After Action Report
Los Angeles, September 30, 2012: Five Americans and one Canadian board a China Air flight bound for Bangkok. This is Team Rubicon’s 2012 Project Karen team, on its way to the hinterlands of Thailand and Burma to conduct its third annual humanitarian mission to aid ethnic Karen refugees and Internally Displaced Persons (IDPs). This year, the scope of the mission goes beyond medical training: in addition to training, the team will develop physical infrastructure in two villages and run mobile health clinics. In the belly of the plane lies the team’s logistics train: solar panels, water pumps, satellite phones, emergency medical packs, and over a hundred pounds of donated medications from AmeriCares. Rob Swain, the team’s “fixer”, awaits the team in the notorious Thai border town of Mae Sot, preparing ground transportation, lodging, food, security forces, and translators.
This year’s team has a deep bench: team leader Jason Jarvis, a former Army Special Forces medic and Thai linguist; emergency physician Jennifer Eisner, on leave from clinical practice in rural Alaska; nurse practitioner midwife Laura MacPherson from Seattle; photographer Ross Fenter, a former Army tanker, now executive producer at Seattle’s Lustre Communications; water pump expert John Long, a former Navy SEAL from upstate New York; and electrical/aerospace engineer Stephen Hunt, a former Army infantryman, construction and communications specialist.
Once in Mae Sot, the team procures a truck full of rice and noodles and an armload of additional medications before moving via pickup truck to the Burmese border, where the team links up with a small group of Karen paramilitaries. At the border all personnel and equipment are cross loaded onto tractor-drawn carts and driven by the paramilitaries along narrow mud tracks into Burma’s Karen State, a region the locals call Kawthoolei. The Karen are one of several ethnic groups seeking independence from the militant central Burmese government. These ethnic groups exist on the geographic and economic fringes of Burma, persecuted by Rangoon, with austere resources and scant healthcare service. IDP villages, built of bamboo, teak, and thatched leaves, house many thousands of Karen families. The Karen are more or less unified under
the Karen National Union (KNU), the unofficial government that manages the affairs of its constituents, most of whom have been displaced from their ancestral villages by the Burmese junta. In addition, the KNU shields its people from Burmese aggression with the might of the Karen National Liberation Army (KNLA). The Karen have the dubious distinction of being a party in the longest-running civil war in modern history, a conflict that spans from 1949 to the present day .
Team Rubicon’s humble tractor caravan (Figure 1) finally arrives at a fortified and well-armed KNLA base camp – the paramilitary outpost the team will call home for the next two weeks. A double-wall of bamboo punji sticks line the perimeter, while a tripod-mounted World War II-era 50 caliber machine gun points ominously at the spike-studded vehicle gate. The team meets its gracious KNLA hosts (armed with Kalashnikovs, mini-30 carbines and grenade launchers) (Figure 2), and then spreads its hammocks and equipment out in an elevated wooden hut. By the time the team has situated into its quarters a dinner of rice, noodles, eggs, and locally-harvested morning glory has been prepared by Karen cooks. This Spartan menu will be the template from which all other meals consumed in Burma are derived. In the darkness beyond the reach of headlamps lie rustic squat toilet shacks, and the river in which Karen and Americans alike will bathe. That night, under a triple canopy of bamboo trees, thatched leaf roofs, and mosquito nets, the team makes its final preparations.
Mission concept: To make sustainable contributions to the physical infrastructure, health, and medical education of the displaced ethnic Karen people living in Internally Displaced Persons (IDP) camps along the Thai-Burma border.
- 1) Provide improved access to water: Install solar powered water pump in Camp A (all Karen place names withheld for security reasons) to bring water from a well via PVC pipe to the camp and nearby Village, with accompanying backup generator [UN reference]. Work with and train local personnel on equipment installation and operation (Figure 3). Also install a small hand pump in a co-located small shallow well.
- 2) 2) Install hand operated water pump in Camp B, in an existing well. Expand the well and build levee to protect it from contaminated surface water (Figure 4).
3) Assist in providing medical care to the Karen populace in Camps A and B, plus refugees from Burma living in Mae Sot, Tak Province, Thailand. Roughly 50 medical and dental patients were examined, diagnosed, and treated (Figures 5 and 6).
4) Train ten KNU community health workers in the following topics: midwifery (Figure 7), prenatal care, neonatal care, introduction to Tactical Combat Casualty Care (TCCC) and the nine contributors to mortality, tourniquet application, bandaging, peripheral intravenous cannulation (to include jugular vein technique), treatment of shock and electrolyte depletion, local and regional anesthesia, field patient transport and documenting, and suturing. Practical application exercises and demonstrations performed for most of the topics. All topics were chosen by the trainees.
5) Explore potential for future missions in Karen State, the Mae La handicapped Karen veterans camp, and the Mae Tao clinic on the border in Thailand (Figure 9).
Project Karen Shan 2012
9/30/12 – 10/16/12
Infrastructure development, healthcare & healthcare education
TR main body
4 (Jarvis, Fenner, Long, Hunt)
BURMA 2012 TOTAL CASH RAISED:
LESS: CREDIT CARD FEES:
FOOD & LODGING
BURMA 2012 TOTAL EXPENSES:
NET OPERATION GAIN/ (LOSS)
Rob Swain and Ross Fenter developed the mission concept and proposed it to Team Rubicon in early 2012 (Figure 10). Team Rubicon Headquarters approved the concept and began putting together the team, with TR’s 2011 Project Karen/Shan veteran Jason Jarvis as team lead. Rob Swain would be an integral part of the team, with his vast experience in the Area of Operations (AO) and numerous connections among the Thais and Karen. Ross Fenter, a media executive producer with experience along the Thai-Burma border, was a shoe-in for the role of photographer and videographer. The next step was to fill the team with enough technical and medical expertise to maximize mission success. John Long, ex-SEAL and water pump specialist, was recruited to procure and install the water pumps. Stephen Hunt, former infantryman turned PhD electrical engineer/construction specialist, also experienced in Southeast Asia, would prepare and deploy the solar panels, UHF radios, and Iridium satellite phones. Dr. Jennifer Eisner and nurse practitioner Laura MacPherson would fill a critical role with family practice style medical care, as the patient population was expected to be largely women and children.
