The PHTT concept

The PHTT is a small clinical team based around a lead clinician with the ability to prescribe. This clinician can be an RMO, a general duties medical officer (GDMO) or a military nurse practitioner (MNP). The MNP is endorsed to treat and prescribe autonomously within their scope of practice.4 In turn, the clinical lead is supported by a mixed team of CMTs, nursing staff and drivers. The team is able to provide both primary care and prehospital emergency care. Typically two PHTTs work in tandem providing mutual support and an ability to move around the battlespace.5

Composition of a PHTT

On SS3 the manning composition of the PHTTs varied (see Table 1). Having CMTs dual trained as drivers provided more clinicians, however, this is caveated with the requirement to ensure sufficient rest to drive and treat patients safely.

Transportation of the PHTT

The vehicle platform used in a PHTT is selected to reflect the environment they are operating in. On SS3, the platform used was a Bulldog ambulance variant as the battlegroup were operating with tracked vehicles. However, if the BG were using wheeled vehicles a PHTT could be mounted into a battlefield ambulance or mastiff platform depending on the threat. Mounting the PHTT in a similar platform to that of the battlegroup allows the medical team to closely follow the battle, this enhances the ability for clinical timelines to be achieved. As alternative platforms with medical evacuation capability are brought into service, for example, Boxer, a wheeled armoured personnel carrier medical planners will need to take these in to consideration when creating a PHTT.

On SS3, the PHTTs moved close behind the assaulting companies and the two PHTTs worked in concert with each other. This enabled both teams to move independently of each other, and for one team to provide a working facility while the other team moved forward, thus the battlegroup always had a fully operating medical facility ready to receive casualties at kinetic phases of the exercise. That said, the PHTTs could come together to provide a greater clinical presence if required. Communication is vital between BGHQ and the PHTTs, such information such as location was relayed to the Sub Units via the radio network enabling streamlined evacuation of casualties.

Mobility and flexibility underpin the ability to respond effectively to incidents.6 This was a theme throughout SS3, the PHTTs were able to move with the battlegroup providing reassurance to the chain of command (CoC) that appropriate medical care was closely located as required. At the basic level, emergency care could be provided from the back of the vehicles, the benefit being optimum mobility was maintained and notice to move times were relatively low, less than 10 min. In contrast the fully erected treatment facility, using all the equipment of the PHTT including camouflage nets and resuscitation bays took approximately 30 min to establish (Figure 1). This provided greater protection from the elements which was particularly useful in the Omani desert and in the treatment of heat casualties, a sizeable proportion of casualties.7 8 After the teams had practised and developed an appropriate load plan, PHTT establishment became increasingly rapid; a basic treatment bay with monitoring could be erected in less than 5 min from arriving in location (Figure 2). This could in turn be modified if a heat casualty was to be received, a tarpaulin could be erected over the stretcher providing shade from the sun rather than utilising a camouflage net. The use of a tarpaulin to offer shade in this instance afforded a degree of protection from the elements could be provided in a shorter time frame, essential when treating heat casualties.9 The main time constraint for establishing a fully functioning PHTT, ready to receive casualties as displayed in Figure 2, was the construction and dismantling of camouflage nets. A camouflage net provided some clinical advantages, it offered a large area that was partially shaded for the treatment of multiple casualties and the PHTT personnel. The flexibility of a PHTT provides options to the CoC and enables a form of medical care that keeps pace with an advance. The ability of the PHTT to choose how it is established provides a key advantage that allows greater tactical flexibility and faster medical response.

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Figure 1

Armoured vehicle of a PHTT under cam netting. Supplied by Royal. PHTT, prehospital treatment team.

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Figure 2

Casualty treatment Bay in deployed PHTT. Supplied by Maj P Royal. PHTT, prehospital treatment team.

Function of the PHTT

Initial stabilisation of that casualty relies on forward deployed CMTs or ambulance assets.6 PHTTs are designed to meet the 1-hour timeline of being treated by a Battlefield Advanced Trauma Life Support trained practitioner in a safer environment than the forward medical assets. The PHTT can take multiple casualties from different locations allowing the forward clinicians to stay with the fighting companies. This provides a forward triage and holding area where casualties can be concentrated, receive life-saving treatment and be sent for more definitive care via the most appropriate means, identifying the highest priority casualties to be moved first.3

In SS3, the CMTs integral to the fighting companies decided the clinical pathway depending on the situation. If the casualty warranted immediate medical evacuation to hospital the Medical Emergency Response Team (MERT) was activated. MERT is a concept that came to public awareness during the recent conflict in Afghanistan. They provide advanced mobile care, despite the public perception MERT can use any vehicle and is not confined to helicopters.10 Identifying the most appropriate clinical pathway for a patient is challenging in an austere environment.9 Knowing when and where to use a capability provided is critical given the military often operate in resource limited situations.11 The PHTTs provided forward advanced decision making and a close source of support as needed to the CMTs imbedded within the infantry companies.

