MILITARY MEDICINE, 182, 11/12:e1819, 2017 A New Approach to Organization and Implementation of Military Medical Treatment in Response to Military Reform and Modern Warfare in the Chinese Army Yang Pei, PhD*; Yue Song, PhD ; Min Yu, PhD ABSTRACT Background: Recent system reforms within the People s Liberation Army (PLA) have led to establishment of 5 theatre commands and a general joint logistics command. These reforms have presented new challenges to the organization and implementation of medical services. The medical service of the PLA must keep pace with these reforms by applying innovative theories to establish appropriate organizational guidelines and structures. The medical service must also adapt to the modern and future eras of information warfare. Methods: We review the existing structure and features of the military medical service of the PLA, highlighting issues related to ongoing reform within the PLA and the characteristics of modern and future information warfare. Reflection on current rules for medical evacuation and treatment of war-related injuries were made, and related organizational and structural innovations were proposed. Findings: Recent reforms and the characteristics of modern information warfare have rendered the current medical service and medical evacuation system of the PLA inefficient. The scale of the echelon configuration should be adjusted to establish a more focused, effective, and intelligent medical service. Resource allocation and general joint logistics should be optimized to establish a new well-rounded, three-dimensional medical evacuation system, and the stabilize before healing rule should be applied at all levels of the medical service. These changes should help to create a modern, effective, and responsive medical service within the PLA. Discussion: This article explores how the military medical service of the PLA could adapt to system reform in order to implement efficient treatment of war injuries, reduce mortality and morbidity rates, and maintain combat readiness in the modern era of information warfare. INTRODUCTION Treatment of war trauma remains a core military medical service in the modern era. Indeed, the ever-changing nature of war directly affects the type of medical services required. Adaptations to the organization and implementation of military medical services will be required to reduce battle mortality, hospital mortality, and morbidity. The ability of military medical services to treat war trauma is dependent on a combination of their organization, technical capabilities, and equipment available to perform field surgery. 1 Therefore, it is important to review and maintain the battle readiness of military medical services. Military reforms within the People s Liberation Army (PLA) in 2016 have focused on unification of leadership functions and establishment of a joint operations command system (Fig. 1). Along with establishment of five new theater commands, a new army leadership structure was established and the leadership of various branches of the armed forces were refined. The difference between new theater commands and the former military region is that theater commands emphasize joint operations. These reforms have presented new challenges to the organization and implementation of medical services. Now the military medical service belongs to the command of joint security forces which is an independent arm instead of being led by a military region. The medical service of the PLA must keep pace with these reforms by applying innovative theories to establish appropriate organizational guidelines and structures. The medical service must also adapt to the modern and future era of information warfare. This perspective provides an in-depth review of the current structure of the medical service of the PLA (Fig. 2) and its rules for medical evacuation (MEDEVAC) and treatment of war trauma. Moreover, in the context of operational and command structure reforms and the characteristics of information warfare, we examine issues related to the complexity, lack of coordination during battle, and inflexibility of the current medical service and MEDEVAC system. Thereafter, a number of proposed changes and innovations to the structure of the military medical service of the PLA are recommended. *School of Public Health and Military Preventive Medicine, The Fourth Military Medical University, 169 Changle West Street, Xi an, People s Republic of China 710032. Department of Orthopaedics, The Fourth Military Medical University, Xijing Hospital, 15 Changle West Street, Xi an, People s Republic of China 710032. Academy of Military Medical Sciences, Institute of Medical Service and Medical Information, 27 Taiping Road, Beijing, People s Republic of China, 100850. AMSUS The Society of Federal Health Professionals, 2017 doi: 10.7205/MILMED-D-17-00051 CURRENT STRUCTURE OF THE MEDICAL SERVICE OF THE PLA, RULES FOR MEDICAL EVACUATION, AND TREATMENT OF WAR-RELATED INJURIES The current medical service of the PLA extends from the front line to the rear, with organizational and regional services divided into three segments and seven echelons. This unique system was developed on the basis of experience from past wars fought by both the PLA and foreign armies, e1819