After many conference calls, the travel and logistics began coming together: TR HQ arranged the flights, set aside a cash operations fund (opfund), and constructed a wooden crate to house and protect the four large solar panels during their shipment to Thailand. The team specialists researched, procured and organized the electronics, small tools, electrical components, water pumps, clinical equipment, and emergency medical bags, while the humanitarian NGO AmeriCares donated an extensive formulary of pharmaceuticals to the cause. The initial survey of the water-pump installation sites conducted for planning purposes was performed using low-tier GPS equipment. This potential shortcoming did not significantly hamper the engineering team as the team stood down on the pre-planned sites after being alerted by local authorities (KNLA) of security concerns once we arrived in Burma. The situation was fluid; upon our arrival goals were adjusted, secondary sites with acceptable risk were evaluated and then selected for water system installation following consultation with the local populace.
Jason prepared a 7-page Warning Order that went out on July 14, followed by a 21-page Operations Order (OPORD) on 21 September. Rob flew to the Area of Operations (AO) a week prior to the main body arrival in order to prepare food and lodging, personnel, and ground travel. Approximate field measurements, constraints and documentation were prepared for the engineering portion of this mission. A part of this survey included the critical assumption that the present water sources (shallow wells) had sufficient water capacity to service the intended local populations.
The team converged on Team Rubicon headquarters in Los Angeles on September 29th. The first order of business was a final detailed inspection of all medical and engineering gear. This inspection was followed by adjustments to the packing of the many bottles of medicine, solar panels, and water pumps into flight-ready bags. The mountain of medicine from AmeriCares was slimmed down by removing extraneous packaging before stuffing it into duffel bags. Radios and satellite phones, some rented by TR, were charged and tested, and Stephen created brevity codes for radio traffic verbiage, e.g., “arrived at objective,” “returning to base,” etc. The pre-deployment radio testing uncovered the fact that the vendor did not properly pre-program the radio sets to properly communicate with each other.
Team reliance on personal smart-phone and low-tier GPS gear (backpacker-level technology) was used for the mission to support personnel tracking, image geo-tagging and engineering survey applications. Even top-quality GPS gear has difficulty in providing reasonably accurate geolocation in near equatorial settings; for example Mae Sot, Thailand is located near 16 degrees north latitude, relatively close to the equator. Paper maps were not made available; Google maps were investigated for navigation and situational awareness. But at all times the team relied on our Karen hosts for guidance through the potentially landmine-prone regions in Karen state. Only one specific area was pointed out during our travels.
Team Rubicon cofounder and vice president Will McNulty visited the office to assist the preparations, as did Director of Field Operations Andrew Stevens. On the following day the team gathered for a formal meeting in which the concept of the operation was discussed, along with the mission timelines, travel, and gear loadout. Stephen Hunt gave a class on radio and
satellite phone usage, while Jason Jarvis reviewed the contents of the primary and secondary emergency medical bags.
After a final gear and passport check at the office the team loaded all of its belongings into two trucks and drove to LAX. After a bit of negotiations with China Airlines (to include a full dismantling and inspection of the solar panel crate) the team secured good seats on its flight to Asia. Antimalaria prophylaxis began at this time.
Once in Bangkok International Airport the opfund was converted into Thai baht at an exchange rate of 29:1 baht:$US. Customs was cleared without too much hassle, though the solar panels raised the eyebrows of some of the Thai officials. A brief negotiation with the airport official on the irrelevance of the mysterious solar panel container to the Thai GDP or state security secured their immediate release. The team’s arrival time was quite late in the evening, and the flight to Mae Sot from Bangkok Don Muang Airport was scheduled for early afternoon of the following day, so the team overnighted in a no-frills hotel near the international airport. The next day, the team traveled via shuttle van to Don Muang and flew to Mae Sot via local air carrier Nok Air.
Rob Swain and a Karen driver/translator met the team in Mae Sot and helped get the team moved into a nearby guesthouse. The next day was spent picking up food for cooking, medications, IV fluids, and hammocks. After the shopping was completed, the medical team visited a Karen refugee camp on the outskirts of Mae Sot and provided medical aid. On the following day, the team loaded two pickup trucks and drove to the Thai/Burma border crossing point. At the border we met a handful of our KNLA hosts; then, all equipment and people were loaded onto two-wheel hand-crank-start diesel-powered tractor-drawn carts and driven along muddy roads into the rural borderlands of Burma. Once in the KNLA camp (Figure 11), we met with the local KNLA brigade commander, his lieutenants, and the camp commandant. We conducted a tour of the camp and the adjacent village, and were given quarters in the thatched-roof hut that housed the camp’s communications and power distribution network.
During the first few days the medical team traveled via foot and tractor from village to village, seeing roughly 50 medical and dental patients (Figure 12).
Given the change in location for the water system installation a new site survey was conducted to:
- 1) Understand how the local populations were currently performing water management activities
- 2) Estimate water needs; quantity and quality (exact population size unknown)
- 3) Establish sufficient water sources
- 4) Devise a pump installation and distribution system with intermediate water storage locations
Meanwhile, after much debate, politicking and at the suggestion of the local Karen, the engineering team settled on a site for the primary water pump that everyone could agree on. The primary water pump, with its attendant solar panels and generator, would be installed just outside the KNLA base camp at the largest local water source behind a dammed river (just up-river from the bathing area), and would service both the KNLA soldiers as well as the civilian village it protected.
The engineering team split into two efforts:
1) John and Rob returned to Thailand to acquire a generator
2) Steve remained near the camp to research the inoperable water systems (currently in place), potential water pump locations and to trace the jungle distribution systems (PVC pipe) with the KNLA personnel (Figure 13).
