Operation: Karen Shan

Burma AAR PDF

EXECUTIVE SUMMARY

 

Burma 2010:

 

Team Rubicon decided to do a proactive mission to train medical personnel who would treat internally displaced persons in Burma. The military controlled Burma Junta has been in a civil war with multiple ethnic groups within its borders for the past 50 years. Persons in the ethnic controlled regions receive no medical aid from the government. Since it is not probable that Team Rubicon members will be allowed to enter Burma after a natural disaster, we decided to proactively train personnel who will then be in a position to treat the Burmese people in times of medical need.

 

Mission start date:          August 1, 2010

Mission end date:            August 13,2010

TR personnel sent:           Five

Total cost:                              $13,354.86

 

The mission to Thailand was 13 days in duration from August 1-August 13, 2010. Team Rubicon sent 5 personnel on this mission.

 

In the summer of 2010 Team Rubicon discussed the possibility of sending personnel to train ethnic Burma medical teams that would treat internally displaced persons in Burma. The goal of this training was to train personnel that could treat internally displaced people in Burma. During a natural disaster, Team Rubicon personnel would not be able to deploy to the ethnic regions of Burma due to the current Burma government. Team Rubicon contacted one group to coordinate training, but due to logistical reasons the training plans fell through. Having already assembled a training team, Team Rubicon contacted other relief agencies that provide medical support for internally displaced people in Burma. Ultimately we were put in contact with 4th Wall Relief International. 4th Wall coordinated training with KDHW (Karen Department of Health and Welfare) to train 37 medical personnel. The medical personnel had varied skill levels ranging from beginner community health workers to seasoned medics. They included approximately 60% female and 40% male personnel.

On August 1, 2010 Team Rubicon deployed 5 members to the Thai/Burma border to train Karen medical personnel.

The members included:

Bob Thomann                      Team leader and Trainer

Jeff Lang                                                    Security and Trainer

Zach Smith                                               Communications and Trainer

Kevin Whitcomb                                  Media

Dr. Glen Geelhoed           Chief Medical Officer

 

Burma 2011:

 

In August of 2011 Team Rubicon deployed five volunteers to the Thai-Burma border for the purpose of training indigenous medics and community healthcare workers (CHWs) belonging to the Karen and Shan hill tribes. The team leader on this mission was Zach Smith, a paramedic and seasoned Team Rubicon member with deployments to Haiti, Chile, and Sudan. The formidable Dr. Glenn Geelhoed grounded the team with excellent medical direction and his unsurpassed passion for helping others in need.

 

The political situation for the Karen and Shan hill tribes is dire. Many of the people in these ethnic groups are driven from their home villages by the junta government of Myanmar, ending up along the Thai border either as Internally Displaced Persons (IDPs) or outright refugees. Within these IDP or refugee camps they survive primarily through subsistence farming, providing cheap labor to the Thais, and foreign aid. Our medic students had previously received piecemeal medical education from various organizations and have limited physician-level oversight in their workplace. Malaria continues to be their primary health concern, followed by acute respiratory infections, intestinal worm infestation, and many other ailments common to the rural jungle environment. In addition, injuries caused by Myanmar-deployed landmines pose a serious problem to all enemies of the junta.

 

The team flew from Los Angeles to Chiang Mai, Thailand and then drove to the border to link up with our Karen and Shan contacts. Upon our arrival at the border camps, we conducted rounds of the local clinics before beginning training the next morning. Our training topics included basic primary care with an emphasis on tropical medicine, field trauma care in a remote setting in the face of delayed evacuation, minor surgical skills, and building construction techniques. Our total numbers of students trained were 22 Karen and 52 Shan, all of whom received handsome certificates of training printed on George Washington University letterhead (courtesy of Dr. Geelhoed)! In addition to the training that we provided, we furnished our students with much-needed donations of improvised tourniquets, hemostatic agents, pressure dressings, and antibiotics.

 

This was Team Rubicon’s second trip to the region; in 2010 we fielded a team to work with the Karen medics only. We retrained many of these enthusiastic Karen medics in 2011, and their enthusiasm was shared by the Shan medics who we met later in the mission.

