Operation: Haiti Relief AAR

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     TEAM RUBICON, After Action Report

EXECUTIVE SUMMARY

Following its operations in Haiti, Team Rubicon finds itself poised to make a substantive difference in the disaster response field. TR began as the grassroots efforts of four individuals to help the people of Haiti by any means possible; however, it has grown into a nationally recognized movement that we hope will change the paradigm of disaster response.

Team Rubicon discovered that its make-shift model of rapidly deploying small, independent teams into the areas of greatest need increased its ability to disseminate medical care. By being autonomous, adaptive and quick, Team Rubicon was able to identify areas of need ‘on the fly’ and employ itself in a manner that best met those needs. This limited TR’s idle time and maximized its effectiveness in a constantly evolving environment. Instead of waiting for conditions to become ideal, Team Rubicon chose to assess the risks involved, mitigate what it could, and accept a level of risk in line with the marginal benefit derived from those operations. Ultimately, this led to medical care being provided when larger aid organizations were continuing to plan, coordinate and wait.

In addition to its organizational concept, Team Rubicon appears to have pioneered the creation of a direct ‘link’ between donor and rescuer. TR achieved this by integrating social networking technology (Facebook, Twitter, blogs) with cellular devices (Blackberries, iPhones). By continually updating online sites, Team Rubicon created a window that donors could use to see their dollars at work in ‘real time’. Donors could click the submit button on their donation and minutes later watch a TR responder treat a Haitian patient. This fostered a sense of true worth for the donor, and helped make the Team Rubicon model go viral.

Team Rubicon’s Haiti Operation did, however, reveal some issues that need to be addressed. Most importantly, heavily regulated drugs, necessary for more advanced medical procedures in the field, must be made organic to the team from the beginning of deployment. TR must increase its ability to conduct minor amputations, serious infection debridement and other ‘field surgery’ operations while local hospitals remain offline.

Additionally, Team Rubicon discovered its limitations for operating within the scope of its abilities. TR leadership has determined that Team Rubicon is an effective disaster response organization for only the initial 10-14 days following a disaster. Once this window has passed, larger organizations have established their logistics and command structure, and become a more effective aid supplier. Team Rubicon also discovered that, in order to remain effective, it must keep its teams small, between 7-10 individuals. A team size larger than this experiences the law of diminishing returns, and TR operations get bogged down; similar to what larger agencies encounter.

This After Action Report is the first crucial step in improving Team Rubicon’s ability to respond to future disasters. TR must improve on what it did correctly, correct what it did wrong, and brainstorm for what could happen next. Perhaps most importantly, Team Rubicon must continue to fundraise, so that appropriate gear and proper drugs will never be an issue.

 

Jake Wood                                                                 William McNulty

President & Board of Directors                  Co-Founder & Board of Directors

 

OPERATION OVERVIEW

OPERATION NAME:                                               Haiti Relief 2010
DURATION:                                                                 18 days
OPERATION DATES:                                                                                                      January 13, 2010 – January 30, 2010
OPERATION TYPE:                                                   Medical Relief Operations
LOCATION:                                                                  Port au Prince, Haiti
ELEMENTS:                                                                 TR1, TR2, Rubicon HQ
TOTAL CASH RAISED:                                            $123,176.54
   TOTAL PAYPAL FEES:                                           ($3,412.76)
NET CASH RAISED:                                                 $119,763.78

 

IN-KIND DONATIONS:                                           In excess of $140,000
     TEAM RUBICON, After Action Report

Operation Summary


PRE-DEPLOYMENT

On January, 13th 2010, Team Rubicon was launched when Jake Wood, Jeff Lang and William McNulty began formulating plans to travel independently, with private funding, to the nation of Haiti to aid in the medical relief operations taking place there following the devastating earthquake experienced on January 12th.

Team Rubicon quickly enlisted the help of common social networking sites (Facebook, Twitter and http://badgerjake.blogspot.com) to spread word of their efforts and attempt to raise cash via private donations to PayPal. The Milwaukee Fire Department became aware of the effort and enlisted local media outlets to spread word of a cash donation fundraiser at a downtown Fire Station.

Team Rubicon began privately purchasing necessary gear at local sports and outdoor stores, as well as over the counter medications from drugstores such as Walgreens and CVS. Additionally, William McNulty contacted a doctor in Chicago, Mauricio Consalter, who began forming a medical team to rendezvous with Team Rubicon once a secure base of operations was established in Port au Prince. Dr. Consalter began arranging for the purchase of prescription medication, as well as coordinating for local medical supply companies to donate first aid material.

Jake Wood enlisted the help of his father to update the blog live while the team was in Haiti. Jeff and Sarah Lenger immediately began making changes to the website, renaming it blog.teamrubiconhaiti.org and retooling it to represent the current effort in Haiti. Meanwhile, with help from Ernie D’Antonio from the Marine Corps Intelligence Association, William McNulty secured official letters from both the Haitian and Dominican Ambassadors, endorsing Team Rubicon as critical to the relief effort, and guaranteeing our unhindered travel through both countries.

Two local connections were established prior to departure. Team Rubicon was put in contact with a female Haitian student, Corinne Joachim, who was studying at the Wharton Business School in Philadelphia, Pennsylvania. Ms. Joachim’s home had been destroyed and her grandmother killed during the quake. She was trying to get into Haiti but needed an escort for security purposes. TR agreed to provide her safe passage in return for her local knowledge and language skills. Second, McNulty reached into his Jesuit High School connection and established a contact on the ground, Brother Jim Boynton, S.J., a member of the Jesuit Order, and recently a teacher at a Jesuit school north of Port au Prince. The Jesuit Novitiate in Port au Prince agreed to serve as base for our operations in return for our medical and security skills.

 

DEPLOYMENT

On January 16th, Jake Wood, Jeff Lang, Craig Parello and William McNulty boarded planes heading for Santo Domingo, capital of the Dominican Republic. While en route, three other individuals became members of Team Rubicon. Jake Wood met Dr. Dave Griswell, ER doctor at the Arlington Medical Center, Jeff Lang met Doctor Eduardo Dolhun, of Dolhun Clinic, and William McNulty made contact with Mark Hayward, Physician Assistant and former Army Special Forces medic.

Before all members of Team Rubicon could assemble, Corinne Joachim was forced to leave for Port au Prince early, after learning her grandmother’s funeral had been moved up to the following morning. Once all seven members arrived in Santo Domingo they rallied at an apartment owned by a childhood friend of Ms. Joachim’s, Marie-Leslie. There they linked up with Brother Boynton and immediately began consolidating and redistributing gear. At this time, Mark Hayward also built and distributed individual first aid kits (IFAKs), he then conducted a brief class on self-applicable trauma medicine.

The following day, January 17, TR had bus tickets to take a public bus from Santo Domingo to Port au Prince. However, because of doubts about the drop-off site and the amount of gear the team would be allowed to bring on board, TR opted to share two private buses with a Haitian citizen travelling to the border. Once at the border, Team Rubicon loaded into three Toyota Hilux trucks provided by the same Haitian citizen and were ferried to the Jesuit Novitiate. TR arrived at the Novitiate at approximately 6pm, once inside they pitched their tents and prepared to begin operations the following day.

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Meanwhile, Jeff Wood, located in Bettendorf, IA continued to operate the Team Rubicon blog from his home. Visits to the website approached 20,000 page loads per day at its peak, which inundated TRs fundraising efforts with donations. Sarah Lenger and Dan Sweeney, located in Iowa City, volunteered to take over website design and operations, freeing up Mr. Wood to promote Team Rubicon’s efforts in Haiti to the press. This press exposure further fueled traffic to the website, creating a ‘grassroots’ network of volunteers looking to help in any way possible. Mr. Wood at this point began to organize this network to produce a second Team Rubicon element, dubbed TR2.