There was some question as to the value of the generator given the existence of the solar panels.
The generator proved quite valuable for two specific reasons:
1) Without direct sunlight the solar panels did not have sufficient energy to drive the pump.
2) The existence of the generator enabled the team to prove out the pump system without the existence of sunny weather.
The immediate movement of water gained the confidence of the local population and enabled the engineering team to move ahead on each stage of the proje ct without wondering if the system would work. It can remain cloudy for weeks in Thailand during rainy season; in principle, if only relying on solar panels, the engineering team could have spent the whole time in Thailand without moving a drop of water due to cloudy conditions. Multiple forays by the engineering team back into Thailand for additional plumbing and electrical supplies provided items such as wire and PVC pipe that were too large for shipment by air. After initial pump installation and testing John devised the pump housing system (Figure 16) out of PVC that enabled its submersion in the largest water source available in the area. A hand-powered water pump was installed in another village that lay about an hour away by foot.
After seeing all of the patients living in the surrounding area, the medical team transitioned into training mode. The ten Karen medics that met us to discuss training topics were quite young, with a median age of 22. The very first question we asked of them was what training they wanted, as opposed to dictating to them our own agenda. They responded eagerly with a long list: midwifery, field trauma medicine, IV cannulation, nerve blocks, prolonged field care, suturing, and dentistry. The team made good on all of the topics but ran out of time before the dental discussion could begin.
The missions wrapped up on schedule and culminated in a pig roast and special dinner with the camp commandant. Not one to miss a training opportunity, Jason harvested two feet and the trachea from the freshly-killed pig in order to give the Karen students a chance to suture on skin, while the team underwent a cricothyroidotomy skills class that night using the trachea. All leftover AmeriCares pharmaceuticals were donated to the Karen.
Redeployment from Burma to Thailand proceeded without mishap, from Mae Sot to Bangkok, Bangkok to Taipei, and from Taipei to Los Angeles. TR president Jake Wood and Will McNulty personally picked up the team and its remaining gear from LAX and returned to TR headquarters for the communications gear handoff and debriefing.
As stated in the OPORD, the post-deployment activities consisted of writing the AAR and completing antimalarial prophylaxis. On December 17, Jason presented an overview of Team Rubicon and its key 2012 missions at the annual meeting of the Special Operations Medical Association in an effort to recruit specops medics and other field medical practitioners for future TR missions.
AREAS OF ANALYSIS
4. Communications and Navigation
Air and ground transportation was very good throughout, with the following two exceptions:
- 1) Shuttling a large group with a lot of gear in Bangkok needs to be preplanned to as great an extent as possible, particularly on arrival at the airports.
- 2) The team was down one truck on the return from Burma to Mae Sot; Rob and Ross volunteered to ride via public conveyance back to Mae Sot, enduring unsafe conditions.
Preplan big city ground transportation; in the case of pickup trucks, ensure there is at least one truck per five team members (indigenous driver plus three to four team members in the cab, the other one or two plus gear in the back).
Given the ambitious mission scope (engineering, medical education, and clinical practice), the selection criteria for volunteers was stringent. There were no advertisements as such for the positions; each one was filled by word of mouth. Will McNulty phoned Jason Jarvis and asked if he would act as team leader/medic. Matt Pelak, TR’s Director of Strategic Partnerships, recommended John Long and Stephen Hunt for the water and electrical engineer positions. John Sutter, Team Rubicon’s medical director, recommended Jennifer Eisner for the position of onsite medical control and primary clinician. In anticipation of neonatal and OB/GYN patients, Jason brought in nurse practitioner midwife Laura MacPherson, a personal acquaintance and fellow medical practitioner. Rob Swain was as always a phenomenal on-the-ground resource with his wealth of contacts and experience along the Thai-Burma border; this was his third mission with Team Rubicon. Ross Fenter, one of the initial mission planners and a dedicated photographer with experience in the mission AO, worked out perfectly.
As previously stated, the scope of this mission is one that TR hopes to repeat in future missions. US Special Forces teams run similar missions, with its Foreign Internal Defense (FID) missions and Medical Civic Action Programs (MEDCAP). On these and other Special Forces missions, the team composition is diverse: medical, engineering, communications, weapons, intelligence, and leadership roles are staffed with two personnel per position (for a total of 12 personnel), and there are overlapping duties and extensive cross-training to add redundancy in the event that one or more team members are “out of the fight.” Additionally, some or all of the members of the Special Forces “A” team are trained to be conversant in the language of the country to which they are deploying. This year’s Team Rubicon Burma team adhered to the spirit of this staffing model with excellent results.
It bears mentioning that virtually any TR mission that is providing medical care to indigenous populations should bring at least one female medical practitioner because the women of many cultures are disinclined to allow male medical practitioners to examine them. The added advantage of being able to examine and treat indigenous women, who account for a large proportion of the patient population, cannot be overstated.
Team Rubicon’s personal gear recommendations for overseas missions were adequate. It should be noted that while hammocks were universally used (and should be used in Burma, given dangerous fauna such as snakes and giant centipedes), some people have great difficulty sleeping in hammocks, and should find this out before they deploy. Non-hammock users can opt for a sleeping pad, though there will be an increased risk of unwelcome nocturnal visitors. Mosquito nets were used as well, giving much-needed protection against endemic diseases such as malaria and dengue fever. Team water filters were provided but proved inadequate as they eventually failed when pitted against the murky waters of Karen state. Iodine tablets and bottled water brought from afar filled the gap.
Big-ticket logistics (solar panels and water pumps) were researched by the team’s subject matter experts. The water pump vendor was Pumps of Oklahoma (manufacture GRUNDFUS) and its owner Richard Greenly (whom we called to confirm the generator capability we needed) was of great assistance. In addition, Mr. Greenly sold us the pump at cost. The hand pumps were recommended by and obtained at cost from Caleb Holsey at the Water 4 Foundation (www.water4.org), a non-profit that could serve Team Rubicon well on future missions. Team Rubicon approved and purchased these items, then packaged them for travel from their office in LA. A significant amount of heavy materials for the water system project were purchased in Thailand, to include the generator, PVC pipe, wire, glue, nails, and tools that were too heavy to load as checked baggage.
