An analysis of the Medical Planner's Toolkit MPTK model for operational medical support planning

An Analysis of Medical Planner’s Toolkit MPTK Model (CREst-T)

Introduction and Background The right equipment, personnel, and supplies are essential in providing lifesaving care in theatre and health maintenance. This is required primarily for the warfighters involved in a range of operations so that the proper care can be delivered to them wherever and whenever needed. Since logisticians and medical planners have not found a better way that has the basis of science with the proper standard methodology, predicting the likelihood of illnesses and injuries has continued to be done in hospital theatres. This existing gap has consistently undermined planning for operational medical support effectively. Therefore, the Medical Planner’s Toolkit was developed to fill this gap.

Purpose and Use/Capabilities and Limitations of the MPTk Model The Medical Planner’s Toolkit (MPT) is a powerful suite of powerful tools developed to be used in the community of medical planning and whose features reveal the capability to conduct medicine missions that relate to end-to-end modeling of expeditionary. This planning tool has powerful features like creating patient condition occurrence frequencies (PCOFs) and casualty stream estimations. From the information obtained, estimates of the requirements of the theatre hospital are made to provide care to the patients within the casualty streams. [footnoteRef:1]The background about this toolkit is that it was designed to provide care involving lifesaving in the theatres and the readiness and health of fighters in various wars. These warfighters cut across multiple operations that require supplies, the right equipment, and personnel to offer delivery care when needed and at any given place. [1: Brown, John, Robert Hunt, Trevor Elkins, Vern Wing, and Andrew Olson. Afloat Medical Materiel Estimates Submarines: SSN Attack, SSBN Fleet Ballistic Missile, and SSGN Guided Missile Submarines. NAVAL HEALTH RESEARCH CENTER SAN DIEGO CA SAN DIEGO United States, 2018.]

Furthermore, those in the military medical planning and the logisticians do not have a methodology that has the standards of a science-based method to determine the possibility of illnesses or injuries occurring. They also lacked streams of estimating patients and casualties and estimation of the requirements to care for the patients in the theatre hospitals. This gap that has been there consistently undermines operational medical support due to a lack of adequate planning. To fill up the gap, the Medical Planner’s Toolkit was developed together with the Joint Medical Planner’s Toolkit (JMPT). The team relating to this modeling and simulation created these tools as an additional value. The value was to provide providers, trainers, medical planners, logisticians, and trainers with the ability and power to examine various courses that happen before, during, and after the deployment.
Additionally, these tools like the MPTk can allocate the resources required, make assessments of the risks, estimate the number of casualties and determine how ready a mission is. This toolkit can enable the medical planners and the military leaders to be equipped with a validated tool to make plans about medical contingencies given a diverse range involving operational scenarios. The other goal that these medical planners and the military had in mind for this toolkit was to manage the resources in the theatre in an effective manner. The MPT consists of several constituents like the Patient Condition Occurrence Frequency (PCOF) tool, the Expeditor Medicine Requirements Estimator (EMRE), the Casualty Rate Estimation Tool (CREst T), and the Estimating Supplies Programme (ESP). These suites of tools support medical planning among the many military operations.
On the other hand, PCOF tables can provide the probability in which a contingency response of a specific disease and the different types of injuries. For the different operational scenarios, there lacked a consistent way of estimating the function of PCOFs accurately by the medical planners. PC as a tool provides the ability to access evidence-based baselines and generate tailored specific operations involving evidence-based baselines. [footnoteRef:2]MPKTk can also offer the capability of generating PCOF distribution for Humanitarian Assistance (HA). As well as in disaster relief missions and in the operations related to combat. The PCOF tool was accredited for DoD-wide use by the FHPIC. [2: Brown, John, Robert Hunt, Trevor Elkins, Vern Wing, and Andrew Olson. Afloat Medical Materiel Estimates Submarines: SSN Attack, SSBN Fleet Ballistic Missile, and SSGN Guided Missile Submarines. NAVAL HEALTH RESEARCH CENTER SAN DIEGO CA SAN DIEGO United States, 2018.]