The 1 Mercian RMO was located at BGHQs during the exercise. This meant they could project forward to casualties themselves if required allowing the maximum benefit from the senior clinician on the ground. This differed from the more traditional approach based around a more concentrated RAP but provides scope to position medical support where required with disseminated decision making.12

Management of casualties

The skill set contained within the PHTT influences the flexibility afforded to the CoC. If receiving a single patient, a complete resuscitation team could be used with personnel assigned to specific roles. As additional casualties present then the team can be subdivided further with the clinical lead ‘hands off’ providing advice to each subteam. Examples of possible team configurations are shown in Figure 3. During the deployment, the PHTTs would often see multiple primary care casualties simultaneously, on occasion heat or trauma casualties. Two or more critically unwell casualties diminishes the PHTT’s ability to undertake non-clinical tasks such as operate the radio or force protection (FP), an important factor if to be used in a real war fighting situation. Therefore, assistance may have to be drawn from those conducting the casualty evacuation or the CoC accepts that the PHTT loses the FP element if treating multiple casualties.

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Figure 3

Possible team configurations of a PHTT. Supplied by Maj P Royal. D, driver; PHTT, prehospital treatment team; T, Treatment; TL, team lead; VC, vehicle commander.

The diversity of skill sets within the PHTT including the presence of a nurse provided complimentary skill sets lending additional experience and a more holistic approach to running the facility. The PHTT was a valuable learning environment for all members of the team. As mentioned in the introduction those not in a clinical role in the firm base were allowed to reacquaint themselves in a supportive team. This is best demonstrated through the care several unwell casualties received from the PHTT. Casualties included heat injury and road traffic accidents, the teams were able to effectively initially manage these and evacuate to higher level care within timelines. During the exercise, the PHTTs treated several casualties that were triaged to be among the most unwell. These included from heat casualties as well as those from road traffic incidents. The teams were able to effectively initially manage these and evacuate to higher level care within timelines.

Learning points

One of the prime advantages of the PHTT is the flexibility, the use of two in unison provides a medical footprint over a greater area and they can either work in isolation or together for best effect, dependant on the operational requirement. However, this come as at cost within the PHTT was provided internally, there was no battlegroup asset assigned. In a permissive environment, this is not a concern, in the operational environment an isolated PHTT would be vulnerable. Protection is afforded from harm under the Geneva convention,13 but against an enemy that does not subscribe to this a PHTT would be vulnerable. For a PHTT to be used on operations it would require a supporting defensive force. This would increase the size of the PHTT and manning would have to be taken from within the battlegroup, reducing capability somewhere else.

Basic soldiering skills are essential to the viability of the PHTT; this was a key learning point from SS3. Anecdotally, often basic soldiering skills are often not focused on within the clinical cadres due to other training demands. Oman represented difficult terrain with large expanses of featureless desert, a challenging environment to navigate in. Navigation through this can be easily achieved in the modern era through the use of a Global Positioning System (GPS), and indeed it is apparent how an over-reliance on this technique could easily develop. As seen in recent examples, GPS is not a system14 that is immune to actions by the enemy and so the ability to use map and compass to navigate through difficult terrain is required. It was noted within the PHTTs that skill levels with regard to navigation, operating radios and maintaining vehicles varied as did the experience with the vehicle platform. An inability to successfully navigate could have a disastrous effect on clinical delivery and survival of the facility. Thus, basic soldiering skills for those within a PHTT should form a key part of future predeployment training package.

The Omani desert is an austere environment where temperatures can exceed 50°C, having a serious impact on sustainable work rate. The PHTT must be able to maintain themselves and their equipment at the same time as providing high level medical care.15 Therefore, emphasis on the environment a PHTT is going to operate in is required before leaving the UK. The team need to be physically robust to withstand the demand of the job, providing medical care, in an austere environment. Physical training prior to deployment on operations or overseas exercises to hot countries aids acclimatisation9and ensuring that basic soldiering is revised as part of the predeployment training are key to an effective PHTT. A summary of key learning points can be found in Box 1.