Crossing the DR-Haiti border

On January 18th, MFD members Jeff Lang and Craig Parello conducted a structural analysis of the Jesuit Novitiate. They determined that the building was highly unstable and had a high likelihood of collapse should another large aftershock hit the area. Both firefighters recommended that all members of the compound maintain a minimum safe distance of 80 ft (1.5-2 times the height of the building).

Afterward, Team Rubicon loaded all personnel, gear and supplies into two Toyota Hilux trucks hired and provided by the Novitiate. Approximately 40 minutes later, TR arrived at a refugee camp near Manresa, a Jesuit compound which had been destroyed in the quake. TR immediately began setting up a pharmacy and triage area. TR found the Haitians to be self organizing, triaging their most badly wounded to the front of the crowd. Team Rubicon treated patients for approximately 9 hours throughout the day, seeing a range of compound fractures, crush wounds, amputations, infections and gangrene, internal injuries and late-term pregnancy. Team Rubicon continually set to the side patients in urgent need of higher medical care. Lacking proper casting material, splints and casts were made from doors, window frames, window screens and broken tree branches. TR determined that it lacked certain necessary medications to properly provide the range of medical care necessary in the field, primarily heavy-duty antibiotics and Ketamine, for field debridement and surgery.

After treating approximately 300-400 crucially injured patients, TR chose to stick to its drop-dead time of 4:30 pm. Team Rubicon packed up and began developing plans to take approximately 6 critical patients who had injuries ranging from pelvic/spinal fractures, to distended abdomens to severe amputations. TR relocated all supplies to the pickup point which had been pre determined with the drivers that had conducted the drop off. While waiting at the pickup point, Dr. Dolhun and Br. Boynton began seeking and securing transportation from local drivers passing by. In this manner, all six patients were successfully delivered to higher level medical care. By 6pm it became apparent that TR’s transportation was not coming for pickup, so Team Rubicon TL Jake Wood and other members began planning contingencies. Two options were on the table- staying the night in the refugee camp with a two-man, armed watch around the clock; or splitting the physician element plus gear from the rest of the team and sending them with a local-national willing to provide transportation to the Novitiate. As the decision was being made, Dr. Dolhun was able to persuade a local taptap driver to take all of TR to the Novitiate for $100.

Local transportation, known as a taptap

     TEAM RUBICON, After Action Report

The following morning, January 19th, TR began operations at an AIDS clinic being operated by the Sisters of Calcutta. There were far fewer patients present than at Manresa the previous day, however, the majority of patients present were in critical need of higher medical care. After approximately 90 minutes, Br. Boynton took a taptap full of patients to the nearest hospital, General Hospital, located downtown. Upon his return, he stated that General Hospital was in desperate need of doctors and emergency room management, and suggested we would be of greater use there. TL Jake Wood and Mark Hayward (PA) decided to split the team, with Drs. Dolhun and Griswell, as well as Hayward, proceeding immediately to General Hospital, while Wood, Lang, McNulty, Parello and Edmund Lo, a Jesuit Novice, remained behind to finish treating patients at the clinic. Once Br. Boynton returned with the taptap, all remaining TR members would load up and rendezvous at General Hospital.

The plan was executed quickly, and TR first responders continued to treat patients at the clinic as Griswell, Dolhun and Hayward proceeded to the General Hospital. While finishing up the remaining patients, TR linked up with a reporter, David Ono, and cameraman from KABC Los Angeles. KABC began documenting TR’s triage, and, when the remaining TR members identified 5 patients that needed to be evacuated to General Hospital, KABC offered their own vehicle in support.

Once at General Hospital, all Team Rubicon members were immediately put to work. Dr. Dolhun was working in an OB-GYN area, while the remaining members established a triage system in the emergency room similar to what they had been doing in the field. Dr. Griswell became the de facto doctor in charge, while Mark Hayward began delegating other physicians and nurses in order to establish order and efficiency. Remaining TR members were put to work as assistants and nurses, aiding in wound cleaning, IV starts, and pain management. Team Rubicon held to its 4:30 drop-dead time, in order to ensure return to the Novitiate during daylight hours.

Meanwhile, in the United States, Jeff Wood had tasked Gary Cagle, a former Army Special Forces medic and retired Army Major, with developing the second Team Rubicon element, TR2. Gary Cagle began sorting through the hundreds of volunteers and eventually established a team of qualified individuals. These individuals began assembling in Fayetteville, North Carolina, at 21st Tactical, a military gear store outside of Ft. Bragg, which had volunteered its extra storage for all of TR2’s gear. 21st Tactical owner Bill Mathes began acquiring needed equipment for TR2’s mission, as Gary Cagle networked various flight options to get into Port au Prince. Eventually, room was secured on a privately funded Boeing 737 out of Pittsburgh, and TR2 had a departure date of January 21st.

The morning of January 20th, a 6.1 aftershock struck Haiti. Team Rubicon members were just waking up for the morning and no members of TR or the Novitiate were injured in the earthquake. As a result of the aftershock, General Hospital evacuated its buildings, causing critically injured patients to lie in the sun until the buildings could be cleared by the Army Corps of Engineers. TR once again assumed control of Emergency Room operations, utilizing various groups of volunteers to complete multiple tasks. Team Rubicon began constructing hasty shelters in order to provide shade for the patients. While this was taking place, TR firefighters Lang and Parello conducted an initial structural analysis of the buildings, clearing all buildings for reentry. However, the only unit willing to heed their clearance was the 82nd Airborne, who immediately reoccupied their structure. Throughout the day, two different members of Team Rubicon made public pleas for relief agencies to bring food and water, as well as to release doctors being held back at the airport and embassy. Dr. Griswell was interviewed by Anderson Cooper (CNN) and Mark Hayward located and spoke with an 82nd Airborne Colonel. Within hours of these pleas, food, water and medicine were plentiful.

Outdoor ER at General Hospital

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At approximately 3 pm, the buildings at General Hospital were deemed safe for use by the Army Corps of Engineers. At this time, TL Wood organized a group of 15 individuals to completely clean and restock the entire trauma center in preparation for bringing the patients back inside. Once completed, the patients were litter carried back into the building, where Dr. Griswell once again directed care in the ER. While this was being conducted, part of Team Rubicon’s medical element from Chicago arrived and was transported to General Hospital by William McNulty. Their United flight landed at noon and by 1:55pm they were quickly brought up to speed and put to work. Team Rubicon adhered to a drop dead time of 5:30 pm and retrograded back to the Novitiate. The following day the remainder of the medical team arrived from Chicago, bringing with it seven personnel and 2.5 tons of medical supplies. Outside the airport, TR hired 3 trucks and a Haitian police escort to transport the medical supplies back to the Novitiate.

Team Rubicon’s numbers continued to swell in the following days. Various elements from around the United States found themselves augmenting TR’s efforts based out of the Novitiate. This included a medical team of surgeons from Florida, neurosurgeons from Oregon, and volunteer aid workers from Canada. During this initial week, Team Rubicon’s roster grew to 38 names. At this point in time, Team Rubicon stepped aside from running operations at the General Hospital, as ample help had been released from the airport and embassy.