FIGURE 1. Military reforms within the PLA. and influenced by historical factors (nature and circumstance of war, differences between various branches of armed forces, weapons and equipment, level of medical care available, means of transportation) and the geographical landscape of China. This echelon configuration has provided effective medical care in past wars/conflicts, thereby saving countless soldiers from death and disability and maintaining battle capabilities. Treatment follows the internationally recognized echelons of medical care, which the PLA calls grading of treatment. The PLA Rules for the Treatment of War Trauma, 2006 2 classify treatments into five basic categories and indicate the form and extent of treatment available at the medical facilities in each category: (1) battlefield first aid provided by the medical team in each company and battalion medical stations (company and battalion usually can be combined), (2) emergency treatment provided by the medical aid station in regiment, (3) early treatment at division or brigade medical stations, (4) specialized treatment in the combat hospital and base hospital, and (5) recovery treatment at a strategic rear hospital (Fig. 3). 3 Treatment is defined by the circumstances of the war, mechanism of injury, and extent of medical care required, according to a unified standard under a single system to ensure that treatment is continuous and without repetition in each echelon. The medical aid provided by each division is organized centrally according to battlefield conditions and its range can be expanded to suit the individual situation, and each division organizationally directs MEDEVAC. The MEDEVAC system is tasked with obtaining treatment for casualties as soon as possible, and is also arranged in three segments and seven echelons (Fig. 2) 4 : (1) tactical rear: medical stations in companies, battalions, regiments, and divisions; representing four echelons; (2) campaign rear: army field hospitals (first-line hospitals) and theater base hospitals (second-line hospitals), representing two echelons; and (3) strategic rear: hospitals under Central Command and the various branches and theaters of the armed forces, as well as designated local hospitals. MEDEVAC must be safe and rapid and follows the following principles: restoration before fixation, bandage only after hemostasis, treat severely injured casualties before lightly wounded casualties, apply aid before evacuation, always call for help while applying aid, and always monitor injured casualties while in transit. MEDEVAC uses ground, waterborne, and airborne vehicles. The use of transport ships and helicopters for MEDEVAC is relatively rare because of equipment limitations and the limited occurrence of maritime and airborne battles as a result of the geographical characteristics of combat. FIGURE 2. The current structure of the medical service of the PLA. OPERATION MANAGEMENT AND COMMAND STRUCTURE REFORM The Military Commission of the PLA has shifted from a centralized structure to a multidepartment structure. The seven military regions were redivided into five new operation e1820
FIGURE 3. Medical organization and evacuation system. theaters. This challenges the existing three segments and seven echelons structure of the medical service, which currently provides aid according to the organizational placement of the military arm and its regional relevance. In the past, every military region had its independent medical services. Now all medical services are commanded by the logistic support forces. Moreover, the traditional three segments and seven echelons model only paid attention to grading, instead of rapidity. This model causes the overlap of treatment, delaying treatment time. The newly anointed Military Commission, combined with the joint operation commands of various theaters, are firmly pushing for reformation to a commission theater soldier system for operation command and commission branch soldier system for leadership management. The new landscape of the general joint logistics of the PLA also presents new issues to the current medical service. The Joint Logistics Force of the Central Military Commission was established in September 2016; the Wuhan Joint Logistics Base and five logistics centers in Wuxi, Guilin, Xining, Shenyang, and Zhengzhou were established at the same time. This enables the logistics system to function at optimal capacity as a whole, as well as within separate sections. Allocation of tasks and resources is optimized across the board, realizing a network of logistical power that is interconnected, yet allowing for independent operations. The e1821
old logistics system (including the medical service), which was previously divided by units and type of force, no longer exists. Therefore, the medical service, whose organization previously depended on the identity of the military arm and its regional relevance, needs to be reorganized. CONDITIONS OF FUTURE WARFARE Modern warfare poses new challenges to military medical services. Future wars will be fought with information, using fast and very mobile high-tech weapons and platforms. Owing to the application of new concept weapon and massive destruction weapons, injured casualties often require professional treatment as soon as possible. Highly efficient transport vehicles and weapons that can adapt to wider ranges of battlefield conditions will accelerate the suddenness of war, representing a breakthrough in the depth of operations and tactical maneuver mobility. With the disappearance of battle lines and trenches, the boundaries between the front line and rear of the battlefield will continue to blur. Warfare has started to become nonlinear and hot contacts are no longer required. 