MC4 Training in Iraq Versus CONUS - SGT(P) Larry R. Rogers, 1st Infantry, Battalion Aid Station NCOIC

I just completed the system administrator (SA) training at Al Assad, Iraq. I think that if the providers received a brief on what MC4 does before they deployed, it would be a great help to the setup and use of the system. There were several things that I didn't know about the capabilities of MC4 that I will now be able to implement when I get back to my forward operating base.

The training that I received at Fort Carson, Colo., was nowhere near the total capacity of what the medical systems are doing in theater. The training lab at Al Assad should be an example for the training classes in CONUS. During new equipment training it is great to go over the programs but you don't get the experience of using all the systems. Some applications, such as Theater Medical Data Server (TMDS) and Joint Medical Workstation (JMeWS), were not even covered during my initial training. Now I can access patient notes from level 2 and 3 facilities that didn't usually make it back to CONUS with the patients.

This system is a great improvement over the paper trail that was used in the past. If we could get the physicians to train on the applications, I don't think that there would be so much angst about the difference between CHCS II T (AHLTA-T) and AHLTA.

It seams that the physicians that talk badly about MC4 do not understand the complexity of the system or they have never used MC4 in theater. My physicians love with the system because it means completing a lot less paperwork even though they do not fully understand the capabilities of Theater Medical Information Program (TMIP) yet. When I get back and teach them what they can do, they're not going to want to go back to AHLTA.

Comments From the Field

SPC James Elliott, 1st Infantry Division
The MC4 service is great. They are the best. I am so grateful to have them.

SSG Muriel Nash, 352nd Combat Support Hospital
Great hardware!

SPC Teya Smith, C Company, 2nd Infantry Division
Easy, convenient, user-friendly system. Truly a great way to track patients and patient progress without the fear of losing paperwork.

Additional Uses for the MC4 Handheld - LTC William Smith, 550th Area Support Medical Company

My biggest criticism is not so much about the MC4 system, but the fact that we routinely lose power causing the servers to not work. To combat the power loss and continue doing our job, I think the providers should try using an MC4 handheld as a backup instead of using pen and paper. This way, you can upload your notes when the MC4 system is up and running again. Another idea is to have a flatbed scanner available so hand-written notes can be included into a patient's electronic medical record (EMR).

During my deployment, I have been to Kandahar, Afghanistan, where the conditions are really austere and since this is a multi-national base with the Canadians running the hospital, there is no MC4 system. We often get patients flown into Kandahar without documentation of injuries or previous treatments.

I have had two HP 4700s to document patient care. Both of which I purchased myself. The dust over here destroys them, even with the protective case. Also, the case makes the handheld very cumbersome to use.

I would like to try an experiment where we use the new Motorola handheld to record patient data every day. Then at the end of the day, we burn a CD-ROM. This way, when we return to an area with the MC4 system, we can upload the records on the CD-ROM so they are part of the EMRs.

Are flight medics getting and using the handhelds? I truly think that point-of-contact documentation is going to be essential. When the patient gets to a level II facility, which may not have MC4, one can continue to document care with the handheld.

I want to help refine this technology for our troops.

MC4 Handheld Used During Treatment of a Sniper Victim - MAJ John Rumbaugh, Battalion Surgeon, 36th Infantry Division

While deployed to Hit, Iraq, the 36th Infantry Division used MC4 handhelds and laptops to document the care given to all of the patients that came into our aid station. We called our aid station the "Shine on the Crazy Diamond Aid Station" and our motto was "No diamond stops shining in our aid station." We understood the importance of the PDAs and we gave training sessions to document patient care on a daily basis.

One day, the system was used to document an injury for a Soldier in our unit – he was shot in the head by a sniper. Upon learning of the injury, I ran into the aid station to get additional medical personnel to come out and help the Soldier.

Providers ran to the Soldier's location and began treatment. The injury, vital information and the treatments performed were also being documented into the MC4 handheld. The Soldier was moved into the aid station where treatment continued.

We evacuated the injured Soldier to a level II medical treatment facility (MTF) with Navy providers and then he went on to a level III MTF to be treated by an Air Force neurosurgeon. From that location, he was transported to Landstuhl Regional Medical Center for additional medical attention. I was able to track the Soldier's treatments through the various levels of care since his information was entered into the MC4 system.