Beginning January 18st, Team Rubicon resumed its mission of identifying areas of Port au Prince which had not received medical attention. With its new numbers, TR was now splitting in to as many as three separate, autonomous medical elements, named Alpha, Bravo and Charlie; with a surgical detachment tasked to the Sacre Ceur Hospital, which had been identified as the most functional OR in the city. Each element was responsible for replenishing its own supplies, coordinating locations, and developing a rough mission plan. These locations and mission plans were then briefed to Jake Wood, who retained control of the entire operation. Once plans were briefed and approved, Rubicon elements were cleared to depart on their own schedule, maintaining an approximate drop-dead time of 4:30 pm.

From January 18th to January 21st, Team Rubicon elements serviced various refugee camps both inside and outside Port au Prince. TR would establish hasty field triages at each location, and then utilize local transportation, along with a TR chaperone, to evacuate cases to Sacre Ceur, where Team Rubicon’s surgical team was located and operating. This ensured that patients delivered to Sacre Ceur were properly cataloged and triaged upon arrival at the hospital, guaranteeing that they would not be turned away or overlooked. What Team Rubicon discovered in this process was that the hospitals needed a better system for receiving critical patients. Patients were continuously getting dropped off outside the hospital by relatives and well-meaning Haitians; however, they were arriving without a medical diagnosis. As a result, they were either being turned away at the door, or misdiagnosed by workers serving as ‘receptionists’ inside the door. A Team Rubicon member escorted each patient with a note from a TR physician, which explained in full detail the reason needed for immediate higher medical care. This method streamlined the in-processing at Sacre Ceur, making it a much more efficient medical facility.

During these ‘expeditionary’ medical operations, Team Rubicon identified two critical problems. First, TR Alpha was led to a shanty town built into a steep valley by a local who introduced himself at a prior triage location. This shanty town had received no medical aid, water or food in 8 days since the earthquake. The reason was there was absolutely no possible way to reach this village by vehicle; the buildings were all built one on top of the other, directly into the hill side, and the bottom of the valley was a stream which was used for water. The only way to deliver aid and supplies was to pack them up and hike them in through the steep trails. TR Alpha responded to this situation by carrying in packs of medical supplies on foot. A triage was established, and roughly 35 Haitians received their first medical aid. This mission emphasized why it is important for TR responders to be physically fit- the valley steps were very steep, and the medical supplies brought in were heavy and cumbersome. Additionally, it drove home the need for employing and fairly compensating trustworthy locals, since TR Alpha was forced to leave many of its supplies in the taptap truck, guarded only by the local nationals who had been working with the team throughout the week. They were given explicit instructions, and these instructions were followed, because they knew they would be adequately compensated. The second problem identified was the fear many patients had of being evacuated to the hospital. As Team Rubicon policy, every patient, regardless of age, that was taken to the hospital was transported along with a family member our guardian, ensuring that someone would be there when they were discharged. However, many patients were unwilling to go because they lacked even the one or two dollars that would be needed to hire a driver to bring them back to their camp once discharged. To combat this issue, TR began distributing ‘cab fare’ to patients who exhibited this hesitation, thus convincing them to get to the hospital for the care they badly needed.

     TEAM RUBICON, After Action Report

On January 21st, TR2, led by Gary Cagle, arrived in Port au Prince with its gear and medical resupply. That evening, members of TR1 briefed TR2 on standard operating procedures developed throughout the previous week. Jake Wood and Gary Cagle established a master roster of all Team Rubicon personnel, and set to creating medical elements for the following morning which would allow TR2 members to observe how triage operations were run, and to gain familiarity with the locals who were being employed daily by Team Rubicon. On Monday, January 22nd, TR2 deployed to the field for the first time, while Jake Wood and Gary Cagle remained behind to finalize the transfer of operations.

 

 

Areas of Analysis

 

 

  1. Transportation
    1. Air (private, commercial)
    2. Ground
  2. Staging Area
  3. Base of Operations
  4. Operational Teams
    1. Size
    2. Composition
    3. Roles
  5. Operational Concept
    1. Scope of Mission
    2. Duration of Mission
  6. Local National Employment
    1. Transportation
    2. Guides
    3. Translators
    4. Community Leaders
  7. Security

 

  1. Media Reports
  2. On Site Analysis
  3. Security Element
  4. Weapons
  5. “Posturing”
  1. Medical
    1. Special Skills Needed
    2. Typical Wounds
      1. Complex Fractures
      2. Amputations
  • Infection/Gangrene
  1. Other
  1. Medicine
    1. Controlled
    2. OTC
  2. Medical Supplies
  1. Stateside Headquarters Unit

 

 

 

Areas of analysis will be presented in the following format:

Summary: Summary of issue and how Team Rubicon specifically dealt with it

Recommendation: What lessons TR learned, and how it should proceed in future operations

Action: What steps need to be implemented by TR to ensure the recommendation is followed

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ANALYSIS

TRANSPORTATION

Summary

Team Rubicon failed in its original attempts to arrange travel directly into Port au Prince due to the airport being restricted to military and UN flights in the initial aftermath of the earthquake. Consequently, all members opted to fly on separate flights into nearby Santo Domingo, Dominican Republic and arrange for ground transportation to Haiti. The flights were arranged to land within 6 hours of each other.

Some airlines charged excess baggage fees, and other airlines were restricting the amount of baggage allowed. This could result in critical gear not being allowed on board in future operations. Also, some TR gear was left in the US during a connection in Miami, delaying TR 5 hours at the airport, which could result in timelines shifting to the right in future operations.

TR had their guide, Corinne Joachim, pre-purchase bus tickets on a tour bus company running daily trips into Port au Prince. The ticket price was $40USD/person. Upon arriving in Santo Domingo, TR members discussed whether this was the best option, considering the large amount of gear to be taken, and the logistical issue of getting from the bus drop-off point to the Jesuit Novitiate. On the morning of departure, Team Rubicon met a young Haitian man who had rented a private bus to take him to the border, and 3 pick-up trucks to pick him up at the border and take him into Port au Prince. After brief negotiations, TR opted to hire a second van with this man and travel with him to Port au Prince.

The van drivers proved reliable and fast. Gear was easily stowed and could be accounted for at all times. Having private drivers provided options for picking up necessary supplies en route. At the border, the three truck escort provided vehicles more suitable to travel within the crowded, rubble strewn city, and also provided a means to establish security from the truck beds.

Recommendation

Air- Develop “Memoranda of Understanding” with current operators (corporate or private) of aircraft that will allow TR instant access to planes with the ability to move teams plus equipment into disaster areas rapidly. If private flights are not a plausible option, Team Rubicon should seek to regionalize its team members, so that whole teams can fly out of the same airport at the same time, alleviating the hassle of trying to rendezvous from various cities.

Ground- Private transportation is always a better option. Itineraries remain flexible, and it minimizes the number of people who have access to the team and its gear. The price of hiring a van plus driver was less than the total cost of 8 bus tickets.

     TEAM RUBICON, After Action Report

Action

  • Contact large corporations and gauge interest in ‘lending’ their corporate jets as a charitable contribution to future efforts.
  • Contact jet-leasing companies, such as MarquisJet, and negotiate special rates for use of its fleet.
  • Contact charity flights, such as Wings of Hope and Air Cavalry, and develop MOUs.
  • Ensure team has enough cash to hire a private driver and escort within the country. Determine the going rate for tickets on public transportation, cut that price in half and multiply it by the number of team members to determine a baseline offer.
  • Research whether private vehicles are allowed to cross from one country into the next without hassle (they were not in Haiti-DR).