 

 

 

Jake Wood                                               William McNulty                                 Jason Jarvis

 

President, Team Rubicon              Vice President                                      Team Leader

 

 

 

 

OPERATION OVERVIEW

 

OPERATION NAME: Project Karen
DURATION: 10 days
DATES: 1-10 August 2010
LOCATION: Thai-Burma border
OPERATION DIRECTIVE: Train Burmese hill tribe medics
ELEMENTS: Team Rubicon main body
TOTAL VOLUNTEERS: Five (Thomann, Smith, Geelhoed, Lang, Whitcomb)
     MILITARY VETERANS: Three (Thomann, Geelhoed, Whitcomb)

 

 

 

 

 

 

 

OPERATION NAME: Project Karen Shan
DURATION: 16 days
DATES: 15-30 August 2011
LOCATION: Thai-Burma border
OPERATION DIRECTIVE: Train Burmese hill tribe medics
ELEMENTS: Team Rubicon main body
TOTAL VOLUNTEERS: Five (Smith, Geelhoed, Jarvis, Stevens, Fiorito)
     MILITARY VETERANS: Three (Geelhoed, Jarvis, Stevens)

 

Mission Objectives:

  1. Team Rubicon will gather supplies, both donated and purchased, and hand carry them to the Thai-Burma border for donation to Burmese hill tribe medics from the Karen and Shan states. Supplies include antibiotics, improvised tourniquets, pressure dressings, and hemorrhage control agents.
  2. Team Rubicon deploys five Americans to train Karen hill tribe medics in field medicine, tropical medicine, minor surgical skills, and building techniques using indigenous materials. The training course will run four days, allowing for the use of a translator.
  3. After a one-day rest and refit, Team Rubicon deploys five Americans to train Shan hill tribe medics in field medicine, tropical medicine, minor surgical skills, and building techniques using indigenous materials. The training course will run four days, allowing for the use of a translator.

 

 

 

BURMA 2010 TOTAL CASH RAISED: (TO BE FILLED OUT BY TR HQ)
     LESS: CREDIT CARD FEES:
NET:
EXPENSES:
     TRANSPORTATION:
     EQUIPMENT:
     FOOD:
     LODGING:
     AUTHORIZED CASH DISBURSEMENTS:
BURMA 2010 TOTAL:
BURMA 2010 NET OPERATION GAIN/ (LOSS)

 

 

BURMA 2011 TOTAL CASH RAISED: (TO BE FILLED OUT BY TR HQ)
     LESS: CREDIT CARD FEES:
NET:
EXPENSES:
     TRANSPORTATION:
     EQUIPMENT:
     FOOD:
     LODGING:
     AUTHORIZED CASH DISBURSEMENTS:
BURMA 2011 TOTAL:
BURMA 2011 NET OPERATION GAIN/ (LOSS)

 

 

 

 

 

OPERATION SUMMARY

PRE-DEPLOYMENT

 

 

 

Burma 2011:

Zach Smith, the team lead, was in voice and email contact with indigenous points of contact long before the mission kicked off in order to arrange ground transportation, lodging, meals, classroom venues, and to ensure that plenty of students showed up for training. As Smith hand-picked his team members, medical supplies were purchased or donated, and satellite communications equipment were procured and tested. Smith conducted multiple conference calls with the team to ensure that passports were in order, air travel arranged, personal gear readied, vaccinations were current, and that the overall scheme of maneuver of the mission was known to everyone.

 

DEPLOYMENT

 

Smith personally picked up incoming team personnel at LAX on August 15. The first stop was the Team Rubicon west coast storage unit, where we picked up medical bags and equipment, and team gear along the lines of water purification apparatus and rehydration salts. The team overnighted at Zach’s parents’ house just outside Los Angeles. We spent the next day reviewing the medical teaching topics we would be covering during the mission, familiarized the team with the Inmarsat BGAN and Iridium satellite communication devices, and reviewed the mission plan step by step.

The next day, the team flew via commercial air to Thailand by way of the Philippines. During our layover in the Philippines the team paid its respects to our fallen World War II brothers at the Manila American Cemetery and Memorial. While laid over in Bangkok Airport, we met briefly with Team Rubicon cofounder Will McNulty before boarding yet another plane destined for the fair city of Chiang Mai in mountainous northwest Thailand. In Chiang Mai we changed our mode of travel from air to ground when we were picked up by an American working fulltime with the hill tribe IDPs and refugees. After a long drive in the back of a small pickup truck, we stopped in Mae Sariang near the Burmese border to rest overnight at a cheap guesthouse.