The two emergency medical bags were provided by Jason, packed according to his experience in Southeast Asia and Iraq, and the US military Tactical Combat Casualty Care (TCCC) guidelines. An overview of the contents of the medical bags is listed in the medical section of this AAR.
The generic TR personal gear packing list is a great foundation for any reactive or proactive mission; however, new AOs warrant research for any unique essential equipment.
Team specialists should be tasked in future missions to research the materials they will need to accomplish the mission and supply an OPORD annex. Also, a site survey by one or more of the team specialists should be performed prior to the actual mission so as to minimize time lost during the adjustment to “ground truth.”
TR needs stocked emergency aidbags on hand for deployments, particularly for reactive missions. In addition, TR needs a basic clinical kit for missions during which clinical care will be rendered to indigenous people. Jason is happy to help facilitate the process of stocking these kits, although an MD’s license will be required for the procurement of prescription medications.
Due to legal reasons, the team did not deploy with prescription pain medications. The procurement and transport across borders of prescription pain medications such as Oxycodone, Toradol, morphine, and ketamine continues to be an issue that needs to be resolved before a medical or trauma disaster strikes.
If TR deploys engineers on the reactive missions pre-planned tool bags and survey gear should also be readied at the LA office.
Higher volume, high quality team water filtration system be researched for future missions at a capacity that is expected to exceed team requirements for drinking water quantity and quality.
COMMUNICATIONS AND NAVIGATION (RADIO)
Two Iridium satellite phones accompanied the team; these were adequate for steady communications with the TR home office. As the mission progressed, there were some minor challenges in maintaining battery life on the satellite phones as they had integrated battery systems that could not be removed and recharged. In other words, to charge a phone it had to be taken offline. This shortcoming should be overcome for future TR missions because the satellite phones are the most reliable form of communication; losing them to charge a battery versus swapping out the battery is an avoidable (and unacceptable) feature. TR should seek to purchase satellite phones with removable batteries with stand-alone charging devices. Another key feature of the satellite phones is the store-and-forward capability of text messages. A user can send a message from the AO (in this case Karen state) and it will be received on the receive-side (in this case LA) when the satellite phone is turned on. This feature is very helpful communicating across several time zones. And finally the satellite phones should be included in a communications annex of the operations order with phone numbers, standard check out and check in procedures etc.
The satellite phones operate at frequencies near 1.6 GHz (similar to GPS), even at this frequency their transmissions to and from iridium satellites can be significantly impacted by the ionosphere. The only means for overcoming these effects is to wait until the ionospheric disturbance passes or until the satellite has moved to a different part of the sky. A typical
satellite pass is only about 10 to 15 minutes so communications should be possible after only a couple of minutes. In extreme cases (during the early evening, it may take much longer (tens of minutes to hours) for an equatorial ionospheric disturbance to clear.
GPS and GLONASS (Russian equivalent of GPS) systems operate at frequencies just great than 1.2-1.6 GHz and can also be severely affected by ionospheric signal distortion. In this case the signal distortion leads to erroneous geolocation thereby affecting the teams’ ability to navigate, survey and tell where it’s been while traveling in unfamiliar territory. Adding to this mystery is the fact that not all GPS equipment is equal; the junk that is sold for recreational use and put in cell phones will provide marginal capability when employed in a hostile ionospheric region near the equator. These low-quality GPS devices often produced inconsistent and unusable location data, quite likely due to their inherent weakness (low signal-to-noise) and the daily occurring equatorial ionospheric disturbances (Figure 18) on GPS (signal interference) or from readily available GPS jamming gear employed by Burma forces [reference]. This was the experience of the Karen 2012 team. Given our lack of paper maps and functional GPS gear, we would be hard pressed to identify exactly where we had been.
Stephen researched and recommended Motorola UHF radios for intrateam use. These worked well for distances less than one mile in the hilly terrain in which we worked. The communication range of these radios can be greatly increased with elevated antennas or repeater systems.
The basic selection options for intrateam communications include UHF (around 440 MHz), VHF (around 150 MHz) or HF (around 10 MHz). Each system has its strengths and shortcomings:
- 1) UHF and VHF are effectively ground line-of-site systems where VHF will provide a slight advantage of greater a communication range when there are no hilly obstacles involved. UHF provides greater communication range over VHF in the presence of jungle and urban dwellings.
- 2) With sufficient transmit power HF systems can provide communications at great ranges (10s to 100s of km) and, unlike UHF or VHF signals, the signal will follow the slope of the earth to bend around hills and structures. HF signals will also bounce off the ionosphere to provide transcontinental communications; but the ionosphere has to cooperate. Earth’s ionosphere is a fickle beastie at the equator where radio-frequencies suffer (signal distortion and dropouts) from the incongruities of space weather.
Local cellular “drop” phones were carried by Jason and Rob. Steve also carried a $35 hockey-puck style cell phone with a ($6) Thai Sim card (name omitted to mitigate geo-location) that provided coverage in the Bangkok and Mae Sot areas. This cell phone was not effective in the AO even though, at one point, a local KNLA soldier was in conversion with his girlfriend in the US from the back of our tractor ride in Karen state. Presumably the soldier used a different cell carrier. In the future, Sim cards and their areas of coverage from the different carriers in Thailand for Thai-ready cell phones (GSM) should be researched and included in the OPORD communications annex. This will ensure, if it’s possible, that the TR team has effective cell-phone coverage from Bangkok to the AO for future missions. Cell coverage maps for Thailand can be obtained online, by word-of-mouth from strategic partners and from previous mission experience.