 

Staging Area

Summary

TR1 members initially utilized a local apartment in Santo Domingo which was provided through Corinne Joachim as a staging area prior to departure for Haiti. They used the space provided to meet one another for the first time, redistribute gear, and discuss basic standard operating procedures. Similarly, TR2 utilized 21st Tactical, in Fayetteville, NC, as a staging area prior to departure for Port au Prince. This allowed TR2 to itemize and properly pack a large quantity of crucial medical supplies before departure.

These staging areas allowed:

  • Team members to meet and get to know one another for the first time
  • Redistribution of gear, which ensured that no single pack or crate contained the whole quantity of a single crucial item
  • Quick classes to bring all TR members up to speed on individual first aid, medications, security, communication and mission details.
  • Establishment of command hierarchy and individual teams assignments
  • Introduction to basic Standard Operating Procedures

Recommendations

Always have Team Rubicon elements rally at a central location prior to departure. This location will ideally be situated in a major US city in the future, where gear and supplies have been prepared in advance. Volunteers activated would meet at this city within 24 hours of a disaster (assuming Board of Directors activation), collect and check gear, and deploy to the disaster zone (DZ).

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As a secondary option, teams should be prepared to assemble at a rally point near the DZ, either in a neighboring country or metropolitan area, as was the case when TR1 rallied in the Dominican Republic.

Action

  • Determine US cities that provide the most access from multiple areas across the US, allowing for volunteers to rapidly assemble, and which have a large volume of international flights for deployment to DZs
  • Establish gear depots in climate-controlled storage facilities near these airports, which will house pre-packed ‘go bags’
  • Continue a global outreach for TR volunteers, thereby establishing potential rally points abroad when domestic rally points are not ideal

 

BASE OF OPERATIONS

Summary

Team Rubicon established its base of operations at the Jesuit Novitiate located approximately one mile north-northeast of the Port au Prince Airport. The compound was located slightly away from main roads, but was accessible by all commercial vehicles and most helicopters. The neighborhood surrounding the compound had escaped most major damage, resulting in a relatively stable environment. This location provided necessary space for pitching tents, organizing supplies and bringing in transportation vehicles for loading. However, the long ‘commute’ to the heavily hit area of Port au Prince reduced the daylight hours available for operations.

The Jesuit Compound was being used as a supply hub for multiple charitable organizations, which resulted in ample food, water and medicine at all times for TR elements. Additionally, the compound had a working well, which provided water suitable for hygiene purposes, and could have been filtered had a water shortage occurred. The ample supplies eliminated a significant logistical hurdle for TR, freeing up time to focus on medical operations instead of securing food, water and medicine on a daily basis.

The Novitiate, since it was operating as a supply hub, had local security guarding the entrance, which eliminated the need for TR to stand post. Additionally, the compound was surrounded by 10 foot walls topped with razor wire, again eliminating the need for a 24 hour gear watch. Having a 24 hour security presence allowed TR to leave unnecessary personal gear and expensive medical supplies back at the compound. This eliminated the need to pack up camp every morning, which in turn provided more time during the day for medical operations.

     TEAM RUBICON, After Action Report

Team Leader Jake Wood gives a daily mission brief at TR’s Base of Operations

RECOMMENDATION

Team Rubicon must work to establish a global network of charitable organizations which have well established presences on the ground in multiple at-risk countries around the world. These charities will most likely be religious in nature, because of their deep network into local communities. Team Rubicon must ensure that no preference is given to any one religion, so as to not alienate alternative options. Priorities for base of operations selection should be in the following order: supplies, security, and then location. Location can be overcome, security, while not ideal, can be internally provided, but supplies allow continued operations.

ACTION

  • Identify global charities that have well established presences on the ground
  • Reach out and develop MOUs with these organizations

 

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OPERATIONAL TEAMS- SIZE

SUMMARY

Team Rubicon initially deployed as a 4 man element with the intent of adding two guides. By the time TR1 crossed into Haiti, its number had grown to eight. In the initial stages of triage operations, Team Rubicon operated as this eight man team, with up to three full-time local hires. As Team Rubicon’s numbers continued to swell, members were continually broken down into smaller field teams, always aiming to maintain approximately eight TR members plus local help.

Team Rubicon field teams also moved in multiple vehicle configurations, with the smallest field team at any one time consisting of a single operator on a hired motor bike, and the largest consisting of a 16 operator, 4 vehicle element. The single operator scenario, while not optimal, is plausible when specially trained individuals are involved and a defined mission has been identified. In these rare instances, a single operator can serve as a ‘force multiplier’ leaving the remaining TR element free to conduct triage operations, while a supplemental side operation is accomplished. The larger, four vehicle scenarios should rarely, if ever, be adopted under field conditions due to communication break-downs, having more personnel than needed to accomplish mission objectives and problematic traffic conditions for large convoys. Two vehicles appear optimal; it allows both radio and visual communication, easier movement in congested traffic, and a second vehicle allows flexibility in the event of vehicle breakdowns and patient transportation.

Recommendation

Team Rubicon’s deployment model seeks to employ teams that are as small as possible in order to deliver maximum impact in multiple areas. These teams must be just large enough to provide security and adequate medical attention. Operations in Haiti appear to indicate that a two vehicle, 8-10 person team is ideal for triage operations. This team size can be tailored according to individual mission profiles and security situations. It is essential that team members be cross-trained in multiple disciplines in order to fill multiple roles on site. Personnel with single-track skills (i.e., a police officer with no medical experience, a doctor with no previous disaster experience) should be minimized, but not excluded.

ACTIon

  • Establish a database of volunteers, carefully categorizing them according to skill, location and experience, allowing 8-10 person response teams to be rapidly assembled
  • Ensure team members display a willingness to accept multiple roles within a team, and have the ability to operate autonomously
  • Begin purchasing, packing and storing appropriate gear in sets of 10
     TEAM RUBICON, After Action Report
  • Ensure that local hires explicitly understand their role within the operation, and make attempts to cross-train them in simple operational functions such as security, litter bearing, photography, etc.

 

OPERATIONAL TEAMS- BACKGROUND COMPOSITION

SUMMARY

The ability of a majority of members to perform multiple roles was essential to the effectiveness of field operations. The only truly ‘single-tracked’ operators on Team Rubicon were its physicians, who functioned primarily in a focused medical capacity. This is a necessary break from the ‘cross-disciplined’ operator approach, since undivided attention should be paid to patients by the medical professionals. However, ideally a physician would have either a military background or previous disaster and mass casualty training experience. In the absence of traditional operating rooms, TR physicians should have a background in emergency and general medicine, since the injuries encountered are widely varied.

Operators with prior combat military experience performed medical and security functions almost interchangeably, and cross-trained rapidly to fill roles as the mission required. Team Rubicon members with experience in the Marine Corps and Army infantry were already familiar with cellular level operations, which is heavily emphasized in current US military operations in Iraq and Afghanistan. The current TR model has been heavily modeled after the Marine Corps infantry squad, which is often an autonomous 13 man element tasked with a broad mission objective. Within the squad, every member is expected to be able to complete the job of every other member, thereby resulting in continuity of operations when unexpected hurdles occur. Military combat veterans also provide a security ‘posture’ presence on teams, which diffuses potential security situations through body language alone. ‘Posturing’ is a simple, but crucial, lesson that has been learned in Iraq and Afghanistan, and which has been credited with greatly reducing attacks on coalition forces.

First responders (firefighters, paramedics, EMTs) also performed multiple roles seamlessly for Team Rubicon. Perhaps their greatest asset was their significant experience working in uncertain environments on a daily basis, which requires them to have a broad knowledge base and the ability to adapt and overcome. First responders with no prior military experience are easily placed in security roles with limited training in crowd control, posturing and rules for taking action. Firefighters also played a crucial role in implementing various training, specifically structural analysis. This skill proved crucial in evaluating both the Novitiate and the General Hospital. Other skills that could prove useful in future operations are rope rescue, confined space operations, water rescue, etc.