In addition, modeling those patent streams used is usually constructed after constructing and combining a casualty estimate with a PCOF distribution. There lacked a science-based process of estimating the casualties by the medical planners. Hence CREst-T was designed to fill this gap. A crest is a fast-running tool that calculates the casualties for shipboard, ground combat and fixed installations, DR and HA scenarios. The application of empirical data is used in Crest-T to fit the probability distributions to produce estimates of the casualties for non-battle injury, disease, and wounded in action. The other tool used is the EMRE tool which provides estimates that are time-based for the operating room tables, ward beds, intensive care unit beds, evacuee numbers, blood supplies which are helpful in the level three requirements. These estimates are the force laid down in the other tool kit model, JMPT.
They provide solutions on an end-to-end basis. The Medical Planner’s Toolkit was designed for humanitarian assistance (HA), disaster relief (DR), ground combat fixed base PCOF distribution tables and shipboard. The other purpose for its development is for the estimation of the roles f three expeditionary requirements in the medical field used in operating rooms (OR), ward-based intensive care units (ICU), critical care transport teams (CCATTs), evacuations, and products of the blood. All these are usually based on the anticipation of the patients’ loads. Estimation of those casualties in the HA and DR missions and those in the ground, those in the fixed base combat operations and shipboard, and those casualties inpatient stream as a result of operations. Estimation of usage of the supplies daily, including those estimates of volume and weight. This toolkit is a combination of other tools, which, when used together with this toolkit, provide information that may be utilized to enhance the efficiency of the medical planners.

Pros and Cons of the MPTk Model This particular toolkit has some advantages and, at the same time, disadvantages. The good side of this toolkit is that it is used to relieve disasters. The disasters that we are talking about here are hurricanes and earthquakes. It does this using CREsT which consists of two modules capable of developing patient streams. As a result, these streams are then used to estimate the reasonable effort to respond. The user can input treatment capability and the day of arrival for the earthquake. Immediately after the arrival, based on the treatment, casualties are treated based on the capacity of treatment. This happens until the mission ends in the case of a hurricane; almost everything applied in the earthquake scenario is applicable in the hurricane scenario.
Another advantage is that it offers models used for modification and decision making so that they can help in the various analysis. Some models are used in military combat and non-combat operations. Compared to traditional methods, it is far beyond being better. It is reliable since it provides calculations and definite results to be content with the outcomes. A well-developed analytical tool helps to analyze various concepts and components more quickly. The MPTk tool is of a high advantage since it is one of the few modern ways of medical planning in the military system.
The other advantage is that it differs significantly from the different analytical and simulation tools. To begin with, it provides a global framework that considers the conventional approaches that deal with various patients or casualties. It is based on CREsT as a tool that contributes greatly to its efficiency. CREsT helps estimate casualties, which provides a better way of coming up with responses since efforts will be put after the casualties are determined.
Another advantage of this tool is that it can be used as a blood planning factor. This is usually historically founded. The respective medical planners can utilize the people who plan these systems; for example, CCMD helps generate initial blood product estimates.
Some shortcomings are associated with this model; this includes the threats seen in some tools, considering the health support planning, some endemic diseases, and illnesses act as psychological stressors.
Another shortcoming related to the Medical Planner Toolkit is that most of the information is dated back to the second world war. This is seen in the adjustment factor for the region. The development analysis is data collected during the world war. [footnoteRef:3]This data might have been outdated since it happened a long time ago. The data baseline may not produce the required results since information should continually be updated. Having this in mind, this seems to be a shortcoming, and therefore, this field of study should be explored since it appears to have been abandoned. [3: Brown, John, Robert Hunt, Trevor Elkins, Vern Wing, and Andrew Olson. Afloat Medical Materiel Estimates Submarines: SSN Attack, SSBN Fleet Ballistic Missile, and SSGN Guided Missile Submarines. NAVAL HEALTH RESEARCH CENTER SAN DIEGO CA SAN DIEGO United States, 2018.]

