading these missions for all
the reasons I already described.
We tend to makemake the best decisions under
pressure, we tend to understandthe dynamics that are involved,

(50:02):
we tend to not get so zeroed inon the medicine that we lose the
big picture. And so I would telleverybody who's listening today,
that if you are planning onmaking the career or a career of
the US military, in the medicalcorps, that you should, without
a doubt, try to be involved inone of these missions during the
course of your career. And ifyou're a senior leader or a

(50:24):
senior officer, you should tryto lead one of these missions. I
will say that for my personalcareer, it was incredibly
gratifying. I learned a tonabout myself and learned a ton
about my role kind of in thebigger picture. And I thought it
was very professionallygratifying, one of the best
experiences of my career. And soI would highly encourage
everyone to take a part of oneof these missions.

(50:47):
And so that's all I have. Iappreciate everybody's time. If
you have any questions, I'd behappy to feel those at this
time.