I think it is extraordinary that a Soldier was shot in the head, and within 24 hours, he was operated on by a neurosurgeon and then transported to Germany to be with his family.
We thought the system was a success during our deployment.

A Sailor's Perspective of MC4 -HM1 Thomas L. Mendenhall14th Marine Regiment Medical Department

I was deployed with my unit to Kuwait in 2003 during the first rotation supporting Operation Iraqi Freedom (OIF). During my tour of duty, I was stationed at Expeditionary Medical Facility-Dallas (EMF-Dallas), which operated all the clinics and troop medical centers (TMCs) in Kuwait.

When my unit arrived in Kuwait, we received MC4 equipment to record medical data. At first we were very wary of Composite Health Care
System II-Theater [CHCS II-T (AHLTA-T)] because MC4 is an Army system. Besides the fact that the system was in its infancy, the system was new to us and we found it confusing to use.

Shortly after our arrival in theater, we attended a 4-hour class on how to use the system, but this did very little to help due to the tremendous amount of information that was covered. We might have grasped the system a little better if we had been given student guides, but since we were in a combat zone, I can understand why they were not provided.

One of the first difficulties we experienced with MC4 was getting logon permission into the system. Even our IT personnel were new to the system. They were still learning how to get personnel logged in and how to unfreeze individual passwords. I guess that happens with most new network-based computer systems.

After approximately three weeks, we became better acquainted with the system. We mainly used MC4 for the standard Subjective, Objective, Assessment and Plan (SOAP) medical report functionality and to request labs. I realize that we could have used MC4 for additional uses – including readiness data and pre- and post-deployment health assessments – but we did not use it to its fullest capability.

If my unit used the system to its full potential, it would have made pre- and post health deployment assessments a little easier. It took us a while to learn how a non-provider could close a SOAP note so it could be later signed by a provider.

In time, we became more comfortable with the technology. It was great to print out neat, readable SF600s – chronological record of medical care – and SOAP reports in the desert. Not only were we able to give the Soldiers, Sailors and Marines a copy of their medical records, the electronic documentation ensured that the records would not get lost in the fast moving environment of Kuwait. This is important since units are continuously moving through the region.

Another aspect of the MC4 system that we were impressed with was the anatomic body within CHCS II-T (AHLTA-T). It was good to be able to click on areas of the body to designate wounds.

I think the MC4 handheld would be a tremendous resource for Marine corpsmen and invaluable to have during drills and maneuvers. I'm a believer in training like you want to perform. Having the systems during training exercises would only increase familiarity with the system and makes its use second-nature.

Many times a Marine corpsman will be out in the field with their unit and is the only person to document and apply medical treatments. Being able to legibly and accurately document any ailment – from minor rashes to major wounds – would be great. Additionally, the handheld would reduce the amount of gear to be carried into the field and improve documentation.

Then when the corpsmen return to the medical facility, the handheld is synched with laptop and the data is entered into CHCS II-T (AHLTA-T) and any additional documentation can be added to the record. At that time, if hardcopy documentation needs to be kept, the records are printed out and placed in individual folders.

My only concern would be that the data entered into
CHCS II-T (AHLTA-T) by the corpsmen could be merged into or accessed by the Medical Readiness Reporting System (MRRS), the Internet-based system currently used by the Marines.

Continuity of Care via First Generation of MC4 CPT Jason R. Weir, HHD Commander / USAMITC Chief, Network Support Branch / USAMITC

When I was deployed to Mosul, Iraq, from 2003-2004 as a Medical Platoon Leader in the “1st Stryker Brigade” 3rd Brigade, 2nd Infantry Division, we were fielded the MC4 system and began using it during its infancy stage.

The Soldiers at the aid station and Company level used MC4 handhelds to document sick call and saved the encounters to Soldiers’ individual Personal Information Carriers (PICs).

The PIC didn’t always work well because of space limitations and terminals often corroded. Also, because we didn’t have solid communications connectivity dedicated for Medical Ops, when we docked our handhelds to our MC4 laptops the information flow stopped there. It wasn’t until we returned home 12 months later that the data was pulled off of the MC4 laptops and added into the Central Data Repository (CDR).