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Some members of Team Rubicon had no emergency response skill sets. These team members ultimately played vital roles in TR operations as pharmacists, logisticians, and basic security. These individuals are also easily trained as medical assistants.

recommendation

A majority of Team Rubicon members should ideally be military personnel with overseas experience, preferably Marines or Army combat arms, for the following reasons:

  • Military veterans have unique experiences operating under stressful, uncertain and austere environments; conducting training and real-world operations with limited food, water and sleep. Veterans who were successful under these conditions succeeded due to level-headed thinking, determination, and unorthodox techniques.
  • Veterans have in-depth security training, including Security and Support Operations (SASO) which emphasizes operations not involving combat that take place in a combat environment.
  • All veterans have basic cross training in emergency trauma medicine.
  • Team members must be able to follow orders once the debate is over and orders are given.
  • Military veterans with experience in Iraq and Afghanistan have likely experienced casualty situations in scenarios where security was uncertain, if not dangerous.

The perfect Team Rubicon candidate would be a former military operator who now serves as a medical professional or first responder. This person would be able to perform their primary role (physician, nurse, etc) while maintaining an understanding of the operational scope and priorities as directed by the team leader.

Not having military experience in no way makes a volunteer unqualified. In fact, the majority of TR volunteers had no prior military experience. Physicians are an irreplaceable asset to the team, and it is unrealistic to expect to deploy only former military medical officers. Additionally, firefighters and other first responders often work in US cities that have security risks similar (albeit on a smaller scale) to those found by military members in Iraq and Afghanistan. These individuals, especially firefighters, are accustomed to working within small teams that have an established team leader.

Individuals with no military, emergency, or medical experience can serve an important role on Team Rubicon, primarily filling in voids as assistants and in secondary jobs as pharmacists, photographers etc. Additionally, non-military participants serve to soften the image of Team Rubicon, ensuring that TR does not come across as too military in appearance. This is essential eliminating the feeling that TR is operating with an ulterior motive. However, involvement of these individuals should be kept to one or two per team in situations similar to Haiti.

     TEAM RUBICON, After Action Report

The intangible qualities Team Rubicon is seeking (lack of ego, self direction, commitment to others) are almost impossible to screen for, however they are vital to mission accomplishment. Probably the best indicator of suitability for Team Rubicon operations is experience in a similar environment, whether a previous disaster or on the job situation.

action

  • Carefully categorize all applications that are filled out by individuals looking to conduct future operations with Team Rubicon. Possible category tags include: Military, Physician, RN, PA, EMT, Paramedic, Firefighter, Prior Disaster Experience, Special Language Skills, Location
  • Begin to geographically organize teams, allowing them to be modularly assembled, according to the disaster, by a regional team leader when teams are activated
  • Conduct phone interviews and reference checks on individuals seeking to deploy with Team Rubicon, in order assess personal character

 

ORGANIZATIONAL TEAMS- ROLES

sUMMARY

The basic Team Rubicon field element consisted of approximately 8 individuals and relied on operators performing multiple roles at various times. Only three roles are vital to mission accomplishment-

  1. Team Leader: The TL plays an essential role in planning, coordinating and communicating. It is essential that the TL have the ability to accomplish the mission when limited information and resources are available, without wasting time with bureaucratic steps. The TL will ideally have military leadership experience, thereby understanding the team’s role within a large picture context, while focusing solely on his or her team’s individual fit. The TL must be able to multi-task and coordinate across multiple functions, communicate operational objectives, procedures and professionalism, and lead by example not by virtue of title.
  2. Chief Medical Operator: The CMO is responsible for making all key decisions regarding patient triage and care. The CMO should have extensive experience in either general medicine or emergency room medicine, and should ideally have significant experience in disaster or mass casualty response. The CMO is not responsible for multi-tasking, and the only function of this position is medical care. The CMO serves to advise the Team Leader on decisions involving patient evacuation and treatment, however, final decisions affecting the team are made by the TL.
  3. Local Liaison: The LL is an irreplaceable asset to the field team. He or she is either a citizen of the country of operations, or has significant experience in the language, layout and local customs of the community. The LL serves as an advisor for the Team Leader, and does not necessarily need disaster relief experience. The role of Local Liaison was effectively filled by Brother Jim Boynton, a local Jesuit school teacher with only three months experience in Haiti, and also by Francis, a local citizen who spoke English well and was hired on a daily basis.

In addition to these three roles, Team Rubicon employed numerous other primary roles, including:

  • Security: This role can be filled by someone with military/police experience or a commanding presence. This role is essential during team movements, when teams are more vulnerable and partially separated. This role is flexible and adaptive to the security environment encountered, however, a minimum of one individual will serve as security at all times when in a field environment.
  • Medical Specialists: Physicians (other than CMO), Physician Assistants, and Special Operations Medics are primary care providers, handling all cases referred to them by medical assistants. Special cases are further referred to the CMO for evaluation.
  • Medical Assistants: RNs, Paramedics, EMTs and other individuals with prior medical training serve as medical assistants- conducting initial triage, treating minor wounds, and referring severe cases to medical specialists. Individuals in this role should be prepared to serve in numerous other capacities, as listed below.

Team Rubicon also identified a number of secondary roles that needed to be filled by members in conjunction with their primary roles, these included:

  • Social Network Specialist: This person updated the blog, Facebook and Twitter accounts, which proved vital to the success of TR’s model. It connected donors with the teams, establishing a feeling of “being there” for individuals at home in the United States. This grassroots network snowballed Team Rubicon’s donations and increased its presence on the web.
  • Videographer/Photographer: This is an essential role that provides donors and supporters back home with tangible proof that their donations are actively working to help those in need. This role can be handled by a professional augment/attachment sent by a third party, or can be done internally with personal cameras.
  • Pharmacist/Medical Supply Logistician: This role can be made a primary role if additional elements are folded in to TR operations. But, at minimum must have one operator assigned this as a secondary role. Having a sensible logistics system reduces lag in patient care and in beginning day to day operations.
     TEAM RUBICON, After Action Report
  • Paymaster: This role can be filled by any member of the team. Responsibilities primarily include negotiating and paying local help at the end of operations each day, and keeping a record of money disbursed to local nationals.

RECOMMENDATION

Team Rubicon should seek to establish and deploy teams based off of a basic eight to ten person model, which will allow flexibility for breaking down further into smaller teams once in country.

Teams should have two of the three vital billets (TL, CMO) explicitly filled prior to team deployment. All members of that team should understand that command decisions coming from the Team Leader are final and medical decisions coming from the Chief Medical Officer are also final. The Local Liaison position can either be filled prior to departure, or once a base of operations is established in the DZ and a local national has been identified and hired.

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Teams should never be activated and deployed without adequate security for the situation presented. All other primary and secondary roles are a luxury and add value to the mission; however, the top priority for Team Rubicon is team safety.

action

  • Identify all volunteers by their potential role
  • Create a template/leader board that identifies roles and displays who is filling them
  • Brief teams daily on what their roles are, and what needs to be done to fill them. Ensure expectations for the role are clear

 

LOCAL NATIONAL EMPLOYMENT

SUMMARY

Team Rubicon relied heavily while in Haiti on the employment of local nationals to serve in various capacities within the team. Team Rubicon hired locals as local guides, transportation, and translators; in addition to identifying and utilizing community leaders once on site. TR discovered that in a DZ where government services have broken down, cash is king. Team Rubicon generously compensated locals when hired (according to purchasing power of parity), which served two purposes. First, it put crucial cash flow into the pockets of locals devastated by the earthquake, allowing them to feed and clothe their families. Second, by paying a generous sum of cash at the close of business each day, TR ensured that locals would remain loyal throughout the days’ operations and return for work the following day.

