When the Army sends Soldiers into harm's way, it promises that if those Soldiers fall sick or get injured, the Army will do everything possible to save and restore their lives. In recent years, military leaders have honored this assurance by placing the most sophisticated health care equipment and providers as close to the front lines as possible.

The result has been a 90 percent or greater survival rate for injured service members who make it to a role 3 facility, such as a combat support hospital. However, in order to preserve this lifesaving capability, the Army must also sustain advanced medical devices in the area of operations.

Medical materiel is a complex commodity. To keep pace with advancements in civilian health care, the military often leverages commercially available products that must be modified for a battlefield environment. A medical device that works well in a clean, clinical setting may not be as easy to use or effective on a sweaty, dirty, or bleeding Soldier. The operational environment itself also creates sustainment challenges, such as extreme temperature variations, rough terrain, and limited access to reliable electricity.

To overcome these challenges and keep the promise of quality health care, the Army has invested in training medical maintenance experts focused on the readiness of fielded equipment and unit-level Soldier support.

CURRENT PROGRAM STRUCTURE

Army Medicine's focal point for medical maintenance is the U.S. Army Medical Materiel Agency (USAMMA), a subordinate organization of the Army Medical Research and Materiel Command. Of USAMMA's nearly 500 employees, about 40 percent are aligned to the Medical Maintenance Management Directorate (M3D).

M3D is structured into two major components: the Medical Maintenance Policies and Analysis (M2PA) and the Medical Maintenance Operations Division (MMOD). The M2PA provides enterprise-level medical maintenance analysis and policy development that is patient-focused and quality-centric. It maximizes the Army's global medical sustainment capabilities in support of readiness.

The MMOD oversees depot-level medical maintenance operations at three stateside locations: MMOD-Tobyhanna, MMOD-Hill, and MMOD-Tracy.

MMOD-Tobyhanna in Pennsylvania handles audiometer calibration, optical equipment, dental hand-piece rebuilds, the Military Entrance Processing Station Direct Exchange program, and table of organization and equipment lab equipment.

MMOD-Hill, located at Hill Air Force Base, Utah, focuses on anesthesia, pulmonary equipment, and field oxygen.

MMOD-Tracy, located at the Defense Distribution Center in San Joaquin, California, manages maintenance and calibration for medical imaging equipment and special purpose (medical) test, measurement, and diagnostics equipment.

Each MMOD location also provides medical maintenance support for its region's National Guard units. The top equipment experts from each MMOD are employed on a rotationally deployable team called the forward repair activity-medical (FRA-M) that travels around the globe to operational theaters to provide expert-level training and support to unit-based military occupational specialty 68A (biomedical equipment specialist) Soldiers. These Soldiers install, service, calibrate, repair, and maintain medical equipment. The Army has 68As spread throughout units all across the force, and these Soldiers, while not directly assigned under USAMMA's M3D, are essential partners in medical materiel readiness.

"The skill level that we require for the FRA-M is not something that can be bought 'off the shelf,'" said M3D director Jack Rosarius. "We have to grow them."

GAP ANALYSIS

As the Army shifted toward a focus on readiness, USAMMA began to look harder at its current medical maintenance programs. Leaders took a critical look and asked two key questions: Is our medical equipment ready? Are 68As properly enabled to sustain this equipment?

Internal assessments and an April 2018 Army Audit Agency report titled "Medical Device Maintenance" found several areas for improvement, starting first with medical equipment readiness and accountability. More than half of audited units had not accounted for the true readiness of their medical equipment.

To understand how this can happen, it is important to understand how the Army packages its medical equipment, which is by sets focused on a capability, such as tactical combat care. Each set can have hundreds of items and include several embedded complex medical devices that likely require medical maintenance, such as ventilators or defibrillators.

If the unit only looks at the big picture (the set) and does not review down to each line item (for example, the medical device), it may not be tracking the current condition of the device. A compounding issue is also that some medical devices do not have a standard line item number, which means Army leaders may not have true visibility of the readiness of these medical devices.

Another identified gap was knowledge management and education. About 40 percent of units that were assessed had not developed local policies and procedures to inform equipment operators (technicians and clinicians) about medical maintenance requirements. This documentation is essential for units that do not have embedded 68As. Often clinical staff members (users) are unfamiliar with how to properly schedule, maintain, order, or account for medical devices.

"This is a real problem," said M2PA Chief Warrant Officer 5 Jesus Tulud. "With medical equipment, leadership cannot accept risk. If a piece of medical equipment is overdue on its routine maintenance, it is non-usable because it could put a patient or staff member at risk."

Tulud explained that unit assessments also indicated that some 68As were unsure of when they were supposed to try to repair a piece of medical equipment on site or when to send it to a higher level of support at an MMOD. Some also reported problems with getting repair parts in the timely manner.

"We found that our 68As need access to better decision-making tools and resources in order to aid in their on-ground product support," Tulud said.

To address these identified gaps and improve support to the force, USAMMA has developed a concept plan to expand medical maintenance support in three key areas: equipment readiness and accountability, enhanced 68A Soldier training and support, and repair parts procurement.

EQUIPMENT READINESS AND ACCOUNTABILITY

To address shortfalls in equipment readiness and accountability, USAMMA plans to provide additional support at strategic military installations, such as Fort Hood, Texas; Fort Bragg, North Carolina; and Joint Base Lewis-McChord, Washington. These locations are considered power projection platforms because they deploy one or more high-priority active component brigades. Expanded support will come in the form of medical liaison officers (LNOs) and on-site FRA-M expertise.

