2010-2011 Burma AAR

After Action Report

Thai-Burma Border, 2010 & 2011 Project KAREN SHAN

TABLE OF CONTENTS

2. Executive Summary

4. Operation Overview

5. Operation Summary

6. Areas of Analysis

12. Volunteers

14. Logistics

15. Communications

17. Transportation

19. Medical

23. Media

23. Security

24. Key Lessons

25. Key Actions

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TEAM RUBICON, After Action Report

EXECUTIVE SUMMARY Burma 2010: From August 1-13, 2010, Team Rubicon (TR) conducted a medical training mission to train Karen medics along the Thai-Burma border. The military controlled Burma Junta has been in a civil war with multiple ethnic groups within its borders for the past 50 years. Persons in the ethnic controlled regions receive little to no medical aid from the government. Since entering Burma after a natural disaster is not probable, TR decided to proactively train personnel who would serve Karen displaced persons during times of medical need. Over the course of 13 days, five TR personnel trained 37 Karen medics in austere medicine. TR volunteers included Team Leader and Physician’s Asst. Bob Thoman, Firefighter/Paramedic Zach Smith, Firefighter/EMT Jeff Lang, Former Marine and Media Specialist Kevin Whitcomb, and Chief Medical Officer Dr. Glenn Geelhoed. Team Rubicon operated through 4th Wall Relief International who coordinated the training evolution with the Karen Department of Health and Welfare (KDHW). Approximately 60% of the trainees were

female and 40% male. Ultimately TR deployed the wrong team to the Thai-Burma border. The team lacked enough qualified medical personnel to train the Karen medics. Once training began, TR found that the medics were more advanced than previously thought and the course curriculum that TR prepared to be grossly inadequate for the students. Fortunately, Dr. Glenn Geelhoed was there to quickly put together a new course curriculum. Burma 2011: In August of 2011, TR deployed five volunteers to the Thai-Burma border for the purpose of training indigenous medics and community healthcare workers (CHWs) belonging to the Karen and Shan hill tribes. The team leader on this mission was Zach Smith, a paramedic and seasoned TR member with deployments to Haiti, Chile, Burma and South Sudan. The formidable Dr. Glenn Geelhoed grounded the team with excellent medical direction and his unsurpassed passion for helping others in need. The political situation for the Karen and Shan hill tribes is dire. Many of the people in these ethnic groups are driven from their home villages by the junta government of Myanmar, ending up along the Thai border either as Internally Displaced Persons (IDPs) or outright refugees. Within these IDP or refugee camps, they survive primarily through subsistence farming, providing cheap labor to the Thais, and foreign aid. TR’s medic students had previously received piecemeal medical education from various

TR Burma 2010 Team

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organizations and had limited physician-level oversight in their workplace. Malaria continues to be their primary health concern, followed by acute respiratory infections, intestinal worm infestation, and many other ailments common to the rural jungle environment. In addition, injuries caused by Myanmar-deployed landmines pose a serious problem to all enemies of the junta. The team flew from Los Angeles to Chiang Mai, Thailand and then drove to the border to link up with Karen and Shan contacts. Upon arrival at the border camps, TR conducted rounds of the local clinics before beginning training the next morning. TR’s training topics included basic primary care with an emphasis on tropical medicine, field trauma care in a remote setting in the face of delayed evacuation, minor surgical skills, and building construction techniques. The total number of students trained was 22 Karen and

52 Shan, all of whom received handsome certificates of training printed on George Washington University letterhead (courtesy of Dr. Geelhoed). In addition to the training that we provided, TR furnished the students with much-needed donations of improvised tourniquets, hemostatic agents, pressure dressings, and antibiotics. During the 2011 mission, TR retrained many of the same Karen medics from the 2010 mission. The mission was sponsored by Triple Aught Design, a San Francisco clothing company specializing in tactical outdoor/field apparel. Jake Wood William McNulty Bob Thomann President, TR Vice President, TR 2010 Team Leader Jason Jarvis 2011 Team Member 2012 Team Leader

TR Burma 2011 Team

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OPERATION OVERVIEW Burma 2010: Mission Objectives: To provide training for personnel that would treat internally displaced people (IDP’s) in Burma in a sustainable way.

OPERATION NAME: Project Karen DURATION: 10 days DATES: 1-10 August 2010 LOCATION: Thai-Burma border OPERATION DIRECTIVE: Train Burmese hill tribe medics ELEMENTS: Team Rubicon main body TOTAL VOLUNTEERS: Five (Thomann, Smith, Geelhoed, Lang, Whitcomb) MILITARY VETERANS: Three (Thomann, Geelhoed, Whitcomb)

BURMA 2010 TOTAL CASH RAISED: $7,575.00 LESS: CREDIT CARD FEES: ($227.25) NET: $7,347.75 EXPENSES: TRANSPORTATION: ($10925.40) EQUIPMENT: ($250.00) FOOD: ($867.67) LODGING: ($459.46) AUTHORIZED CASH DISBURSEMENTS: ($843.33) BURMA 2010 TOTAL EXPENSES: ($13,345.86) BURMA 2010 NET OPERATION GAIN/ (LOSS) ($5,998.11)

Burma 2011: Mission Objectives:

Team Rubicon will gather supplies, both donated and purchased, and hand carry them to

the Thai-Burma border for donation to Burmese hill tribe medics from the Karen and Shan

states. Supplies include antibiotics, improvised tourniquets, pressure dressings, and

hemorrhage control agents.