The next morning, after a hearty breakfast at the local open market, we ventured into the hills above the city to receive a blessing from Buddhist monks residing in a cavernous monastery. On the way out of town we purchased a Thai cellular phone for local communication, continuing to the border and the camp in which we would spend the next four days training Karen medics and community health workers. Given the difficult terrain and remoteness of the camp, the team was forced to hike in the last several hundred yards via footpath.

At the camp we were joyously greeted by the displaced Karen people, to include all 22 of our medic students; the ones who returned to us from last year’s training were particularly happy to be reunited with Zach Smith and Dr. Geelhoed, who were both members of the 2010 training team. We dropped our personal and team gear off in the upper floor of a bamboo hut and immediately made for the local clinic. Led by Dr. Geelhoed, we made rounds of the handful of patients in the clinic and made the following diagnoses: shigellosis, peptic ulcer, impacted mammary gland, and generalized skeletal pain secondary to load-bearing wear and tear. We had decided ahead of time to not render treatment to the indigenous people, unless in the case of a crisis situation, as we were strictly conducting a training mission. We simply did not have the logistics or the time to provide medical care with good follow through; in future missions, direct patient care will be considered on a mission-by- mission basis.

Meals in the camp consisted of chicken with either rice or noodles; ablutions were performed inside a small cinder block building housing a squat toilet and a cistern of cold water equipped with a bucket. A prosthetic limb workshop lay just down the trail from our sleeping quarters and the camp kitchen. The village was not connected to any kind of offsite electrical power grid; instead, generators were run during the day to charge car batteries that would in turn power lights and electrical appliances during hours of darkness. The team slept beneath mosquito netting, either in hammocks or on inflatable air mattresses.

The next morning we began our program of instruction on the second floor of a large hut. The students filtered in and sat on the bamboo floor as we prepared our teaching materials. Disaster struck when the video projector provided to us by the Shan turned out to have a bad bulb. Fortunately the class was small enough that we could get by with displaying our medical presentations on the laptop screen. And so, with the aid of a translator, we began training.

Topics covered over the next three days included: basic primary care with an emphasis on tropical diseases, field trauma care, basic surgical skills, and building construction techniques. Didactic instruction was interspersed with hands-on drills with tourniquets and pressure dressings, and suturing practice. Dr. Geelhoed introduced the students to the global top five killers: dehydration secondary to diarrhea, acute respiratory illness, malaria, malnutrition, and measles (DAMMM); the four top areas of concern for community health workers: growth charting, oral resuscitation, breastfeeding, and immunizations (GOBI); and the Neglected Tropical Diseases (NTDs): soil-transmitted helminths, Filariasis, Schistosomiasis, and trachoma. Jason Jarvis, a veteran Army medic and operational medicine trainer, taught the principles of Tactical Combat Casualty Care (TCCC) – the US and NATO standard of care for battlefield trauma. TCCC is founded upon the distinction between blunt and penetrating trauma and why the MARCH algorithm approach to patient care fits the gunshot wound and blast injury profile better than ABCs, which is the civilian standard of care for car accidents (blunt trauma). Andrew Stevens, a former Marine and the Department of Homeland Security head of security vulnerability assessment team for Alaska, brought his knowledge of building construction to bear and offered the students recommendations on constructing houses able to withstand natural disasters.

For the next three days, our chief activity in the deployment zone consisted of approximately seven hours per day of medical classes. Aside from meals, laundry and hygiene, we filled our free time with interactions with locals (clinical rounds, speaking with students, a foot tour of the beautiful jungle, and the occasional rattan-ball game); reading, journaling, and occasional satellite phone sessions with loved ones stateside. On Day 4 of our stay the students graduated, proud recipients of Team Rubicon training course Certificates of Completion.

By now the team was ready for a hot shower and the luxuries of indoor plumbing and beds. We departed the camp and our Karen friends, stopping at another camp to address students at a combined primary and secondary school (plus a vigorous pickup game of rattan ball), returning to Mae Sariang by nightfall. After an overnight rest and refit, we loaded our faithful pickup truck yet again and made the day-long journey into Burma’s Shan State. The drive was long, made even longer by the rainy season which had washed away a lot of the roads and reduced what was left of the road into a muddy quagmire. Just short of our final destination in the Shan State we encountered a long uphill slope accompanied by the worst mud we had yet seen. Our Shan drivers applied snow chains to the tires and, with the use of shovels and a lot of pushing and cajoling (plus one bee sting), we spent the next four hours crossing the last ten miles.