As a fail safe, we kept paper records. While deployed, we had Soldiers attached to our Infantry Battalion from the Brigade Support Battalion. As redeployment grew closer, the Support Medical Company asked that any records we had for the attached Soldiers be handed back over to the Support Medical Company for redeployment. Of course we complied with the request and handed the records over to the Support Medical Company in typical controlled fashion. However, once everything was unpacked back at home the records were nowhere to be found.

One of the Soldiers we had treated for back injuries in Iraq had no documentation to share with his doctor to continue treatment because his records were lost. Fortunately, by working with the Fort Lewis MC4 Site Lead (Mr. M.D. Mandeville) and everyone’s favorite MC4 Systems Administrator (Mr. Cody Smith) we were able to retrieve his encounters that had been saved to the Soldiers PIC.

While we had a gallon size bag of these PICs that didn’t work, in this instance the PIC did work and proved essential. It’s not a proof of longevity for the PIC device, but it helped the Soldier get access to medical benefits at the VA upon his ETS.

Another problem that I encountered was keeping my veteran medics and new medics interested in using the MC4 system during training. I attributed this to the lack of interoperability of the system when in a garrison environment.

After we returned home, I had such a hard time getting my Soldiers to willingly training with our MC4 systems because we could not use the MC4 laptops LAN in our Battalion Aid Station (BAS), which was provided by Madigan Army Medical Center. But my Platoon Sergeant (SFC Douglas D. Wallace) and I pushed hard tbuy into theo get it approved for use on the network.

Once connectivity was approved and the drops were installed, my Soldiers almost instantly took ownership of the systems and felt more comfortable with the laptops and were much more willing to train with the handheld devices as well. No longer did they see it as just a “dumb box” to dump info from the field into. No, it was also useful to them in garrison as well.

In my opinion, if you want MC4 to really take off, the system should be approved for use in Garrison BAS’s and configured so there’s a seamless transition from field to garrison and back. That way, if you go to a three-week field exercise you’re using the same hardware system being used in theater. It’s only logical that we “train as we fight” and practice using the same system we’re equipped with when we’re deployed. There also needs to be a standalone means of establishing connectivity for medical ops and info that is part of the Medical Platoon’s Modified Task Organization and Equipment (MTO&E).

Traumatic Brain Injuries Diagnosed with MC4 - CPT Sheldon Watson, Army Medical Specialist Corps

One of my focuses is on traumatic brain injury (TBI). TBI is often missed in the acute phase, but the condition can well be debilitating. Basically the brain is compressed by the shock-wave of a blast; something goes "boom", a blast overpressure wave develops and is immediately followed by underpressure prior to equilibration at normal atmospheric pressure.

Internal organs are not protected from the effects, so when brain tissue is in the way, this event causes rupture of cells, bleeding in brain tissue and brain damage. This is not always diagnosed in the acute setting, especially if there are other obvious injuries. And if a soldier is medevac'd for other injuries, his chances of not being diagnosed increase. Strangers don't know what is normal for the patients' personality and behavior.

With MC4, serial neurological exams and patient notes are readily available throughout the evacuation chain, and more importantly providers can get in touch with one another if they have questions.

It's a great system.

View My Milblogging.com Profile

Events of September 11, 2006 in Afghanistan - Daniel Fitzwilliam, MC4

On September 11, 2006, I was providing supporting for the MC4 system at Forward Operating Base (FOB) Salerno, Afghanistan. That morning the FOB was busy and a flag ceremony was held in front of the hospital in memory for those who lost their lives during the terrorist attacks in the U.S. on September 11, 2001.

During the ceremony, we received word that there had been a suicide bombing at the funeral of the governor of Khost province in eastern Afghanistan who had been assassinated the day before. According to press reports, the blast during the funeral occurred near a tent where more than 1,000 people had congregated.

The local hospital was beset with casualties and realized it did not have the ability to treat all of the injured. Many were turned away and told to seek treatment at FOB Salerno. Shortly after learning of the attack, preparations began to receive mass casualties at the front gate. I helped the medical staff prepare a triage area at the front gate by moving stretchers and medical supplies. It seemed like there wasn't much time between the time we learned of the suicide bombing and the casualties began arriving.