Team Rubicon will deploy five Americans to train Karen hill tribe medics in field medicine,

tropical medicine, minor surgical skills, and building techniques using indigenous materials.

The training course will run for four days, allowing for the use of a translator.

After a one-day rest and refit, Team Rubicon deploys five Americans to train Shan hill tribe

medics in field medicine, tropical medicine, minor surgical skills, and building techniques

using indigenous materials. The training course will run for four days, allowing for the use of

a translator.

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OPERATION NAME: Project Karen Shan DURATION: 16 days DATES: 15-30 August 2011 LOCATION: Thai-Burma border OPERATION DIRECTIVE: Train Burmese hill tribe medics ELEMENTS: Team Rubicon main body TOTAL VOLUNTEERS: Five (Smith, Geelhoed, Jarvis, Stevens, Fiorito) MILITARY VETERANS: Three (Geelhoed, Jarvis, Stevens)

BURMA 2011 TOTAL CASH RAISED: $1,486.00 LESS: CREDIT CARD FEES: ($44.58) NET: $1,441.42 EXPENSES: TRANSPORTATION: ($7,779.40) EQUIPMENT: ($3,889.52) FOOD: ($56.85) LODGING: ($81.50) AUTHORIZED CASH DISBURSEMENTS: ($2,040.00) BURMA 2011 TOTAL EXPENSES: ($13,847.27) BURMA 2011 NET OPERATION GAIN/ (LOSS) ($12,405.85)

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OPERATION SUMMARY

*NOTE: There is no Operation Summary for the 2010 Mission to Burma.

Burma 2011:

PRE-DEPLOYMENT Zach Smith, the team lead, was in voice and email contact with indigenous points of contact long before the mission kicked off in order to arrange ground transportation, lodging, meals, classroom venues, and to ensure that plenty of students showed up for training. As Smith hand-picked his team members, medical supplies were purchased or donated, and satellite communications equipment were procured and tested. Smith conducted multiple conference calls with the team to ensure that passports were in order, air travel arranged, personal gear readied, vaccinations were current, and that the overall scheme of maneuver of the mission was known to everyone.

DEPLOYMENT Smith personally picked up incoming team personnel at LAX on August 15. The first stop was the Team Rubicon west coast storage unit, where we picked up medical bags and equipment, and team gear such as water purification apparatuses and rehydration salts. The team overnighted at Zach’s parents’ house just outside Los Angeles. The team spent the next day reviewing the medical teaching topics they would be covering during the mission, familiarizing the team with the Inmarsat BGAN and Iridium satellite communication devices, and reviewing the mission plan step by step. The next day, the team flew via commercial air to Thailand by way of the Philippines. During a layover in the Philippines the team paid its respects to fallen World War II veterans at the Manila American Cemetery and Memorial. While laid over in the Bangkok Airport, the team met briefly with Team Rubicon cofounder William McNulty before boarding yet another plane destined for the fair city of Chiang Mai in mountainous northwest Thailand. In Chiang Mai, the team changed mode of travel from air to ground

when they were picked up by an American working fulltime with the hill tribe IDPs and refugees. After a long drive in the back of a small pickup truck, the team stopped in Mae Sariang near the Burmese border to rest overnight at a cheap guesthouse.

TR at Manila American Cemetery

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The next morning, after a hearty breakfast at the local open market, the team ventured into the hills above the city to receive a blessing from Buddhist monks residing in a cavernous monastery. On the way out of town the team purchased a Thai cellular phone for local communication, continuing to the border and the camp in which we would spend the next four days training Karen medics and community health workers. Given the difficult terrain and remoteness of the camp, the team was forced to hike in the last several hundred yards via footpath. At the camp TR was joyously greeted by the displaced Karen people, to include all 22 of the team’s medic students; the ones who returned from last year’s training were particularly happy to be reunited with Zach Smith and Dr. Geelhoed, who were both members of the 2010 training team. TR dropped personal and team gear off in the upper floor of a bamboo hut and immediately made for the local clinic. Led by Dr. Geelhoed, TR made rounds of the handful of patients in

the clinic and made the following diagnoses: shigellosis, peptic ulcer, impacted mammary gland, and generalized skeletal pain secondary to load-bearing wear and tear. TR had decided ahead of time to not render treatment to the indigenous people, unless in the case of a crisis situation, as we were strictly conducting a training mission. TR simply did not have the logistics or the time to provide medical care with good follow through; in future missions, direct patient care will be considered on a mission-by- mission basis. Meals in the camp consisted of chicken with either rice or noodles; ablutions were performed inside a small cinder block building housing with a squat toilet and a cistern of cold water equipped with a bucket. A prosthetic limb workshop lay just down the trail from TR’s sleeping quarters and the camp kitchen. The village was not connected to any kind of offsite electrical power grid; instead, generators were run during the day to charge car batteries that would in turn power lights and electrical appliances during

hours of darkness. The team slept beneath mosquito netting, either in hammocks or on inflatable air mattresses. The next morning TR began the program of instruction on the second floor of a large hut. The students filtered in and sat on the bamboo floor as TR prepared teaching materials. Disaster struck when the