The first major distinction that impressed us about the Shan village versus the Karen camp was the fact that it possessed a road. The village sat on a ridgeline at an elevation just above 1000 meters (gratefully outside the range of Anopheles, the carrier of malaria) in the midst of a breathtaking panorama of green low-lying mountains strikingly similar to the Appalachian range. As vigorous proponents of education, we were pleased to see that the largest building in the village was the combined primary and secondary school. The next biggest building was the village hospital, a simple yet well-furnished structure in which a 10’ by 10’ room had been cleared out to provide a sleeping quarters for our team.

We settled into our humble quarters and prepared for the next three days of training; we planned to offer the same materials in the same format to the Shan that we had presented to the Karen. A low-ceilinged pavilion adjacent to the hospital was our designated classroom, and the next morning it quickly filled with Shan community health workers and Shan State Army medics, for a total of 52 students. Some of them were as young as 16! We learned that most of our students had arrived from other regions of the Shan State, some of whom traveled for days to reach the training site. To our relief we found a video projector that was in good working order, and we were equally blessed with plenty of skilled translators.

The training went smoothly, with Dr. Geelhoed making the introductions and the rest of us filling in over the next three days according to our areas of expertise. Our Shan hosts were as hospitable as the Karen, and we spent our days in relative comfort. After the conclusion of classes each day we played rattan ball and went on walking tours of the village. On the last day of training we visited a nearby shrine commemorating famous Shan generals from ages past. Graduation day for our students came all too soon; after receiving their Team Rubicon certificates of completion, everyone donned their “Sunday best” for that evening’s spectacular Fire Festival and Sheep Dance performed at the local Buddhist monastery.

The next day we bade farewell to our excellent Shan hosts and began the drive back to Chiang Mai, Thailand. The return trip through rural Burma and its muddy roads was made much easier by being downhill for the most part. We overnighted in Chiang Mai before flying to Bangkok the following day, and engaged in the requisite tourist duties of souvenir shopping and eating fantastic Thai food.

 

 

 

 

 

AREAS OF ANALYSIS

 

 

 

  1. Volunteers
  2. Logistics
  3. Communications
  4. Transportation
  5. Medical
  6. Media
  7. Fundraising
  8. Expenses
  9. Security

 

 

 

 


ANALYSIS

VOLUNTEERS

BURMA 2011:

SUMMARY

 

The volunteers for this mission were chosen primarily for their medical skills and military experience. Medical skills were in high demand due to the nature of the instruction that was performed, while military experience was valuable given the possible risk of reprisal from Myanmar’s central government for educating enemies of the state; the team needed to be “on its toes” at all times as it were. Marc Fiorito, the team’s dedicated photographer, did not fall into either of the medical or military selection criteria, but his past experience in Asia was deemed sufficient to keep him from becoming a security liability.

Zach Smith, the team lead and California firefighter/paramedic, had led Team Rubicon’s 2010 mission to Burma and also had experience with TR in Sudan, Chile, and Haiti. Navy veteran Dr. Glenn Geelhoed was the only other member of the team who had worked in Burma before this mission. Geelhoed’s lifelong experience of running over 200 humanitarian missions and professorial teaching at George Washington University in the topics of surgery, tropical medicine, and microbiology made him the perfect medical director for this trip. Former Army medic Jason Jarvis, a veteran of Haiti, Iraq, and Afghanistan contributed his Thai language skills and knowledge of Tactical Combat Casualty Care to the mission. Andrew Stevens, a former Marine, Iraqi veteran, EMT-Basic, and the Department of Homeland Security head of security vulnerability assessment team for Alaska kept our logistics in order, assisted as needed during the medical skills practicum, and ran point for teaching building construction techniques. In addition, Stevens shone as a gifted rapport builder among the indigenous people. Professional photographer Marc Fiorito’s recent experience in remote China prepared him well for the rigors of living off the beaten path in a foreign country. His array of camera equipment occupied a large backpack, which he used to shoot over 10,000 photos and hours of video.

 

RECOMMENDATION

 

Given the limited formal medical training that the hill tribe medics have received throughout their careers, there is tremendous potential for the addition of other topics to our teaching curriculum. A short list of these topics might include OB/GYN, pediatrics, dermatology, ophthalmic care, wound care, local and regional anesthesia, etc. If it is decided to offer this increased scope of training then the team roster will need to be filled to support these topics.