5 The PLA of the future will be equipped with high-tech weaponry and systems, aided by satellite coordination and unmanned aerial drones, with an emphasis on quality over quantity. Indeed, conventional warfare trauma and injuries by new weapons pose great difficulties in terms of classification of injuries, triaging medical care, provision of appropriate resources, and technology and organization of the entire medical service. Moreover, the medical evacuation requirements of modern warfare need to be refined to improve the land transport, air transport, and maritime medical evacuation system. PROPOSED ORGANIZATIONAL AND STRUCTURAL INNOVATIONS First, a joint rescue organization leadership summit mechanism needs to be established, so the army rescue organization and command center can execute rescues uniformly during war. The war-time rescue organization is a huge medical system that aims to ensure the rescue of war-wounded will be scientific and successfully completed in view of the future nature of war, military logistics, and formation of the joint security integration system as part of military reform. At the same time, the PLA can learn from the successful experience of the U.S. Army joint theater trauma system in Iraq and Afghanistan. 6 It is imperative to establish a joint rescue leadership organization system the army rescue organization and command center urgently. The center will be subordinate to the Joint Security Forces of the Central Military Commission, but also directly led by the Joint Logistics Department of the Central Military Commission. The Command Center shall be defined as a permanent institution, and the Deputy Minister of the Joint Security Ministry of Central Military Commission will serve as director of the Command Center, with the Joint Logistics Force Deputy Commander and several experts as vice chairmen. The Central Military Commission will be responsible for all usual wartime medical training and command the wartime wound treatment service and medical evacuation command functions for the army. Second, the PLA needs to reduce the number of wounded rescue phases and explore establishment of a new, efficient, and intelligent medical service organization for war injuries. According to the existing three segments and seven echelons system, the wounded rescue ladders have not adapted to the characteristics of injuries in future warfare or military reform. On the basis of the experience of the rescue organization system of the U.S. Army during the wars in Iraq and Afghanistan, the PLA will establish a five level rescue ladder and new medical service organization system (Table I), as follows: Level I (battlefield emergency): health paramedics/military surgeons responsible for initial treatment; Level II (emergency treatment): field medical aid station/ battlefield surgical teams that carry out lifesaving surgery; Level III (early specialized surgery): battlefield hospitals (brigade health camps) responsible for recovery up to selected specialized surgery; Level IV (specialized surgery): field hospitals responsible for supplementary specialized surgery, partial definitive surgery, and partial intensive care; and Level V (functional rehabilitation): nonbattlefield hospitals (above central hospitals) responsible for definitive surgery, intensive care, and functional rehabilitation. Third, we propose establishment of a battlefield surgical team and the implementation of super early phase, lifesaving surgery. There is an optimal time for cure during rescue of the wounded. Survival and the efficacy of treatment depend to a large extent on the timing of treatment, i.e., the time-effect rule of treatment. The PLA shall follow the battlefield treatment principles of strengthening advancement, extended configuration, prominent first aid, speeding up medical evacuation and shall establish a battlefield surgery team as soon as possible. Fatal trauma is the main reason TABLE I. The Wounded-Rescuing Organization Classification of PLA Military Classification Military Medical Organization Treatment Scope Level I Health Worker/Military Surgeon Battlefield Emergency Level II Field Medical Aid Station/Battlefield Surgical Team Lifesaving Emergency Treatment Level III Battlefield Hospital From Recovery to Specialized Surgery, Partial Definitive Surgery, Partial Intensive Care Level IV Nonbattlefield Hospital (Above Central Hospital) Complementary Specialized Surgery Level V Field Hospital Definitive Operation, Intensive Care, Functional Recovery e1822