Generally, this toolkit provides the most advantages since it is one of the most advanced planning tools that has been established lately. It uses various models, and the components in this tool complement the toolkit, which is why it is recommendable to use it.
Evaluation of MPTk as a tool for estimating casualties
MPT tool is used in estimating casualties. This description develops to understand the limitations and capabilities of the tool in evaluating the number of casualties. This will put into use the Casualty Rate Estimation Tool (CREst-T), which estimates the casualties and injuries resulting from both combat and non-combat events. This tool, CREst-T, generates the estimates of casualties for ships’, attacks on fixed facilities, disaster relief, humanitarian assistance, and combat ground attacks. Therefore, the medical planners can tailor estimates based on factors that can be adjusted; they can also test operations and develop robust patient streams that are synchronized with the intended environment.[footnoteRef:4] CREst-T can use distributions that are stored since it has an interface with PCOF and can also create that application to develop the streams of the patients based on the casualty streams and distribution of PCOF that has been selected. Its stochastic implementation can provide those using it with percentiles and average results that help them in the risk assessment analysis. Its reporting capability is robust, and data is provided in tables and graphs formats. The data output available is compatible with ESP, JMPT, EMRE, and other tools. [4: Nix, Ralph, Tracy Negus, Trevor Elkins, Jay Walker, James Zouris, Edwin D Souza, and Vern Wing. Develop a Patient Condition Occurrence Frequency (PCOF) Database for Military, Humanitarian Assistance, and Disaster Relief Medical Data. NAVAL HEALTH RESEARCH CENTER SAN DIEGO CA, 2013.] Ground Combat Concerning the casualty rate of baseline, ground combat is usually based on the empirical data, which are rated from the Second World War through OIF and OEF. The WIA casualty rates can be calculated from various factors developed using analysis of historical data. This has been successful after building on research done by Trevor N. Dupuy and the institute of Dupuy in 1990. Recommendations by the Casualty Rate Development Working Group of 2016 were also incorporated.

Generation of WIA casualties The development of the WIA casualty rate model of generation has its details with NHRC reports, the forecasting wounded-in action casualty rates from the ground combat operations. The ground combat operations casualty estimates in CREst-T are calculated using a high-level process for the casualty estimation. This sub-process describes outputs and inputs plus the algorithms required for estimations. For each replication, the process is run independently. Some adjustments are made in adjusting PAR at the beginning of the day on the Par of each operational environment and the replacement settings. The PAR operations are initialized at zero on day 0. After this day, the PAR is initialized to the OAR at the end of the previous day. When the PAR is positive, then it means that it will be added to the Current PAR. In contrast, if it is negative, the assumption is that the withdrawal of troops has only occurred to that level necessary for reaching the resulting PAR that has been planned.

Generation of KIA Casualties Generation of biological, chemical, and biological, and radiological or Nuclear casualties estimates are provided by DTRA (Defence Threat Reduction Agency and is incorporated by MPTk through the CBRN attack in an event set up by the user. It builds estimates that DTRA has developed. To generate the nuclear casualties, they are usually modeled in CREsT, which means that the distribution of the patient’s codes and casualty count remains fixed for all the replications where PAR is of a greater count than CBRN casualties when the day is beginning. This type of casualty estimation is generated in CREsT when the day starts, and the timing from which the DTRA file indicates that they should happen. In the designated KIA-CHEM casualties, the chemical casualties in the DTRA file include the time death occurred. This is usually when death occurs if the loss fails to complete the role number 1 treatment.[footnoteRef:5] The patients are counted using their codes that have the designation KIA-CHEM for every operational environment. In the designated KIA-RADNUC casualties, the radiological or the nuclear casualties in the DTRA file import include the time of degradation. This is the primary time when death should occur if the patient’s role number 1 treatment is not accomplished. The patient count using their codes is usually represented as KIA-RADNUC in every environment that is operational. [5: Brown, John, Robert Hunt, Trevor Elkins, Vern Wing, and Andrew Olson. Afloat Medical Materiel Estimates Submarines: SSN Attack, SSBN Fleet Ballistic Missile, and SSGN Guided Missile Submarines. NAVAL HEALTH RESEARCH CENTER SAN DIEGO CA SAN DIEGO United States, 2018.]