A five-person team was the ideal sized team for this mission, given that our transport vehicle of choice was the four door pickup truck. Five warm bodies plus a driver and all of the gear filled the cab plus the tail bed of the truck with little wiggle room. Future missions should take this math into account, i.e., 1-5 team members plus gear fit into one truck, 6-10 team members plus gear will require two trucks, etc.

 

ACTION

 

  • The plan for a possible 2012 mission needs to include input from our potential students and their medical supervisors as to what teaching topics they want covered. Once this information is received, Team Rubicon can begin filling the team roster with individuals who best support this.

 

 

 

 

 

 

 

LOGISTICS

BURMA 2011:

SUMMARY

 

Logistics for this mission fell into one of four categories:

  1. Personal gear (large carry-on bag, TR T-shirt, TAD pants, hiking shoes, sandals, rain jacket, socks, underwear, foot powder, sleeping bag, sleeping pad, jungle hammock, mosquito net, headlamps, small knife, multitool, spork, Nalgene water bottle, lightweight coffee mug, water blivet, journal, pen, pencil, books, laptop, memory stick, compass, matches, headphones, cameras, watch, spare batteries, insect repellent, first aid kit, toilet paper or baby wipes, basic toiletries, soap, sunblock, hat, sunglasses, dry snack food)
  2. Team gear (multiple duffel bags, satellite communications (Inmarsat BGAN, Iridium phone), Thai cellular phone, cash fund, UV water purification device, oral rehydration salts, TR laptop loaded with training Power Points, Power Point remote slide advancer, memory stick, personnel beacons, parachute cord, student certificates of completion, salt and seasoning, instant coffee)
  3. Training gear (suturing materials and surgical instruments, tourniquets, gauze, pressure dressings)
  4. Donated gear (improvised tourniquets constructed of nylon webbing, HemCon and Combat Gauze hemostatic agents, pressure dressings, antibiotics)

The total loadout was relatively small; all of it fit into two checked bags per team member plus carry-ons. Food and water was paid for in cash to our Karen and Shan hosts. In addition, we relied upon our hosts for electricity, video projectors, dry erase boards, and dry erase markers.

Overall the logistics ran very well; our preparedness ensured that we lacked for nothing once we were on the ground. Future team members need to ensure that they adhere to the Team Rubicon individual packing list.

 

RECOMMENDATION

 

TR should up the ante on donated gear for future missions. The 2011 donated gear focused primarily on trauma patients; this is not the hill tribes’ primary problem. Donated gear in the future needs to focus more on what will do the most good, i.e., mosquito nets, antibiotics, oral rehydration salts, etc.

Looking at some of the medics’ kits, we realized that the typical hill tribe medic is woefully undergeared for dealing with field trauma. TR could help bridge this gap by donating manufactured tourniquets, elastic pressure dressings, hemostatic agents, nasopharyngeal airways, 14 gauge intravenous needles, chest seals, buddy transfusion bags and tubing, and field blood typing cards.

 

ACTION

 

  • Find out from prospective students what their equipment needs are and attempt to bring some of these supplies to them.
  • Solicit donations of the desired logistic items or buy them outright.

 

 

 

 

 

 

 

 

COMMUNICATIONS

Burma 2010:

We utilized four modes of communication during our trip to the Thai/Burma border. These included:

  • Internet available on publically available wi-fi sites
  • Cell phones when networks were available
  • Satellite phone
  • BGAN satellite uplink for our PC

 

We found that each mode of communication was appropriate during different times in the trip.

 

Multiple lines of communication:

Multiple team members had cell phones on this trip. Because of this, multiple lines of communication between the team and stateside members of Team Rubicon were happening simultaneously during the trip. For example, when we were in transit to Thailand, the floods started in Pakistan. Several team members were in contact with stateside members of Team Rubicon, and rumors started that our team would be diverted to Pakistan for flood relief. This happened several times during the trip and caused confusion that was unnecessary. One official line of communication should have been set up between the team leader or his designee and one stateside or alternate stateside Team Rubicon member.

 

Communication policy:

We were incommunicado with the United States for approximately 2 days while on the Thai/Burma border due to weather conditions, terrain and remoteness of our location. Stateside personnel developed great apprehension during this time due to no contact with our team.   We should have developed and went over

 

Equipment:

BGAN Satellite terminal: We could get by with a less expensive model. We did not utilize all of the features that were included with this model.