A local Haitian named Francis proved instrumental throughout TR1’s efforts. Francis was a local second-hand clothes salesman who lost his home and inventory in the quake. He was well spoken, well mannered and incredibly loyal. He knew many locals in the area immediately surrounding the Jesuit compound, which helped TR1 locate drivers with somewhat reliable trucks. He also had the ability to acquire needed items, from diesel fuel to ice to beer. Additionally, Francis had good knowledge of the entire city of Port au Prince, which made him useful as a guide. He was able to help TR find the locations of refugee camps within the city, and then help navigate to nearby hospitals for evacuation. Once on site conducting field triage operations, Francis served as both an organizer and interpreter, making sure the local community understood the process for receiving medical treatment. Francis was compensated with approximately $30 per day, sometimes more depending on special assignments he may have had or extra hours required of him.

Local transportation consisted of old Isuzu pick-up trucks, known to locals as ‘Taptaps’, modified to serve as buses. These trucks appeared to be approximately 30 years old, but for the most part ran effectively. Modifications primarily involved welding or bolting a cover over the rear bed and constructing center-facing seats within the cargo area. Local transportation was secured through Francis on Day 2. Utilizing the taptaps allowed Team Rubicon to maintain a low profile, which helped mitigate security concerns. Locals on the road did not assume that the taptaps were transporting large quantities of critical medicine or water. Since the taptaps were operated by local drivers, wrong turns and blocked roads were avoided; the local drivers had a clear understanding and knowledge of which roads were open for passage. Typically, a taptap had one driver and one assistant driver, as per local custom. The assistant driver did not add any value to Team Rubicon operations, and his seat could have been better utilized by a TR operator. Transportation was compensated on a per truck basis. Each taptap was paid $100 per day, which covered wages for all locals involved (driver plus assistant driver) and fuel.

     TEAM RUBICON, After Action Report

English speakers were easy to come by in Port au Prince, however, adequate translators were often more difficult to find. Problems arose when TR doctors would ask a translator to ask a patient a question, and get an unrelated response in return. This happened because the translators often did not speak English well enough to understand basic sentence structure and vocabulary. When this would occur, the translators would often simply ask any question of the patient, simply to make sure they remained employed. This caused major delays in patient care, as TR medics would then have to wait for a more effective translator to free up from working with other cases. Typical compensation for translators was between $20-30 per day, depending on effectiveness and length of employment. Translators found to be effective were often invited to meet Team Rubicon at the Novitiate the following morning to work with the team again.

An effective method used by Team Rubicon was identifying local Community Leaders at each site where a field triage was established. Community Leaders were easy to identify because they took initiative in organizing the camp members into orderly lines, and had them begin self-triaging. These Community Leaders were exclusively male, appeared to know the majority of locals by name, and often spoke limited to adequate English. Once Team Rubicon members identified Community Leaders in an area, they were pulled aside and offered compensation for continued services. Compensation, while perhaps not necessary, served to further motivate these individuals to help organize an effective triage. Additionally, seeking to make more money, Community Leaders often volunteered to lead Team Rubicon elements to other, similar camps which had not seen medical attention. Typical compensation for a Community Leader ranged from $5-15 per day.

Utilizing local nationals to fill roles on Team Rubicon proved to be an excellent idea for many reasons:

  • Provided instant credibility to Team Rubicon when it would arrive at a refugee camp
  • Ensured local customs and courtesies were understood and adhered to
  • Provided access to local knowledge of roads, camps and conditions
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  • Provided flexibility- If a vehicle broke down, another vehicle was simply hired; there was no wait for repairs or replacements
  • Enabled TR to put cash into the hands of those that needed it most

recommendations

Team Rubicon must continue to employ local nationals wherever it responds. The benefits of utilizing locals far outweigh the potential downside. However, it is vitally important that Team Rubicon be aware of any religious, ethnic or other social tension present within the DZ country. It is possible that TR could run into a situation where certain local nationals will steer aid only to their particular ethnic community. For example, in the Middle East, a Sunni-Shia divide could make using local nationals challenging.

action

  • First priority on site is to locate a Local Liaison, whether a US citizen living abroad or a local national that speaks fluent English
  • Teams should deploy with an adequate amount of cash, no less than $1,000 per operator per week, to cover all expenses
  • Teams should develop a thorough understanding of cultural differences within the target DZ.

 

OPERATIONAL CONCEPT- SCOPE AND DURATION

SUMMARY

Team Rubicon deployed to Haiti hoping to render aid in any capacity possible. Shortly after arriving, TR discovered that there was a large void that needed to be filled- large aid organizations were not pushing their resources out into the hard struck refugee communities. Instead they were forcing the Haitian earthquake victims to find their way to large field hospitals located away from the DZ.

Team Rubicon quickly identified the need for small, mobile teams to insert themselves into the refugee camps where locals were desperately waiting for medical attention. These locals were suffering from multiple acute trauma injuries, which have a small window for life-saving treatment; additionally these locals had either no one to take them, or no way to get to, large hospitals. The result was that only those patients that had surviving family members, or patients that could walk, were receiving professional medical care. Conversely, those who had been recently left with no relatives, and those who were unable to walk, were left to fend for themselves in unsanitary conditions.

Team Rubicon’s small, mobile elements were able to identify, through local contacts, refugee camps with the greatest need. The result was that TR was able to provide life saving medical care to many victims on scene, cleaning wounds, preventing infection, and setting broken bones, while at the same time identifying and transporting critical care patients to larger aid organizations’ established medical hospitals. In this sense, TR’s mobile clinics ensured that wounds not requiring immediate care were treated and would not develop into critical cases, while at the same time identified those critical patients who had no ability to seek out necessary care under their own means. In doing so, Team Rubicon’s efforts and abilities complemented larger organizations’ capabilities, which increased the effectiveness of the response across all levels.

     TEAM RUBICON, After Action Report

In addition to proving its ability to provide vanguard medical care directly to refugee camps, Team Rubicon displayed the versatility that its organizational model allows when it discovered the management and logistical problem plaguing the General Hospital in downtown Port au Prince. On day two of medical operations, TR discovered that the General Hospital, Port au Prince’s largest medical complex, was suffering from a lack of leadership in its Emergency Room operations. Realizing the enormity of this ER’s impact on patient health, Team Rubicon ceased field triage operations and immediately redirected efforts to the General Hospital.

Once on site, Drs. Griswell and Dolhun assumed control of medical operations in the ER, while TL Jake Wood assumed administrative control. Soon, all Team Rubicon members were working furiously to reestablish order and control. Team Rubicon continued operations at the General Hospital throughout the following day, and can claim responsibility for securing food, water, medicine and shelter for the patients following the 6.1 aftershock. The events at General Hospital demonstrate Team Rubicon’s ability to adapt and overcome in any environment. While TR’s primary scope may be mobile field triage units, when opportunities arise that enable a greater magnitude of impact, TR is flexible and dynamic enough to fill the gap.