LNOs are not a new concept for USAMMA, which already provides regional LNOs across the country to provide medical logistics support to active Army, Army Reserve, and National Guard units. The newly added LNOs will focus on building relationships with existing unit medical maintenance and logistics teams and supporting them before, during, and after deployments.

"The LNO's job is to bridge the communication gap. The military is full of vertical organizations and that can make it hard for people to reach out and talk to each other. The LNO is a central point of contact in the field that helps to answer medical materiel questions," said Mike McHale, a USAMMA LNO and task lead.

The FRA-M personnel will serve as an extension of the current MMOD structure, providing permanent, co-located medical maintenance experts at these platforms. The FRA-M will help ensure medical materiel readiness while developing the knowledge, skills, and abilities of the 68As assigned to these units. Leaders also expect the additional FRA-M staff to reduce costs and time lags associated with shipping medical equipment to the depot because the FRA-M will be able to fix it on-site.

"These changes are really about expanding our depot-level support capabilities and providing additional support to units in the U.S. so that we can support readiness across the force," explained Steve Johnson, the former deputy chief of M2PA.

ENHANCED 68A SOLDIER TRAINING AND SUPPORT

Throughout the past two decades, medical technology has dramatically increased in complexity. However, initial-entry and sustainment training for 68As has changed very little. In order to be proficient at maintaining today's fielded systems, unit repairers need additional hands-on training.

Rosarius said that "functional areas such as imaging, laboratory, and pulmonary are complex enough to merit a maintenance specialty in of itself. Yet, maintenance doctrine and limited resources require medical maintainers to maintain proficiency in virtually all medical equipment located in a deployable medical systems environment."

To address this training gap, 68As assigned to units under the Forces Command are offered 30- to 60-day temporary duty assignments at one of USAMMA's stateside medical maintenance depots. The training provides Soldiers with a low-stress, nonoperational environment in which to learn and practice how to evaluate, calibrate, repair, and conduct preventive maintenance on a variety of technically sophisticated medical devices.

"Medical maintenance is a skill that must be practiced," said MMOD-Tracy electronics supervisor Vernon Emmons. "These trainings provide Soldiers with an opportunity to work side-by-side with vendors and Army experts with advanced device-specific training so that they can gain the experience and confidence they need in order to repair lifesaving equipment in the field, where there is no room for error and a working piece of equipment may be the difference between life and death."

Spc. Braian Jardines, a biomedical equipment specialist assigned to the 51st Medical Logistics Company at Fort Bragg, has completed two temporary assignments at USAMMA MMODs. He said of his experiences, "You learn something new. You can be working on a piece of equipment for a long time, get stuck on something, and they just have a real quick fix that you didn't know about. Then you can just do that instead of taking the long way around."

In addition to these training opportunities, USAMMA is collaborating with the Army Medicine Director of Logistics to develop an online knowledge management center accessible through milSuite: https://www.milsuite.mil/book/groups/usamma-national-maintenance-program. This portal will serve as a single, centralized, point-of-reference solution for collecting and sharing biomedical maintenance information, including vital Medical Materiel Quality Control messages related to fielded devices.

"A central knowledge management database for medical equipment maintenance increases a technician's ability to appropriately maintain medical devices because everything they need to know about a specific device, from the calibration requirements to the repair parts and equipment literature, is housed in one single location," said Tulud.

EXPANDING PARTS PROCUREMENT

Another key component to enabling the Army's 68As is ensuring they have access to repair parts. The challenge of buying and receiving repair parts in a timely manner is not unique to medical equipment. However, one distinct complexity of medical equipment is that most fielded medical equipment is commercially developed and then modified for Army use. As such, vendors often update their devices and no longer support the versions procured by the Army. To ensure the Army has access to essential repair parts and can procure them in a timely manner, the USAMMA team is considering two major initiatives.

First, they are evaluating the feasibility and costs of centrally procuring and storing commonly needed repair parts at their depots. If repair parts are not already sourced, it will take at a minimum 30 days to get that repair part. Having an on-hand supply of parts would allow them to repair and return faster, so units can get back the lifesaving equipment they send in. Units that need certain parts would be able to go to USAMMA and order the parts through them instead of having to source the parts through a vendor.

"We believe a centralized repair parts program will significantly reduce wait time," said Rosarius. "The vision would be to have the repair parts located at each depot based on their center of excellence. For instance, MMOD-Tracy is the center of excellence for imaging, so we could have imaging repair parts located there."

Second, USAMMA's medical maintenance experts are seeking to expand their current "cannibalization" process. Cannibalization refers to the process used to harvest parts from one piece of equipment in order to repair another. This process is particularly valuable when fielded equipment is no longer supported by the vendor, which makes repair parts virtually impossible to procure commercially.

With support from Army leaders, USAMMA has begun to implement its concept plan. Last year, M3D reorganized its team to create a new procurement office for centralized repair parts procurement. M3D is also in the process of hiring personnel to support the LNO and FRA-M positions at selected military installations. Teams will support the development of future policy to codify these expanded efforts.

"Implementing these changes will truly be a team effort between Army Medicine, [the Forces Command], National Guard and Reserve units, and our training commands," added Rosarius. "We are all focused on the same goal: readiness."

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Ellen Crown is a public affairs officer for USAMMA. She has a bachelor's degree in communications (journalism) from the University of Maryland, University College, and a master's degree in public administration from Norwich University. She is a graduate of the Defense Information School.
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This article is an Army Sustainment product.