The BGAN was affected by the humidity. After being shut off and charged, the BGAN turned on spontaneously due to humidity near or at 100%. This allowed the BGAN to discharge without us knowing. In one instance when we climbed 45 minutes up a mountain to get reception for the BGAN, we discovered that the BGAN battery was discharged and we could not communicate.

 

Satellite phone: We had issues with cloud cover and terrain such as trees mountains obstructing signal to satellite. We found it easier to get signal with Sat phone than the BGAN.

 

During this trip, the team did not feed enough pictures back to our website. I believe that we should have worried less about quality of photos that would ultimately be put on website which are low mpeg anyway. The team should have sent many lower quality photos during this trip.

 

Summary:

  • Develop stricter communication policy about official communications with a designated stateside TR contact. Team leader or designee communicates on regular intervals with stateside contact. This will reduce rumors, misinformation, and keep safety concerns of team addressed.
  • Reevaluate which BGAN unit is appropriate for TR use.
  • Utilize dry bags in humid conditions to keep equipment working properly.
  • Develop information packeting strategies to reduce transmission costs of pictures and video back to states.
  • Send back higher volume of pictures and information with less emphasis on high quality of pictures.

 

BURMA 2011:

SUMMARY

 

The team was well-equipped for satellite communication with both the Iridium phone and the Inmarsat BGAN satellite uplink via laptop. Smith sent messages to our TR headquarters cell at regular intervals. For communication with the locals we relied on a Thai cellular phone purchased in Chiang Mai. Two team members carried beacons that could be activated in the case of an emergency.

 

RECOMMENDATION

 

Each time a TR mission is launched all team members need to learn how to operate all of the team’s communications devices. This learning can be strengthened in the field by using a rotating roster of responsibility for transmitting situation reports.

 

 

ACTION

 

  • Assemble all satellite communications devices well in advance of mission launch and test them.
  • Cross-train all team members on the different devices before mission launch and keep their skills up during the actual mission.

 

 

 

 

 

 

 

EOC COORDINATION

 

SUMMARY

 

 

 

TRANSPORTATION

Burma 2010:

Team Rubicon secured travel arrangements from the United States to Chiang Mae, Thailand. From Chiang Mai to the training site, 4th Wall International secured transportation.

Team members traveled from Illinois, Wisconsin, Florida, Washington, DC and California. We rallied in Los Angeles before traveling overseas. This allowed us to accomplish multiple goals:

  • Assemble and repack supplies.
  • Distribute capital among members so that one member didn’t carry all cash for trip.
  • Meet with stateside personnel to go over SOP’s for trip.
  • To brief members and train on communication equipment in a user-friendly environment.

 

We originally utilized the help of a travel agent in arranging our travel plans. We found that by going through travel websites we could secure cheaper airfare than found using the travel agent. We ultimately used the travel agent to secure the tickets for the itinerary that we found due to ease of having one source for all the tickets and ease of ability to change tickets if need be. Airline tickets from Bangkok to Chiang Mae, Thailand were booked ourselves due to a significant savings over the travel agent prices.

By applying for a frequent flier membership with the Thai airline we were able to double our allowed weight of carry on luggage.

One of our team members had priority status on Philippine Airlines that allowed all the team members to bypass a several hour-long line in the Los Angeles airport.

With stopovers, our travel time to Thailand was close to 36 hours.

We had planned on carrying on our back packs to avoid losing any luggage in transit. It appears that our approved backpack is slightly larger than some airlines allow for carry on bags. We had no problem on this trip with stowing this bag in the overhead compartments. I know that it is bigger than the approved size for carry on luggage for American Airlines.

One problem we did encounter was the solar panel battery pack. We stowed our solar panel/battery pack in our carryon luggage. This triggered an inspection in every airport because it looked like an AED when seen in the X-ray machine.

 

Summary:

  • When pricing tickets use several resources. If a travel agent is used, check prices on the Internet travel sites for cheaper tickets.
  • Have team members join frequent flier clubs for additional perks such as added weight limits of luggage and priority movement through lines etc.
  • Reassess sizing of team approved carryon bag and downsize if necessary.
  • Do not carry battery packs in carry on luggage due to similarity to bomb design. Assess all equipment that will be carried on board a plane to see if it will trigger luggage searches.