The medical staff worked at a furious pace to check and document injuries, distinguish the severity of injuries and begin treatment. There seemed to be more people injured than what was manageable. As the injured arrived outside the gates of Salerno continued to grow, it was obvious that more people would be needed to help treat the wounded. An announcement was made over the loudspeaker requesting volunteers, so Soldiers and contractors from various disciplines turned out to support the effort.

Casualties continued to come to the gates of Salerno throughout the day and into the night. As evening approached, KBR employees set up generators and floodlights so the rescue work could continue working.

Most of the caregivers had been working non-stop and not eaten or taken a break since breakfast. I called the dining facility and asked if there was anyway they could prepare food, drinks and snacks for two-hundred people and bring everything to the hospital entrance. The normal treatment area for sick and wounded Soldiers now became an area for treating the weary caregivers and volunteers' hunger.

A cafeteria-style serving area was set up and a line formed outside the entrance to the hospital and into the street until everyone was fed. Food was brought to the surgical and emergency medical teams as they were unable to leave their posts.

The surgeries continued throughout the night and into the morning. On September 12th, the most critically wounded patients were evacuated for further treatment.

The day of remembrance for the victims of September 11, 2001, and the reason for our being in Afghanistan had turned full circle. We now had first-hand experience of the victims, emergency responders and caregivers of a suicide attack on a democracy, albeit one in its infancy, and only a microcosm of the events that unfolded in 2001.

Early Days of MC4 Remembered - Cody Smith, MC4

MC4 launched a new blog giving users of the MC4 system the opportunity post your stories and experiences while deployed. Below is a story submitted by an MC4 systems administrator. Cody Smith, the first MC4 SA deployed to Iraq, relays a trip via Stryker convoy to Tal Afar, Iraq.

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I forget the exact date but it was in late 2003 or early 2004 when I was the first and only MC4 Systems Administrator (SA) in Iraq. At that time there were no established rules of engagement on how to support the units...I was basically figuring things out as I went along.

The unit I was supporting at the time was covering a division-sized area with about one-fourth of the needed troops, so they were spread out pretty far. The air taxi service (UH-60 Blackhawks) had not really been established for travel within Northern Iraq, especially in places near the Syrian border. So I had to convoy from place to place.

One of the units I supported, 1-14th Cavalry Squadron, 3rd Stryker Brigade Combat Team, 2nd Infantry Division, had a small element of personnel who were manning a location in the middle of Tal Afar city. This particular unit had been requesting to have me setup their MC4 systems and train their providers and medics. So I coordinated my movement through Squadron Headquarters and was told that I would be riding in the back of a Stryker the following day.

I wasn't really nervous about the trip since, just two weeks before, I convoyed from Balad to Tal Afar in a vehicle with no armor. So the following day I showed up at the manifest area, received my convoy brief and got in the back of the Stryker with all my gear. I had no idea where exactly I was going, I just knew it was in the city.

During the ride to this particular location, I became very disoriented with all of the twists and turns and driving on curbs and through the median. I was not able to see anything outside of the vehicle as the Long Range Advanced Scout Surveillance System (LRAS3) monitor was not turned on. It was a relatively short ride to the location, about 20 minutes or so.

When we finally arrived and the Stryker vehicle came to a stop, the platoon leader (PL) ordered his troops to drop the back hatch and to establish a security perimeter around the three Strykers in the convoy. The back hatch dropped and all of the Soldiers ran out of the Stryker to setup their positions. The hatch went back up to protect the remaining personnel in the Stryker.

After sitting for a few minutes, the platoon leader looked down through his hatch and asked if I was ready to make a run for the front entrance of the compound. I responded with a nod and grabbed my computer case and my assault pack.

Seconds later the back hatch dropped once again and the PL yelled, "Go!," and so I did! Keep in mind I had no idea where I was or where I was supposed to be running to. I just knew that I was outside of the compound on some street in the city and I had to get inside the compound as soon as possible.

So after the hatch dropped I ran out of the Stryker and started heading the exact opposite direction of the compound and into the city! I was clued in on this fact by a few Soldiers who were pointing and yelling, "Not that way, the other way!"

When I finally made it into the front entrance of the compound, I felt very relieved.

Looking back, it was a great time.

One of the soldiers who rode in one of the Stryker vehicles that day has since left the military and works down the street from where I live. I took a picture of him sitting on the back hatch of one of the Strykers eating lunch. Later, I was able to send him a copy of that picture and reminisce about everything that happened during that deployment.