In the generation of biological casualties, each replication is always the same as the total biological count of exposure. However, the count of casualty in CREsT varies due to post-exposure prophylaxis application. The biological casualties are subject to post-exposure prophylaxis treatment. This post-exposure prophylaxis can prevent biological attacks; this prevents it from becoming a casualty. The post-exposure prophylaxis is applicable based on the efficacy of prophylaxis. This efficacy is an input user and varies depending on prophylaxis administered. Removal of CRBN casualties from PAR is the next step. Here the casualties from the chemical, biological, radiological, or nuclear attacks are usually removed for every operational environment from the PAR. They are removed before the application of WIA and DNBI are calculated. Calculations of WIA rates for ground combat for the operations are done using Ridge Regression models that have been derived empirically. This model was generated historically using the available data from world war II spanning operations. After the calculations of the WIA exponents, the values obtained are then used in the estimates of the base rate of WIA, which happens along with the multipliers. The rate of WIA is then calculated and multiplied with the tactical advantage adjustment. The value of the tactical advantage adjustments is then based on gamma and exponential statistical distributions.
User-defined rates are entered in the user revision field. This user rate entered exceeds the calculated rate used as the effective WIA rate. Afterward, what follows is the generation of WIA casualties. This generation involves the outputs and inputs. [footnoteRef:6]All the CREsT casualties are generated using the Poisson distribution. in the MPTk toolkit, the variation of Poisson random means that more than thirty is caused using the method of rejection that Atkinson proposed in 1979. for those means which are less than thirty, there is the usage of Knuth’s method of 2007. After this, there is a generation of casualty counts. The previously generated rates are multiplied by the current PAR, divided by one thousand; this helps develop daily WIA casualty. It is then used as the mean of the Poisson distribution. The number of casualties for the day is simulated when there is the generation of the outputs of WIA casualty. [6: Nix, Ralph, Tracy Negus, Trevor Elkins, Jay Walker, James Zouris, Edwin D Souza, and Vern Wing. Develop a Patient Condition Occurrence Frequency (PCOF) Database for Military, Humanitarian Assistance, and Disaster Relief Medical Data. NAVAL HEALTH RESEARCH CENTER SAN DIEGO CA, 2013.] Generation of POW/WIA Casualties A POW/WIA casualty with their estimated numbers that may not return to duty is calculated as the percentage of the total. This total includes the battle casualties that are conventional from CREsT, KIA, and WIA for every day. The rate of POW or the WIA is based on the guidance from an analysis done in history by Army HRC with a value that has a default of fifteen percent.

Decrement the PAR After the WIA, KIA, and POW/MIA casualties have been generated, the DNBI casualties are not generated before PAR is decremented. After WIA and KIA are generated, all the WIA, POW/MIA, and KIA casualties are removed from PAR.

Apply Adjustment Factor to Baseline DNBI Rate The DNBI (disease and non-battle injury) baseline rate gets its definition from the user of each environment operation after every interval. In determining the baseline rate for DNBI, for an operational environment, the default rate will be a specific DNBI interval. This is normally the case unless there is an entrance of a user-defined DNBI rate that exceeds the DNBI default rate. The adjustment factors for the region for the DNBI, which were developed through the second world war analysis data, are aggregated by both NBI occurrences and disease, and each of them does have an individual factor of adjustment. Finally, the adjustment output factors imply that the applications of the adjustment factors can produce a set of outputs adjusted for the casualties of DNBI.

Generate DNBI Casualties They undergo a Weibull distribution process; this kind of underlying contribution helps create DNBI. The distribution is a cross with standards in the entire operational environment and the intensities of battles. The value that changes in the mean rate. The Weibull distribution always involves the scale and shape parameters. In the CREsT toolkit, an assumption about the shape parameter is given as 1.975658. This is the value that is used to solve the scale parameter. Therefore, the splitting of DNBI follows whereby generation of the number of DNBI casualties uses CREsT. There is the splitting of the casualties depending on the input user.

Decrement the PAR After the generation of the DNBI casualties, before moving to the next day, it is ensured that PAR is adjusted. The DNBI casualties that evacuate Role 3 are then removed, and the WIA and CHEM that had been previously removed are returned. Those casualties that can return to functioning after roles 1 and 2 are returned, and at the end of the day, PAR casualty occurs. From PAR, non-battle injury and disease casualties are removed. RTDs for the disease and non-battle casualties are added back for the production of the final PAR. The PAR of the previous day is used as the beginning of the next day.

Return RTDs The roles of RTDs from the patient stream are calculated; the procedure used in calculating the number of casualties in Role 1 uses the patient’s conditions of those casualties who are returned to duty from the first role. In role 2, CREsT helps calculate the number of casualties returning to duty in role 2. If it is the case of a fixed base scenario of the CREsT scenario, the ashore probabilities are used, and AF is false.