Medical rules of engagement are criteria established by the task force or combatant commander that is responsible for the regional medical care or local regulations for interacting with the civilian population. In developed theaters of operations, thorough guidelines are often established for the various types of injuries that can be treated addition to the amount and type of care that can be provided by US medical personnel. As a baseline, the MROE usually allow for care of injuries that threaten life, limb, or eyesight. However, the MROE change with time, operational conditions, and by location: so always know your local MROE before you commit yourself or US resources! Patients that are injured by coalition activities are usually MROE approved but this can vary depending on the circumstances. In some instances, MROE dictates the type of treatment that can be performed. One example of this is the guideline that local nationals with greater than 50% total body surface area burns are only entitled to comfort care at US facilities. This guideline is based on the resource-intensive nature of burns of this size and the absence of burn care or rehabilitation facilities in the host country that make these injuries nearly uniformly fatal. Another key consideration for whether a local national patient can be accepted and cared for is the hospital capacity and census. These rules usually dictate the refusal or diversion of local national patients when the census reaches 80 or 90% of capacity, leaving the remaining capacity for US or coalition personnel in need of urgent care.

Qualifying for treatment at one facility based on MROE does not guarantee that additional care will be provided at higher echelons of care. This also doesn’t guarantee follow-up care for that patient. This situation can create a disposition nightmare for smaller medical units. In some cases, your team will provide medical treatment to a patient for life-threatening injuries for which the patient will need continued hospital care but the next higher echelon refuses to accept the patient due to limited bed space. This requires creativity and prior coordination with medical treatment facilities of all types. Small local facilities will sometimes take these patients if the family demonstrates the ability to pay or assist with their care. Military or police hospitals in the host nation can be utilized if the family has any connection with these organizations. Other humanitarian aid organizations or nongovernmental organizations (NGOs) can potentially provide care for some patients. In addition, the unit that injured or authorized transportation of the patient to your facility is responsible for arranging transportation back to the patient’s home and assisting with disposition. In some cases, these patients may need to be held at your location until they are ready for discharge to home.

It is CRITICAL that you establish good lines of communication and policies with local hospitals or other medical facilities to facilitate the transfer or medical follow-up of local nationals that you have cared for. Before you do an operation or procedure that depends on close follow-up or postoperative therapies, you must ensure that either your unit can provide this or it is available in the local community. Do not assume that even basic things such as physical or occupational therapy, enterostomal therapy and supplies, limb prosthetics, or local wound care will be available to your patient once they are released from your care. In addition , because there is no medical evacuation chain for injured or ill local nationals, it is critical that you have a mechanism in place to disposition them. If you do not, then your facility will quickly become mission incapable or compromised because of the bed space and resources utilized by these patients. This was a very rapidly learned lesson in the early war experience that led to the hiring of local national medical liaison personnel at most facilities. Your medical liaison will be one of your most valuable assets in helping you navigate the often chaotic and byzantine local healthcare system for patient transfers or follow-up care.

Periodically, units will approach your team for assistance in a medical civic assistance program (MEDCAP) mission. These missions are designed to provide medical assistance to small towns or remote areas that lack any treatment providers. This is another method used by various units to “win the hearts and minds” of local people to improve the environment for US and coalition forces. MEDCAP missions require medics, nurses, and physicians to perform quick symptom-guided examinations of patients and then provide medications or focused definitive treatments to help improve their symptoms (Fig. 42.2). In this setting, time constraints and the lack of testing equipment require that presumptive diagnoses be made based on the history and physical examinations. Often patients are treated to relieve the symptoms despite the lack of a known diagnosis. A significant number of patients will present with common medical problems making their treatment fairly straightforward (Table 42.1). Patients with more complex disease processes such as cirrhosis, renal insufficiency, heart failure, or diabetes should not be given more advanced treatments because of the inability to monitor their response to the treatment and for possible side effects. If a patient has a bad outcome from a treatment or dies, this can be twisted into the idea that the medical team is providing poor-quality care or intentionally harming local nationals .

MEDCAP medications are typically provided by the unit requesting the assistance with the mission. These units have funds that can be used to purchase medications from local vendors or requested through regional military medical supply. Most of the medications are what we consider “over the counter” but are unavailable to the people in these regions. These units will need your assistance deciding on which medications and in what form. When ordering medications, remember that there will be men, women, and children of all ages, so having pill and liquid forms of the medications is important (Table 42.2). Additional items can include tooth brushes, toothpaste, soaps, clothing, and recreational or sports equipment. You will be amazed at how far some soccer balls and equipment can go toward fostering goodwill in almost any part of the world.

To ensure that the unit setting this mission up gets the greatest return for its efforts, make sure to provide all of the services possible during that time. Coordinating with veterinarian services to deworm and immunize local livestock can improve herd qualities and reduce disease related losses. Utilizing the services of the dentist to remove decayed and infected teeth will help to prevent long-term complications and dramatically improve the patient’s quality of life. Familiarizing yourself with the common diseases and infections of the indigenous population will save time and allow you to better tailor your medication and supply list. Physicians with training in infectious disease or tropical medicine are invaluable assets for these types of missions. To be effective, you must be able to communicate clearly and quickly with your patients. Ensure you have an adequate number of translators available, and if possible have translators with a medical background (local nurses or physicians).

There are a few things that are important to ensure a safe and successful MEDCAP mission. The first thing is to allow the line unit to provide transportation, security, and supplies to complete the mission. This is what they do and we need to use their expertise in these areas. Secondly, allow them to determine the location of the MEDCAP site. They are much more in tune with the communities that would benefit the most from the mission and the threat level associated with each area. When setting up at the site, try to be located inside a building or a perimeter wall to reduce your vulnerability to sniper or indirect fire. Patients should pass through security screenings more than once. Utilizing an outer perimeter with local national police or army forces that perform an initial screen followed by a secondary screening prior to entering the building will help prevent weapons or explosives from reaching the treatment area. Let the US or coalition combatant commander decide whether or how to announce the mission for risk mitigation and always be vigilant .

As physicians, we are often uninformed or unaware of the major security issues that even a simple convoy movement can entail. Despite your goodwill, medical units and personnel are very attractive targets for enemy attacks, often by indirect fire or suicide bombings. Efforts to improve relations with the local population will be looked upon as a direct threat to enemy and/or terrorist elements, and they will go to great lengths to destroy or discredit these missions. Do not advertise the date, time, or location of the mission. Doing so will significantly increase your chances of IEDs or organized attacks. You should plan on one interpreter at each of the screening points and for each of the providers. The interpreters assist you with all parts of your interaction and provide verbal and written instructions on medication use. Also, be prepared to honor local customs regarding the interaction with and examination of female patients.