As Team Rubicon’s mission calls for it to ‘bridge the gap,’ its length of operations within a disaster zone is limited. TR only operates effectively up until the point large aid organizations have the full effect of their logistics and planning behind them. Once this occurs, Team Rubicon’s effectiveness on a per dollar basis dwindles, and large NGOs’ effectiveness encounters increasing economies of scale. It is at this point that Team Rubicon should deactivate teams.  The length of this ‘gap’ is not set, but rather a product of multiple factors:

  • Nature of the disaster
  • Infrastructure development in DZ country
  • Effect of the disaster on infrastructure (primarily airports, sea ports, major highways and bridges)
  • DZ country’s political climate
  • Continued natural deterrents (aftershocks, heavy rain, etc)
  • Other

Operations in Haiti suggested that the window for Team Rubicon operations is approximately 10-14 days, the first 2 to 5 of which are critical for stabilizing and saving acute victims. TR discovered that it effectively has a rapid half-life beginning around day 10. TR2, which arrived in Port au Prince on day 12, encountered difficulty in finding refugee camps in dire need of medical attention, forcing them to adapt their operational objective to follow-on care.

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Haiti’s poor infrastructure and building codes magnified the effects of the earthquake and caused the ‘gap’ in aid to widen.

recommendation

Team Rubicon must establish a process for getting an initial evaluation/response team on the ground in a disaster area within 36 hours of a catastrophic event. This advanced team should consist of TR’s most skilled and experienced military operators, as well as a seasoned physician with multiple disaster response experiences. In the initial 24 hours on the ground, the advanced team will attempt to establish a base of operations, identify the primary injuries to be encountered, develop a list of special equipment needed, and determine an appropriate number of Team Rubicon elements that should be activated and deployed as follow-on elements.

Follow-on elements should be waiting in a stand-by status within 24 hours of the disaster, and be prepared to depart within 12 hours of notification and activation from the advance team. With this timeline, Team Rubicon can ensure the rapid deployment of an appropriate number of elements, which is essential in order to provide critical care during the initial five day window.

Additionally, Team Rubicon must continue to foster good working relationships with prevalent NGOs to ensure that future operations are met with cooperation and mutual assistance. This is necessary to making Team Rubicon a force multiplier.

     TEAM RUBICON, After Action Report

 

action

  • Execute actions under Air Transportation section
  • Execute actions under Team Composition section
  • Identify volunteers who most suit the role of Advanced Team

 

 

SECURITY

SUMMARY

Prior to deploying to Haiti, Team Rubicon was aware of media reports that illustrated an unstable security environment on the ground. Reports of violence, looting and mob mentality were being run hourly on all major networks, causing most major relief organizations to hold back on fully ramping up their response capabilities out of fear of violence. Team Rubicon, with its emphasis on most members having a military background, understood that proper planning, posturing and precautions could mitigate the danger of a security situation.

Team Rubicon prepared for violence upon arriving in Port au Prince, but found none. Many media outlets, in an attempt to boost viewership through yellow journalism, were portraying desperation as violence; capitalizing on limited footage of actual looting and making it appear commonplace. Once on the ground, Team Rubicon was quick to assess the security situation, noting that it was stable but teetering on the edge of volatile.

Team Rubicon implemented multiple security measures that lasted throughout operations in Port au Prince, including:

  • Minimum two security personnel were located at the rear of each vehicle during all convoys. Each security person carried some fashion of makeshift weaponry- machete, camp axe, folding shovel, etc.
  • Majority of original TR members wore military style “BDUs” in order to lend a military appearance. These both served as a ‘uniform’, which lent credibility, but also gave locals pause when they considered getting close.
  • Water and food was never given out to local crowds unless for medical purposes. Giving the appearance that you are as hungry and thirsty as the locals reduces their propensity to ask for handouts. If handouts are given, crowds gather, and crowds can quickly become angry mobs.
  • Local help was relied upon to provide a ‘vibe’ of the local tone and mood.
  • TR kept travel outside the Novitiate after dark to a minimum.
  • Radio communication/hand signals were always maintained between lead and rear vehicles.
  • At triage stations, crowds were kept back and away from treatment areas and the vehicles containing all the gear.
  • An emphasis was placed on ‘posturing’ (discussed later).
  • Stating “MEDICINE” clearly conveyed TR’s mission to anxious crowds
  • Doctors and nurses wore their scrub tops. In most countries and situations, doctors will be treated with respect and given room to maneuver and operate.

These security measures mitigated the uncertain situation on the ground in Haiti. Team Rubicon’s emphasis on military experience is not to ensure that an unforeseen conflict is ‘won’, but rather that unforeseen conflicts never happen. Present day military operations in Iraq and Afghanistan often have an emphasis on SASO operations (stability and support ops). The emphasis within SASO is to provide civil projects that positively affect the target population without inviting conflict.

SASO operations have created a new breed of warrior, one focused on how to avoid conflicts and win wars through ‘hearts and minds’. Many of these lessons can be translated to Team Rubicon’s mission of disaster relief. The situation in Haiti required civil projects to be implemented in an unstable security environment, and these projects (medical operations) were successfully conducted by adhering to local customs, learned through our local help, and posturing. Posturing is nothing more than presenting yourself in a manner that projects a quiet authority and power.

Done correctly, posturing presents a ‘hard target’; someone that potential troublemakers choose not to provoke.

recommendation

Team Rubicon learned many security lessons during its operations in Port au Prince. First, initial media reports should be assumed overblown. Violence sells in the media, and that should always be considered. Second, weapons may not be necessary or prudent. TR attempted on multiple occasions to secure firearms prior to crossing the border into Port au Prince, however, once inside Haiti TR realized that the situation did not warrant firearms. Basic camp tools- shovels, machetes, axes- are necessary for disaster relief missions and can also be utilized as impromptu weaponry with minimal training, should the need arise.

Standard security measures such as proper communication ability, dedicated security elements, and proper routes should always be heeded. Water and food should NEVER be given; it creates a slippery slope that can quickly spin out of control.

Posturing is a Team Rubicon element’s best friend. Each situation will warrant a different level of posturing intensity, but it is a tool that, when properly implemented, ensures conflicts never arise.

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action

  • Make sure each TR element has an appropriate number of experienced military/police veterans
  • Properly brief TR elements prior to ALL TR operations on potential security risks, and the measures that will be implemented
  • Ensure individuals on Security Detail know their roles and duties
  • Make sure proper time is budgeted to allow travel back to Base of Operations so that it does not take place after dark
  • Have a uniform appearance, to include scrub tops for medical professionals. Uniform appearance does not need to be military in nature.

 

MEDICAL

Summary

The medical situation encountered by Team Rubicon in Haiti was unique because of the complete lack of infrastructure found in the country. Wounds were being discovered untreated as far as 10 to 14 days post earthquake. This complicated an already overwhelming need for medical attention.

The vast majority of wounds treated were caused by falling concrete blocks, resulting in severe crush injuries, soft tissue damage and extremity fractures. These wounds, often left untreated, then developed secondary complications such as infection, gangrene, sepsis and compartment syndrome. These patients subsequently required amputations of affected limbs. In addition to wound care, woman-centered issues were also prevalent, mainly pregnancy complications and yeast infections.

During field operations Team Rubicon conducted T3 operations (Triage, Treatment, Transport). During initial set up, local translators and community leaders set to the task of organizing the community by urgency of medical treatment needed. Major injuries requiring higher echelon medical care were identified and placed in a holding area. Minor wounds and fractures were treated on site utilizing equipment organic to the team. Once a full load of patients needing transport was assembled, transportation was conducted to a higher echelon of care. This process was repeated multiple times throughout each day.

Basic wound care was primarily tasked to EMTs and paramedics, since it did not require advanced medical skills. Clorhexidine was the primary disinfectant utilized, used in conjunction with scrub pads and gauze. For more severe wounds, surgical debridement was necessary, which was done by both doctors and physician assistants. Once wounds were clean, silver sulfadiazine was the primary topical antibiotic applied, and multiple types of oral antibiotics were issued.