TR’s BGAN satellite uplink was left in LA as this was deemed not worth the space and weight to bring along a system that is redundant to the satellite phone. TR’s personnel beacons did not accompany the team as they were deployed to Sudan at the time.
Stephen Hunt performed the crucial job of educating the team on the use of all communications devices, while fabricating brevity codes and posting the codes onto the devices themselves.
The team employed one translator for this mission. While the translator was exceedingly helpful, there was not enough of him to go around, particularly when the team was split up. During clinics, when we saw from 2-3 patients simultaneously, the language barrier became very problematic, and the whole process was greatly slowed.
Improved lightweight antennas for TR communication gear should be acquired and tested in CONUS and then made ready for future deployments.
Future TR OPORD contains a comprehensive communications annex that covers all aspects of cell phone, UHF/VHF radio, GPS/GLONASS and satellite telephone usage. Tribal communication methods can work (on the fly verbal instruction) but often lead to miscommunication about critical topics or information that is simply forgotten. Therefore, in the future to augment the OPORD, brief paper handouts of relevant information (phone numbers, CONOPS etc) should be prepared for distribution to all team members before team arrival to LA.
Higher quality GPS gear essential to engineering surveys and team tracking need to be researched, tested and purchased for future TR missions (low-cost paper maps should also be
considered). Low-cost paper maps can be produced by printing full large-screen (like from a 47 inch flat screen) versions of Google maps for the AO and then laminated using clear plastic lamination material. GPS gear should record the travels of TR personnel throughout the mission for post mission analysis.
TR purchases more personnel beacons so that all deployed teams possess a good emergency communications plan. Also, a small quantity of drop phones are to be kept at HQ and handed off to deploying team leaders; the team leaders are responsible for procuring SIM cards upon arrival at their destination. Recommend a bare minimum of two translators on future missions when there will be split team operations happening or clinics employing multiple medical practitioners.
- • TR includes an AO specific comms OPORD annex, space weather report, procures additional personnel beacons, GPS gear, readies paper maps, identifies AO sim card carriers and drop phones for deploying teams. TR should budget for at least two translators on proactive missions.
The primary pre-mission medical work that goes into a mission such as this falls into four categories: vaccinations, malaria prophylaxis, training, and logistics.
Vaccination schedules are available through the CDC website; immunizations particular to this AO that people might not have had already include rabies, typhoid, and Japanese encephalitis. Tetanus and hepatitis A and B should be current as well.
Malaria prophylaxis used was either Doxycycline or Malarone.
Ideally all team members (to include non-medics) deploying to a place as remote as Burma should attend a wilderness first responder course as a bare minimum; those with the wherewithal should attend an operational medicine (e.g., OEMS) that covers both acute and prolonged trauma field care prior to deploying. While on mission, any down time should include “hip pocket” medical training; on this particular mission such training included use of tourniquets, bandaging, nasopharyngeal airways, and the cricothyroidotomy procedure (performed on a dissected pig trachea). These training topics were chosen specifically due to the landmine threat and the abundance of military weaponry throughout the AO.
Overall the medical kit that was brought was well-suited to the mission. Luckily none of the emergency aidbags were needed, other than for routine clinical use. Clinic-specific gear was adequate, though quite disorganized as we had no container that organized such gear very well; all of it was packed and carried in duffle bags and packs provided by team members. No dental tools were procured during predeployment; the two dental cases that were seen were
fortunate enough to occur near a Karen clinic which contained ample dental kit (Figure 21).
Most of our medical references were digital: UpToDate, the Merck Manual, the SOF Medical Handbook, and a variety of reference materials downloaded for free from the World Health Organization and other nonprofit groups. Hard copies of of the Pocket Pharmacopeia (drug guide) and Sanford Antibiotic Guide accompanied the medical team and saw much usage.
Training logistics were adequate, though more alcohol swabs and anesthesia needles were in somewhat short supply. The training topics are covered in the Mission Objectives section of this AAR.
Given the split team concept of the overall operation (medical team and engineering team going their separate ways on most days), an advanced medical aidbag accompanied the medical team while a basic medical aidbag accompanied the engineering team. These were both packed according to the modern military field medicine treatment algorithm MARCH (Massive hemorrhage, Airway, Respirations, Circulation, Head injury/Hypothermia/Handling); MARCH is a modified version of the civilian emergency medical treatment algorithm ABC (Airway, Breathing, Circulation). The ABC mnemonic is a better fit for emergency medical/trauma cases in people living in developed countries, who have a statistically higher likelihood (as opposed to people living in developing countries) of falling prey to heart attacks, strokes, diabetic crises, or car accidents. MARCH as an emergency treatment mnemonic is a better fit for victims of penetrating trauma (landmines, gunshot wounds, and stabbing injuries) and those living in extremely remote, primitive, or nonpermissive environments.
Among US and NATO special operations units (as well as White House Medical and the Uniformed Services University of the Health Sciences medical school in Bethesda, Maryland) the MARCH algorithm is currently evolving into MARCH ON (the additional two letters signifying Open wounds and No pain, two additional dimensions of patient care that are often neglected in the field environment, yet factor heavily into patient morbidity and mortality).