Differences in Recording Medical Data - Jorge Guzman, MC4

MC4 Systems Administrator Jorge Guzman describes his experiences collecting medical data with the old paper-based system as an Army medic and and how different the process has become with MC4.

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During my 20 years in the Army as a medic, I always complained that there should be a better way to capture patient documentation in combat and field environments. We always used SF600s – Chronological Record of Medical Care – or the DD Form 1380 – field medical card. Both forms very rarely made it to the patient records – including my own records from Operation Desert Storm.

Then along comes MC4 with its CHCS II-T and BMIST-J. "No!! Change!! I don't like change!! Nobody likes change!!"

There is an old saying, “If it ain’t broke, don’t fix it.” Well, the old system really was broken and needed to be fixed.

I’ve been training units around the world on the MC4 applications since 2003. First it was just theory. Then I had the opportunity to see it in action. First in Kuwait, then Iraq. In its infancy CHCS II-T wasn’t welcomed. It was a change.

By 2005, CHCS II-T was being used by most of the medical units in Iraq and all of the units in Kuwait.

In 2005, I became ill in Kuwait. I woke up dizzy one day. I couldn’t even stand up. Lucky for me, the Arifjan clinic was close by. I was seen by a provider from the Navy and my care was documented on an MC4 system using CHCS II-T.

The check-in process was very smooth. The clerk asked for my CAC and an MC4-provided scanner was used. He quickly entered my demographic information, name, SSN, gender, DOB, as well as all of the information needed to create an electronic medical record.

I was told to have a seat and would be seen in a short time. Before I could sit, the medic called me for a screening. In the screening room, the medic pulled up my encounter in the MC4 computer and entered my vital signs, added any allergies and other medical information the physicians may need to know.

I asked the medic how he felt using the CHCS II-T compared to paper. He told me it made his job go faster. He no longer had to wait for a paper record. As soon as the clerk initiated the record, the medic could see the visit and immediately start the documentation.

Once the medic completed the initial screening, he took me to a chair outside of the provider’s exam room where I waited to be seen by the provider. The facility was very busy that day. I waited about 10 minutes until a Navy physician's assistant called me into the room.

My provider documented all her findings and tests in CHCS II-T and wrote me a referral for an eye exam at Camp Doha, Kuwait. When I had my eye exam, the provider at that location also documented my care on CHCS II-T.

Upon my return to the Arifjan clinic, I was seen by another provider, a neuron specialist, and she was able to read the care that the first provider conducted. Although she couldn’t see my encounter from Camp Doha on the local CHCS II-T terminal, she was able to log into TMDS (Theater Medical Data Server) and see my documentation there. The neuron specialist was surprised to see how easy the site was to navigate and to find my encounter.

I was examined a few more times in Kuwait during follow-up visits and received excellent care each time. My last provider in Kuwait gave me all my encounters in paper format so that I could receive follow-up treatments when I returned to San Antonio.

When I returned home from Kuwait, I made an appointment with my primary provider at Brooke Army Medical Center (BAMC), Texas. Like a good patient, I followed my instructions and took all my paper encounter documentation with me in case the provider had any questions. BAMC uses AHLTA which is very similar to CHCS II-T. I checked in for my appointment and went through the screening process. It was identical to the screening process performed for CHCS II-T in theater.

After a short wait, I went in to see my provider with my encounter documentation from Kuwait in hand. As I was talking to the provider, I told her that my care was documented in CHCS II-T while I was in Kuwait. I informed her that if she had access to TMDS, she could see my encounters or I could give her my paper SF600s. She checked the documents tab in AHLTA and, low and behold, my encounters from Kuwait were in the system. My test results were even entered into the notes.

My provider was very impressed with the capabilities of the MC4 system. She now had all of my documentation and was able to continue the treatment that was started in Kuwait. She commented that with this system, providers are able to provide a better continuity of care then in previous years.

I was confident in the capabilities of the MC4 systems before this experience, but this solidified my belief. I was able to be assessed, diagnosed and treated for my sickness in theater and my medical care was continued without having to start the process all over again. This is a huge leap in the quality of patient documentation and tracking from my experience in 1990 during Desert Storm.

I’m sold.