     TEAM RUBICON, After Action Report

Basic extremity fractures were often treated by Team Rubicon on site, due to the lack of diagnostic equipment and medical personnel at hospitals. TR doctors and PAs reduced multiple inline fractures, which were then casted by EMTs and other personnel. Proper casting and splinting material became a major issue. At one point, splints were being made out of window frames and tree branches, for lack of adequate material. Also, local patients had difficulty understanding the importance of keeping weight off of lower extremity injuries; a situation further complicated by the absence of crutches.

Throughout the operation Team Rubicon had numerous types of medical professionals, with physician specialties including: General, Emergency, Ortho, Neural, Spinal, and Internal. Additional medical professionals included physician assistants, RNs, paramedics, EMTs, and military medics. As Team Rubicon’s pool of medical professionals grew, it began tasking surgeons to local hospitals as they became operational. This created a continuum of care, which allowed TR field elements to conduct T3 operations, and then take critical patients directly to a hospital, where they could be transferred directly to a TR surgeon for immediate care. This also ensured that the diagnosis in the field was directly communicated to the receiving medical authority.

 

recommendation

The emphasis for field operations (TR’s primary mission) should be physicians with sufficient trauma training. They could come from a variety of specialties; however, an emphasis should be placed on Emergency, Ortho and General. Field physicians deploying with Team Rubicon should be comfortable practicing medicine in non-sterile environments, utilizing imperfect methods to achieve the best possible medical outcome given the situation provided. Excellent diagnostic skills are equally, if not more important, than treatment skills because of a lack in diagnostic equipment and the sheer volume of injuries. Operating Room nurses and anesthetists would make field surgical operations easier, but are not vital if appropriate meds are available (Ketamine, Versed).

Each field team needs no more than two physicians, as the majority of wounds can be diagnosed and treated by PAs and RNs, with much of the small work conducted by lesser trained medical professionals. The doctors should be utilized in diagnosing complex cases and oversight.

Military Special Operations medics (Army SF 18Ds, Navy SEAL Corpsmen, Marine Force Recon Corpsmen, Air Force Parajumpers) have an excellent understanding of treating acute traumatic injuries in field environments. Ideally, one such trained individual should be placed on each field team, since they can play a dual role as a field medical specialist or security specialist.

Additionally, appropriate medicine, supplies and gear is essential to conducting field operations. All Team Rubicon teams should deploy with:

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Beginning immediately, Team Rubicon should begin collecting, organizing and storing the above gear so that it is ready to go at a moment’s notice for future operations. This will eliminate a logistical hurdle and provide for faster response times to future disasters.

It is also imperative that Team Rubicon do a better job of providing each patient with triage paperwork that states what symptoms were treated, how, and when. This way follow-up medical care can better be conducted by larger organizations. In addition to this, Team Rubicon should maintain a proper medical log, which will keep a record for the number of patients treated and for what, which will help TR in gear and supply preparation for future disasters.

action

  • Recruit a broad range of medical specialties, with an emphasis in trauma experience
  • Begin seeking medical supply donations from local hospitals and fire departments
  • Obtain a storage facility and stock it with prepacked medical go-bags
  • Identify an expedited way of obtaining controlled medications for deployments
  • Explore further the option of developing a follow-on Forward Area Surgical Team (FAST), which could deploy if adequate medical facilities are not available in country

 

     TEAM RUBICON, After Action Report
STATESIDE HEADQUARTERS UNIT

SUMMARY

Team Rubicon’s success in Haiti is owed largely in part to a solid Headquarters element which was located stateside in Bettendorf, IA. First, HQ was able to continue to promote TR throughout social media outlets such as Facebook, Twitter, and internet blogs; as well as through traditional media outlets, including television, radio and newspaper. This continual promotion was crucial to TR’s fundraising efforts, which, as it grew, allowed for Team Rubicon to assemble and deploy a second element from the East Coast.

Additionally, HQ was able to relay needs and messages from TR members operating on the ground to the thousands of Team Rubicon followers on the web. This allowed Team Rubicon to tackle problems through multiple channels. For example, when Team Rubicon mentioned that CAT Scan machines were sorely needed at hospitals in Port au Prince, HQ relayed that message via the blog. Within one hour, 3 brain scan machines were located and willing to be donated to the cause in Haiti. This direct link between operators on the ground and thousands of supporters around the world allows TR as an NGO to not rely solely on ‘internal fixes’, but instead allows Team Rubicon to delegate needs to capable problem solvers outside the box.

Finally, HQ was able to collect, develop and disseminate back to Team Rubicon elements information that was essential to ongoing operations. This included changes in the political climate, the arrival of significant large scale aid (US Army, Marines), current funding status, information on follow-on Team Rubicon elements, and options for travel coordination back the US.

Recommendation

In future operations it will be essential for an Team Rubicon member to remain behind in the US to conduct Headquarters operations. HQ is too important to the success of TR’s mission to leave the job to individuals not involved with Team Rubicon on a daily basis.

Action

  • Identify individuals capable of the multi-tasking needed to successfully manage from the US a large scale Team Rubicon operation
  • Ensure these individuals have all the necessary access to the multiple TR media platforms
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key lessons learned

 

  1. Speed can be the difference between life and death when responding to natural disasters. Victims suffering from acute trauma injuries have a narrow window during which medical attention can save their life. Team Rubicon must seek to deliver the medical attention as quickly as possible.
  2. Local Nationals have the best, most reliable knowledge of the situation on the ground. There is no substitute for utilizing individuals who have spent their entire life within the affected DZ.
  3. Creating a direct link between donor and operator makes an unbeatable combination. Donors want to see their money make a difference; therefore, Team Rubicon must continue to link its donors to the response through social media.
  4. There is no replacement for having the right medicine and gear. Having the proper supplies allows Team Rubicon to operate more quickly and more efficiently, which ultimately leads to more lives saved.
  5. Teams should be small, light and autonomous. Team Rubicon’s model allows for flexibility in operations because teams are not bloated with size, unnecessary gear or red tape. Decisions are pushed down to the individual team leader, who is given the authority to operate as he/she sees best.
  6. Local religious groups have existed within countries much longer than the present governments. This means that they are trusted by the locals more, and are more likely to implement aggressive plans of action.
  7. A Stateside HQ element is mission essential. Elements on the ground do not have reliable enough communication abilities or time to coordinate all the moving pieces of the larger picture. A reliable HQ is critical to success.

 

 

 

 

 

 

key ACTIONS

 

  1. Continue to fundraise through traditional channels, while constantly seeking potential new sources of funding.
  2. Research and purchase the best, most cost-effective gear available, and have it staged in multiple locations around the country in order to rapidly deploy.
  3. Develop relationships with pilots and private charter companies that will allow rapid access to private flights capable of deploying globally.
  4. Continue to develop a comprehensive database of volunteers with various skill and language sets. This database must be easily searchable, allowing for the modular assembly of teams.
  5. Contact medical supply companies that are capable of supplying Team Rubicon with medication and trauma supplies at cost.
  6. Develop ‘intel’ packets on countries at high risk of social and political collapse following large disasters. Concentrate on typical modes of transportation, medical infrastructure, prevalence of English speakers, and potential for ethnic conflict.
  7. Continue to innovate new ways to harness social media and spread the word about Team Rubicon. Build and develop an online forum that allows any citizen to learn from Team Rubicon’s model and establish and coordinate their own similar grassroots effort.