The advanced medical aidbag was packed as follows (highlighted items were desired but not procured in time for the mission):
Massive hemorrhage kits x2
Kerlex rolled gauze x2
ACE wrap, 4”
ACE wrap, 6”
Res-Q-Vac suction hand powered suction device
H & H cricothyroidotomy kit
#10 scalpel blade
6.0 endotracheal tube
7.5 endotracheal tube
Parachute cord, 24”
Plastic laryngoscope kit
Flashlight (with AA battery)
Macintosh blade #3
Miller blade #3
Spare AA battery
Respiratory trauma / Ventilation kit
HALO chest seal
Hyfin chest seal
Angiocath, 14ga x2
Oral rehydration salts x5
Normal saline IV, 500mL
Lactated ringer’s, 500mL
Tranexamic acid injectable
Blood collection bags, 450mL, with citrate anticoagulant x4
IV tubing, “Y” shaped, with filter
Thick space blanket
SAM splint x2
Kendrick Traction Device
Syringes and Needles
Syringe, 50mL, luer lock
Syringe, 60mL, Toomey
Syringe, 1mL, w/ 25ga needle x10
Syringe, 3mL x5
Syringe, 5mL x5
Syringe, 10mL x5
Alcohol swabs x20
Needle, 18ga x10
Needle, 27ga, 1.5” x10
Angiocath, 18ga, 1.25” x6
Angiocath, 14ga, 2” x2
Syringe, 3mL x2
Gauze, 4×4” double handful
Syringe, 1mL, w/ 25ga needle
Butterfly needle, 23ga x2
Alcohol swab x6
Intraosseous device, sternal (FAST 1, with removal tool)
Levin duodenal tube, 16fr
Minor Surgery Kit
Curved hemostats x2
Curved iris scissors
Needle drivers x2
Rat tooth forceps
Scalpel handle #3 x2
Tick remover w/ magnifying glass
Needle, 27ga, 1.5” x2
Syringe, 1mL, w/ 25ga needle x2
Lidocaine 2%, 20mL
Lidocaine 2% w/ epi 1:200,000, 20mL
Alcohol swab x6
Iodine swab x6
Surgical gloves, size 8 x2
Gauze, telfa (nonstick)
Epi 1:1000, 1mL amp
Benadryl inj 50mg
Ethilon suture w/ needle, sizes 6, 5, 4, 3
Prolene suture w/ needle, size 0 x2
Ligature pack, silk, sizes 2, 0
Reverse cutting needles, reloadable x10
Scalpel #10 x13
First aid kit
Pocket Pharmacopeia Drug Guide (2012)
3×5 cards x3
Steri strips x9
Cera Lyte 50 (ORS)
Moleskin donuts x6
Nonadherent pad x2
Gloves, 2 pr
Hand sanitizer packet
Foley, 2 lumen
Band Aids x20
Alcohol swabs x4
3” tape, 2 strips
“Apothecary” pill pack
Tylenol w/ codeine
“Pharmacopeia” pill pack
The basic medical bag (for the engineering team) was packed as follows:
Massive bleeder kits x2
CAT tourniquets x2
ACE wrap x2
Kerlex gauze x2
Airway & Respiratory kit
H & H cric kit
Suction EZ w/ IV tubing extension option
Angiocath, 14ga x2
Endotracheal tube, 7.0, w/ Stylette
Parachute cord, 24”
Chest seals x3
KY jelly packet x2
Viscous lidocaine tub
Hypothermia & Handling
Space blanket x2
Hammock (patient carrying)
Lidocaine, 20mL, 2%
Needle, 18ga x2
Needle, 27ga, 1.5” x 2
Syringe, 3mL x2
Syringe, 5mL x2
Alcohol swab x4
Benadryl inj, 50mg
Scalpel blade #10
Alcohol swabs x4
Monofilament suture 3-0 w/ needle
Silk suture 2-0 w/ needle
Gauze, 4×4, handful
Casualty cards x4
Resusci Face Shield x2
Moleskin donuts x3
Steri strips x10
“Apothecary” pill pack with instructions
“Pharmacopeia” pill pack with instructions
In addition, all team members carried the TCCC “Combat Pill Pack” in the event of a major open wound, consisting of Meloxicam, Moxifloxacin, and Acetaminophen.
A four-day course of the anthelminthic (anti-worm) drug Albendazole was given to all team members on our exit from the AO as a safeguard against any possible intestinal worm infestations.
The list of medications donated by Americares was long, here is the synopsis:
Lidocaine, injectable and topical
Over the counter medications
Medical cases (Figure 22) seen in the indigenous population were fairly run-of-the-mill: aches and pains, upset stomachs, respiratory diseases, general malaise, minor wound infections, infertility, etc. One suspected case of dengue fever was observed. The two dental cases involved rotten teeth that necessitated extraction under local anesthesia. The overall health and nutritional status of the Karen is surprisingly good considering their economic hardships and the rural tropical environment.
There are three logistics items that could have improved our clinical capabilities: a pulse oximeter, an iStat handheld laboratory, and a better system for organizing clinical gear and medications. A basic dental/anesthesia kit (similar to the one recommended in the SOF Medical
Handbook) should be procured for TR overseas use as well. TR HQ might also consider acquiring a library of electronic medical guides, which could be shared among devices and made available as needed to deploying medical teams.
TR teams must carry, in addition to a standardized medical loadout, prescription pain medications, and tranexamic acid (procoagulant drug, now part of the TCCC protocol). The ability (and SOP) to perform buddy transfusions (blood transfusions in the field from a walking blood bank) should be discussed by senior TR medical personnel.
- • In addition to providing large duffle bags suitable for long distance transport and stocking emergency aidbags and clinical/dental kits at the TR office, TR acquires a pulse oximeter, iStat, clinical tackle box or better jump kit, and appropriate electronic medical reference materials. All team members attend a field medical course prior to deployments. The lack of prescription pain medications, tranexamic acid, and buddy transfusion capability needs to be addressed by senior TR medical practitioners.
The water systems implementation consisted of at least the following areas:
- 1) Karen population needs assessment
- 2) The politics of water in a water-deprived area
- 3) Global standards for population access to water
- 4) Pre-deployment planning and equipment acquisition
- 5) Site surveys in Karen state
- 6) The staffing of qualified field personnel
- 7) Existing water well capacity (volume and refill flow rate)
- 8) Water quality and filtration
- 9) Water distribution and intermediate storage
- 10) Water pump design and capacity (appropriate for rural setting)
- 11) Water pump power systems (gasoline generator and solar arrays)
- 12) Site construction tasks (well area, pump installation, electrical)
- 13) Electrical systems
- 14) Roof water collection systems and basins
Prior to deployment, discussions focused on the water pump need and not on the population size or the type of wells that were in place. Accurate population statistics for Burma are nearly impossible to obtain due to the fragile condition of Karen state and the fact that only about 40 percent of the country’s citizenry is in possession of an identity card. Therefore an estimate of about 50 families per well area was used based on information by our fixer. Pre-deployment site surveys were conducted of village areas that the team never visited during the mission by non-engineering personnel. Fortunately the site survey was enough for water pump expert John Long to identify the Grundfos water pump system for installation (Figure 24). This
comes with electronics packages that enable the integration of solar arrays and generator systems such as those the team used in Karen state. Thousands of these pumps have been in use in rural Africa with great success.