 

BURMA 2011:

SUMMARY

 

The transportation details for this mission were fairly simple:

  1. Commercial fixed-wing aircraft
    1. Philippine Air: Los Angeles to Manila to Bangkok
    2. Bangkok Air: Bangkok to Chiang Mai
  2. Pickup truck with local driver
    1. Chiang Mai to Mae Sariang to Thai border and the Shan State

 

RECOMMENDATION

 

Transportation during the entirety of the mission was smooth; no need to change this in the future.

 

ACTION

 

  • Book flights for future missions well in advance to save on costs.
  • Explore alternatives to Philippine Air and Bangkok Air.
  • Coordinate with the hill tribe points of contact for ground transportation.

 

 

 

 

 

 

 

 

MEDICAL

Burma 2010:

 

This was Team Rubicon’s first proactive training mission. The mission goal was to provide training for personnel that would treat internally displaced people (IDP’s) in Burma in a sustainable way. We conducted training in the classroom setting, in a live tissue lab with an anesthetized pig, and during clinics for local villagers. During clinics we observed the treatment of patients intervening only when necessary and let the trainees run the clinic.

 

Our medical director for the mission, Dr. Geelhoed is very experienced in third world medical care and training. He was our greatest asset in this department. We learned on this trip that tropical medicine in a third world country has many aspects not encountered in the United States. For example in the United States right lower quadrant pain may be a sign of appendicitis, which is a surgical emergency. In the population we were treating and training, due to their diet, appendicitis is almost nonexistent. Right lower quadrant pain would typically be a sign of a parasitic liver abscess in their population which needs to be treated, but is not an immediate surgical emergency.

 

We learned that equipment we take for granted in first world countries is not available in most third world countries. Therefore training must be geared to the equipment available in the target population. For example equipment taken for granted in the United States such as Oxygen sensors and Cardiac monitors are not available. Training on watching signs and symptoms of the patient to clinically evaluate these parameters must be emphasized.

 

Higher levels of care are not readily available to most rural third world populations. Unlike the United States, one cannot call an ambulance to have the patient transferred from a clinic to a hospital in 30 minutes for an emergent surgery. In the third world, an emergent surgical condition such as a C-section delivery needs to be performed locally by a trained person. There is usually not time to transport a person 2-3 days through the jungle to a higher level of care facility.   If no one with surgical skills is close by, the patient has a high probability of dying. Therefore, training medical personnel to a level where they can perform four or five basic emergent surgeries will save many lives.

 

 

The language barrier was an issue with training. All of our trainees spoke Karen. A few of the more advanced medics spoke some English. They translated for their comrades. Medical lectures needed to be slowed down so they could be translated to Karen. Many medical terms used in lectures didn’t have readily available Karen translations. Sometimes lectures were given too quickly and five minutes of lecture was translated with two sentences.   Lectures were best understood when they were given using medical terminology then explained in terms that were easily understood by the trainees. Many times I saw trainees nod their heads yes and not really understand what was said. Asking frequent questions verified that the given message was actually understood by the trainees.

 

Doctor Geelhoed trained the medics and personnel in the Karen Department of Health and Welfare about the WHO (World Health Organization’s) medical model. This included education on the classification of differing types of medical facilities such as a community health care clinic up to the requirements for being a hospital. These distinctions on the surface seemed very academic. In reality, if a facility could be classified as a hospital, supplies and medicines for the facility could be donated or bought very cheaply from the WHO. Getting these classifications for third world facilities would then provide much needed medical supplies and meds for the facility.

 

It was noted that the medical record for patients was always written in English by the Karen medics and trainees. Therefore it was imperative that correct English terminology was taught to the trainees.

 

Utilizing the senior medics to train the junior medics was a very effective practice. For example when a lecture on suturing or surgical knot tying was given, the senior medics then trained the junior medics in the practical training with the trainers observing and giving instruction when needed. This practice also carried over to the surgical when the senior medics taught the junior medics surgical techniques on the anesthetized pig. The senior medics walked the junior medics through the training they had just received themselves. This method of training was very beneficial, and set up a self-sustaining training model which then could be used when TR left. The Karen Department of Public Health and Welfare was very happy with the training conducted by Team Rubicon.