leading to death among the wounded during war; rescue of the wounded is lifesaving. The PLA should establish a battlefield surgical team to adapt to the changing characteristics of war injuries and future warfare. At the same time, the PLA aim to learn from the successful experience of the forward surgical team of the U.S. Army. The battlefield surgical team will belong to the medical battalion or sanitation camp of front-line combat troops, and will mainly be composed of head, chest, and abdomen surgeons and orthopedic surgeons whose main role will be emergency surgery. Such operations should be carried out within 2 hours after an injury, such as potentially fatal massive hemorrhage in the neck, limbs, chest, and abdomen; airway obstruction; severe pneumothorax; etc. The aim is to perform surgery within the optimal treatment time, such as the 10 platinum minutes and 1 golden hour to achieve maximum treatment efficacy. The existing excessive step-by-step evacuation treatment system has not adequately adapted to new military reform under modern conditions, and shall be completely changed. Fourth, we propose a new concept of damage control war wound surgery and to highlight the treatment principle of life first. These new ideas were developed on the basis of 20 years clinical application of the damage control surgery (DCS), which has helped to greatly reduce the mortality rate of severe trauma. Drawing lessons from the U.S. Army with relevant adaptions to the features of the PLA, we put forward a theory of damage control war wound surgery. The DCS is an advanced surgical treatment concept that can be transformed and applied to the principles and characteristics of typical wounded soldiers in the PLA. Because of the nature of war wounds and trauma (mass casualties, multiple injuries, combined injuries, new weapon injury), complexity (battlefield conditions, technical force, military tactics) and unpredictability (battle force requirements of emergency transfer), sometimes wound treatment can only be minimal in the battlefield and only limited to those who have the highest risk of death and cannot survive the evacuation without DCS. Rescue of the wounded shall follow this lifesaving priority to implement front-line emergency treatment. On this basis, according to China s current Rescue Rules (2006 Edition), 2 the relevant personnel shall be reorganized to establish these revisions as soon as possible, to reduce the treatment ladder, actively implement organization of outstanding lifesaving evacuation so the wounded receive proper treatment as quickly as possible, and reduce mortality and disability rates as much as possible. Finally, the PLA need to optimize medical resource allocation and establish a new pattern of all-round medical evacuation for the wounded. Medical evacuation is an important part of war-wounded and trauma treatment. Rapid, safe medical evacuation shall be organized by maximizing human resources, financial resources, and medical technology, which will be conducive to timely treatment to reduce mortality and disability and improve the cure rate and rate of return. On the basis of the successful war experiences of the U.S. Army in Iraq and Afghanistan and the context of the new integrated logistics system and joint guarantee, the PLA plan to use big data, information technology, and intelligence approaches to fully optimize transport resources and human resource allocation, to establish a new, efficient, intelligent, and modern medical evacuation system. The future of battlefield medical evacuation shall employ modern modes of transportation, such as up-to-date ambulances, armored ambulances, health trains, rescue ships, hospital ships, and air ambulances. The severely wounded shall be evacuated by helicopter to form a new 3-dimensional model of medical evacuation in the PLA. CONCLUSION Recent reforms and the characteristics of modern information warfare have rendered the current medical service and MEDEVAC system of the PLA inefficient. The scale of the echelon configuration should be adjusted to establish a more focused, effective, and intelligent medical service; resource allocation and general joint logistics should be optimized to establish a new all-rounded, three-dimensional MEDEVAC system; and the stabilize before healing rule should be applied at all levels of the medical service. These changes should help to create a modern, effective, and responsive medical service within the PLA. ACKNOWLEDGMENTS I would like to express my gratitude to all those who helped me during the writing of this thesis. My deepest gratitude goes first and foremost to Professor Min Yu, my supervisor, for his constant encouragement and guidance. He has walked me through all the stages of the writing of this thesis. Without his consistent and illuminating instruction, this thesis could not have reached its present form. Second, I would like to express my heartfelt gratitude to Yue Song, whohelpmefindrelatedliterature.lastmythankswouldgotomybeloved family for their loving considerations and great confidence in me all through these years. I also owe my sincere gratitude to my friends and my fellow classmates who gave me their help and time in listening to me and helping me work out my problems during the difficult course of the thesis. REFERENCES 1. Wu XJ: A Chinese Study on War Trauma Chapter 1 Introduction to War Trauma Studies, p 76. Zhengzhou, China, University of Zhengzhou Press, 2016. 2. General Logistics Department of Health: Rules for the Treatment of War Injuries, pp 5 9. Beijing, China, People s Liberation Army Publishing House, 2006. 3. Xiao N: A Study on Field Surgery, pp 9 13. Beijing, China, People s Medical Publishing House, 2010. 4. Liang HP, Wang ZG: A Chinese Study on War Trauma Chapter 1 Introduction to War Trauma Studies, p 55. Zhengzhou, China, University of Zhengzhou Press, 2016. 5. Wu XJ: A Chinese Study on War Trauma Chapter 1 Introduction to War Trauma Studies, p 121. Zhengzhou, China, University of Zhengzhou Press, 2016. 6. Eastridge BJ, Jenkins D, Flaherty S, Schiller H, Holcomb JB: Trauma system development in a theater of war: Experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2006; 61(6): 1366 72; discussion 1372 3. e1823