Prior to TR’s arrival in the mission AO, small amounts of water were drawn by bucket from the wells, and Gerry cans were filled in the local river and carried to the KNLA camp and to the local village. This water was boiled for drinking and used as is for washing dishes and other uses. Bathing and laundry were performed by all the villagers and KNLA soldiers at the end of a 3” PVC pipe down at the stream. This is also the location where the Gerry cans were filled and carted away. While TR was working in this area we were careful not to disturb this 3” PVC pipe as it was central to the lives of all of the local Karen. At times there was great concern about where the water would be redirected.
Once the pump was installed in the first shallow well to test its performance, we quickly learned that the “wells” were all low-volume, low flow shallow holes. Most consisted of little more than a concrete pipe liner tipped vertical (Figure 26), and the well was pumped dry within minutes of starting our test. Not only would it have been impossible to supply even the minimum daily basic water requirement of 7.5-15 liters per person with these wells, as defined within the Sphere standards
(http://www.spherehandbook.org), (and Bartram’s paper on domestic water quantity, service level, and health, WHO 2003: http://www.who.int/water_sanitation_health/diseases/WSH03.02.pdf) for humanitarian response, but the Karen were already almost exclusively collecting their water from the adjoining pond rather than from the established wells anyway, and using household based water treatment interventions, such as boiling, to improve its quality at the point of use.
Limited by the constraints of time, available resources, and the austere setting that presented a seemingly endless set of challenges, and knowing that such point of use interventions have been proven effective and economical as well as acceptable to the Karen, we eventually decided that our priority, in accordance with Sphere guidelines, should be to provide equitable access to an adequate quantity of water, even if it is of a lower quality, until minimum standards for both quantity and quality can be met. Studies have shown that the transmission of water related diseases is related to insufficient water for personal use and hygiene as well as to contaminated water supplies, and even water that is safe at the source can become contaminated during collection and storage. After much discussion among team members and local authorities and despite the poor quality of the water, the decision was therefore made to place the pump in the largest available water source, the pond already serving as the primary water collection site, and to continue to rely on point of use water treatment.
Figure 25. Example of one of the many water well enclosures inspected by TR personnel. These wells typically had a depth no greater than 6 feet. Note that TR personnel were happy about not having any significant problems with local wildlife such as pythons, cobras or other dangerous creatures in the work areas.
It took a couple days for the team to make the assessment that a few Gerry cans of water and low capacity wells with buckets could not possibly supply enough water to even meet minimum Sphere water standards for the Karen and to devise a plan. Working closely with the Karen provided invaluable insights that the TR team could not possibly have evaluated in our short stay. The Karen suggested elements of the implementation plan that were conveyed to the team through our expert translator in the first few days of our adjustment to ground truth.
The plan consisted of exploiting the largest water source available by:
- 1) Increasing the size of the existing damn in the local stream behind the 3” PVC pipe
- 2) Cleaning out debris from the larger pool area behind the damn
- 3) Installing a shelter for the generator system and solar panel electronics
- 4) Installing the solar panels
- 5) Constructing a PVC enclosure/intake for the water pump
- 6) Horizontally installing the pump at the base of the pond behind the damn
- 7) Connecting the pump to the water distribution system that runs to the KNLA camp and to the Karen village
- 8) Installing the electronics so that the Karen cannot power the pump using the generator and solar panel simultaneously (one at a time only)
John Long devised and worked with the Karen to construct a first-rate pump enclosure and intake system. Steve worked with the Karen to prepare the damn area, install the solar arrays (Figure 26), electronics, and wiring, and chase down the PVC water distribution systems that ran to tanks in the KNLA camp and in the local village.
While tracing the PVC water lines with medical personnel on their only down-day (due to Sunday worship by the Karen) we attempted to perform a survey using low resolution GPS systems. The results were not adequate for determining the relative height of the pump to the distribution systems. In the future higher quality GPS equipment should be employed with both TR medical (for geo-location in case of emergency) and engineering teams. We also suffered from a lack of certain tools that would have improved the quality of the water system implementation. This caused us to frequently improvise solutions – a well-developed Karen art form. The Karen are extremely resource strapped and seem to be able to make just about anything from bamboo and a homemade machete.
We purposely included the Karen at every step of the process so they would be informed on as many details as possible. The language barrier was a minor to non-problem in completing the installation and testing. KNLA water storage was inside the encampment and the two large blue tanks could be filled in about two hours using the Grundfos pump.
The village water distribution system consists of a single intermediate tank (about 6 feet tall by 3.5 feet in diameter) with PVC pipe used to distribute the water to a series of spigots throughout the village. Once the power systems, the pump, and the PVC distribution systems were in place, water was made available to the KNLA camp (about 1 km) and to the Karen village (about 2 km). Within literally 90 seconds of testing the water system a Karen woman arrived with her laundry (Figure 24). TR’s objective to improve the access to water and therefore the sanitary conditions of the local Karen had been achieved despite many uncertainties and obstacles along the way.
Rob Swain and John Long worked the second water project, which took place at a village located approximately two hours (by foot) from the KNLA camp. In this location a 7×7 foot rectangular hole, 6 feet deep, was set along in the flood plain of a local river downhill from the village (Figure 29). It became clear that this shallow well was in place in the low laying area to take advantage of any available ground water during dry season when the river dries up. Similar to the other village, all of the drinking water was boiled prior to consumption. Any chemical contaminants still reside in the water (note in increased concentration due to the boiling). Also, since the well was downhill from the entire village, contaminated surface water flowing downhill entered whenever it rained. The team decided to improve this well by stacking sandbags around its perimeter to keep out surface water and then installed a floor on top with a small hand pump.