 

Summary

  • Most Team Rubicon medical personnel are trained using first world medical resources in a temperate climate. Team Rubicon members who are treating or training personnel in tropical third world countries need additional training in tropical medicine and third world medical techniques to be effective.
  • Compile a training document that will explain ways to maximize effectiveness of communication when using a translator during training.
  • Train Team Rubicon members on the WHO medical model and terminology.
  • The medics we trained were of differing levels of training. We as trainers need to adapt to their needs.
  • Develop an outline of lesson plans applicable for third world counties for trainers to be able to reference. Trainers need to be flexible to the needs of the trainee group and adjust as necessary.

Equipment:

 

BURMA 2011:

SUMMARY

 

The transporAs a team we carried enough first aid supplies between the five of us to care for any minor illnesses or injuries. Our plan for anything serious was to move the patient to the hospital in Mae Sariang via pickup truck. As it turned out, throughout the mission we required nothing more invasive than a Band Aid.

 

 

RECOMMENDATION

 

Ensure first aid kits brought in the future are sufficient (analgesic medications, foot powder, skin repair, bandaging, oral rehydration salts, and an ample formulary of over the counter medications, etc), and locations, routes, and contact numbers for all nearby medical facilities are known by all team members.

 

ACTION

 

  • Conduct a pre-deployment inspection of first aid kits.
  • Research healthcare facilities in the area of operations both before and during future missions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDIA

BURMA 2011:

 

SUMMARY

 

News of our mission was posted to the TR website after our return from Burma. This included journal entries, videos, and copious photos.

 

 

RECOMMENDATION

 

The after-the-fact media approach worked well and probably increased our safety margin vis-à-vis Myanmar. Recommend we follow a similar format in the future.

 

ACTION

 

  • If we are indeed aiming for as little interference from the Myanmar government on future missions, team members need to keep the mission (particularly dates) out of social media during the time leading up to the mission.

 

 

 

 

 

 

 

 

 

EOC COORDINATION

 

SUMMARY

 

 

 

 

 

 

 

 

 

 

SECURITY

 

BURMA 2010 & 2011:

SUMMARY

 

Physical security was provided by either our Karen or Shan hosts. We were far enough away from the front lines and Myanmar forces that we were not overly concerned about any imminent threat.

 

 

RECOMMENDATION

 

Research the local and regional security situation before future missions and couple this information with the local geography to formulate an emergency evasion plan.

 

ACTION

 

  • Research the local and regional security situation before future missions.
  • Devise an emergency evasion plan that incorporates the local security situation, friendly points of contact, geography, and emergency beacons.

 

 

 

 

 

 

 

 

 

KEY LESSONS LEARNED

 

Burma 2010:

This mission proved to be a great success. Team Rubicon developed lasting relationships with 4th Wall relief group in Thailand and the Karen Department of Health and Welfare (KDHW). This will pave the way for future missions to this region for training of medical personnel that will treat internally displaced persons (IDP’s) in Burma.

 

This mission has also shown areas where improvement is needed for training. These include:

  • Tropical medicine training for TR personnel.
  • Training on the World Health Organization (WHO) medical model.
  • Develop training outlines to be used in future training missions.
  • Develop guidelines for the use of a translator during training.

This mission has also allowed Team Rubicon to refine our equipment and supply lists for future missions.

 

BURMA 2011:

  1. The Karen and Shan medics working in the field are sorely underequipped. The two items they don’t have that would make the biggest difference in their load out would be elastic pressure dressings and tourniquets. Team Rubicon should endeavor to gift some of these items to the trainees next year.
  2. Medical logistics donated in the future need to focus more upon “unglamorous” items along the lines of mosquito nets and oral rehydration salts. These items will likely have a bigger impact on overall mortality and morbidity than any amount of trauma management kit.
  3. The medical topics we covered in training were probably just the tip of the iceberg of what can potentially be covered in follow-on missions.
  4. The security situation in the Shan State is quite good. TR should feel confident that it can deploy to this region and work in a relatively safe environment. Despite this perceived safety, TR should always have an emergency evasion plan in place anytime it deploys outside the United States.

 

KEY ACTIONS

 

BURMA 2011:

  1. Raise awareness of the plight of the hill tribes living along the Thai-Burma border and fundraise in order to support future missions to this region.
  2. Learn from prospective students and their medical directors what teaching topics they wish to have covered during future training missions.
  3. Build a team of volunteers tailored to the training topics to be taught in the next mission.
  4. Solicit donations of medical equipment (or purchase outright) needed by the hill tribe medics and CHWs.