Greatly improve host group (such as the Karen) needs assessments (population size) and field site surveys to improve pre-deployment planning. The field site survey by expert personnel may appear to be a mission luxury but will save money, time and greatly improve the quality of the end result of each TR engineering implementation. It cannot be overemphasized
how much more could have been done with an improved field site survey. Improved well systems and water filtration systems could have been managed at cost if the needs had been better understood ahead of time.
Also, greater exploitation of rainwater collection on buildings should be considered for all projects like this in the future. Gutters, collection basins and water filtration (or boiling) are simple technologies that are more sustainable by local populations. Once a well pump breaks
(as exists all over Karen state from past projects) the local population usually does not have the expertise or resources to make repairs. What makes water pumps and well systems required for Burma and other regions is that roof-based water catchment systems have limited utility during dry season.
With Stephen and John’s assistance, establish ready tool-kits (analogous to field medicine bags) at TR headquarters for future field deployment exercises. Seek AO-specific tool storage drop points around the globe so that TR tools and materials can be left in-country to save time and money on future deployments. This will save on shipping costs and preparation time, as tools are typically durable equipment.
- • It’s not the plan, it’s the planning; as per above recommendations.
Following the lead of TR’s previous Burma missions, the existence of the mission was not publicly announced until after mission completion. This was done to avoid interference from the Myanmar government, who would likely object to TR providing medical assistance to the Karen people.
The option of post-mission media disclosure has worked for us three years in a row, let’s keep it up!
- • As per the recommendation.
24/7 physical security was provided by the KNLA paramilitary forces, armed with an array of assault rifles and grenade launchers. Team members were accompanied by armed escorts anytime we ventured outside the walls of the camp. Their base camp was in communication with other camps and outposts in the area via cell phones and HF radios, prepared to warn the team of any threats.
No recommendations for future missions in this AO beyond what we saw this year. Overall security was quite satisfactory.
- • All TR missions, like all military missions, maintain security as the critical task. Before any proactive deployment the security situation must be thoroughly explored and found to be acceptable by the team leader and TR HQ.
- 1) In the case of specialized missions such as this one, ground truth should be obtained by one or more of the team’s specialist prior to mission launch. If this cannot be accomplished, then the situation on the ground needs to be scouted out thoroughly by the team’s fixer or other trusted personnel.
- 2) Proactive mission OPORDs need to include a thoroughly researched and developed communications annex. The same goes for an engineering annex if the mission warrants.
- 3) TR proactive teams need satellite phones with detachable rechargeable batteries to minimize phone down time.
- 4) TR short range radios should be deployed with more robust antennas to improve range.
- 5) Deploying teams need advanced GPS/GLONASS devices.
- 6) Deploying teams need detailed (and laminated) paper maps of their AO.
- 7) TR needs enough personnel beacons and drop phones to cover all deploying teams.
- 8) Clinical gear should be packaged in a compartmentalized container (such as a tacklebox) that streamlines the clinical process (examination, diagnostics, treatment).
- 9) Two or more translators are needed for complex missions, or clinical missions containing two or more medical practitioners (assuming there is a language barrier).
- 10) Ground transportation for proactive missions should be planned in minute detail, particularly movement to and from airports. Five team members plus gear fit in a pickup truck; groups larger than this will require additional vehicles.
- 11) While prescription pain medications were not needed on this mission, their absence (due to the medico legal challenge of transporting them across national borders) was in the forefront of the medical team’s collective mind. Fixing this issue after a medical or traumatic emergency is not the way this shortcoming should be resolved.
- 12) Tranexamic acid and buddy transfusions should be added to TR’s deploying teams’ medical capabilities.
- 1) Get key personnel into the mission AO to establish ground truth, with enough lead time to adjust the planning process.
- 2) Ensure the proactive team’s communications specialist writes a solid communications annex to the OPORD. Team Rubicon should support the recommendations of this annex to the fullest extent possible.
- 3) An engineering annex to the OPORD will be written for future missions of this nature.
- 4) TR needs to acquire one or more lightweight portable clinic bags/tackleboxes and stock it accordingly.
- 5) TR acquires satellite phones with detachable rechargeable batteries in order to minimize phone down time.
- 6) TR adds long range antennas to its complement of handheld radios.
- 7) TR purchases and deploys advanced GPS/GLONASS devices.
- 8) TR procures laminated topographical paper maps for future proactive missions.
- 9) High-end (and lightweight) medical gadgets that would add capability to the clinical process include a pulse oximeter and iStat handheld laboratory device.
- 10) TR needs to build and maintain stocked emergency medical aidbags that are ready to deploy, along with a library of useful electronic medical references.
- 11) A simple dental/anesthesia kit should be built and maintained at TR HQ for overseas use.
- 12) Proactive team members should attend formal medical training (wilderness first responder or operational medicine) prior to deployment.
- 13) TR acquires additional personnel beacons and drop phones.
- 14) The medico legal challenges of transporting prescription pain medications into (or procuring within) foreign countries needs to be resolved before a medical or traumatic disaster strikes.
- 15) TR medical leadership discusses adding tranexamic acid and buddy transfusion capability to its medical logistics plan.
- 1. http://www.globalpost.com/dispatch/news/regions/asia-pacific/120504/myanmar-karen-rebels-may-oo-mutraw (1-19-2013).
- 2. W.E. Swartz and R.F. Woodman, “Same Night Observations of Spread-F by the Jicamarca Radio Observatory in Peru and CUPRI in Alcantara, Brazil,” Geophys. Res. Lett. 25 (1), 1998, pp. 17–20.
Rob Swain with KNLA soldiers.