TR meets Karen Medics

Dr. Geelhoed assesses Karen patient

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video projector provided by the Shan turned out to have a bad bulb. Fortunately the class was small enough that they got by with displaying our medical presentations on the laptop screen. And so, with the aid of a translator, training began. Topics covered over the next three days included: basic primary care with an emphasis on tropical diseases, field trauma care, basic surgical skills, and building construction techniques. Didactic instruction was interspersed with hands-on drills with tourniquets and pressure dressings, and suturing practice. Dr. Geelhoed introduced the students to the global top five killers: dehydration secondary to diarrhea, acute respiratory illness, malaria, malnutrition, and measles (DAMMM); the four top areas of concern for community health workers: growth charting, oral resuscitation, breastfeeding, and immunizations (GOBI); and the Neglected Tropical Diseases (NTDs): soil-transmitted helminths, Filariasis, Schistosomiasis, and trachoma. Jason Jarvis, a veteran Army medic and operational medicine trainer, taught the principles of Tactical Combat Casualty Care (TCCC) - the US and NATO standard of care for battlefield trauma. TCCC is founded upon the distinction between blunt and penetrating trauma and why the MARCH algorithm approach to patient care fits the gunshot wound and blast injury profile better than ABCs, which is the civilian

standard of care for car accidents (blunt trauma). Andrew Stevens, a former Marine and the Department of Homeland Security head of security vulnerability assessment team for Alaska, brought his knowledge of building construction to bear and offered the students recommendations on constructing houses able to withstand natural disasters. For the next three days, TR’s chief activity in the deployment zone consisted of approximately seven hours per day of medical classes. Aside from meals, laundry and hygiene, TR filled free time with interactions with locals (clinical rounds, speaking with students, a foot tour of the beautiful jungle, and the occasional rattan-ball game), reading, journaling, and occasional satellite phone sessions with loved ones stateside. On Day 4 of TR’s stay the students graduated, proud recipients of Team Rubicon training course Certificates of Completion. By now the team was ready for a hot shower and the luxuries of indoor plumbing and beds. TR departed the camp and our Karen friends, stopping at another camp to address students at a combined primary and secondary school (plus a vigorous pickup game of rattan ball), returning to Mae Sariang by nightfall. After an overnight rest and refit, TR loaded our faithful pickup truck yet again and made the day-long journey into Burma’s Shan State. The drive was long, made even longer by the rainy season which had washed away a lot of the roads and reduced what was left of the road into a muddy quagmire. Just short of TR’s final destination in the Shan State the team encountered a long uphill slope accompanied by the

Marine veteran Andrew Stevens teaches tourniquet placement

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worst mud the team had yet seen. The Shan drivers applied snow chains to the tires and, with the use of shovels and a lot of pushing and cajoling (plus one bee sting), the team spent the next four hours crossing the last ten miles. The first major distinction that impressed the team about the Shan village versus the Karen camp was the fact that it possessed a road. The village sat on a ridgeline at an elevation just above 1000 meters (gratefully outside the range of Anopheles, the carrier of malaria) in the midst of a breathtaking panorama of green low-lying mountains strikingly similar to the Appalachian range. As vigorous proponents of education, the team was pleased to see that the largest building in the village was the combined primary and secondary school. The next

biggest building was the village hospital, a simple yet well-furnished structure in which a 10’ by 10’ room had been cleared out to provide a sleeping quarters for TR. TR settled into humble quarters and prepared for the next three days of training. TR planned to offer the same materials in the same format to the Shan that had been presented to the Karen. A low-ceilinged pavilion adjacent to the hospital was the designated classroom, and the next morning it quickly filled with Shan community health workers and Shan State Army medics, for a total of 52 students. Some of them were as young as 16. TR learned that most of the students had arrived from other regions of the Shan State, some of whom traveled for days to reach the training site. The TR team was relieved to find a video projector that was in good working order and was equally blessed with plenty of skilled translators. The training went smoothly, with Dr. Geelhoed making the introductions and the rest of the team filling in over the next three days according to our areas of expertise. TR’s Shan hosts were as hospitable as the Karen, and the team spent the days in relative comfort. After the conclusion of classes each day TR played rattan ball and went on walking tours of the village. On the last day of training TR visited a nearby shrine commemorating famous Shan generals from ages past. Graduation day for TR’s students

came all too soon. After receiving their TR certificates of completion, every student and

TR works to cross into Shan State

Shan medics graduate from TR course

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team member donned their “Sunday best” for that evening’s spectacular Fire Festival and Sheep Dance performed at the local Buddhist monastery. The next day, TR bade farewell to our excellent Shan hosts and began the drive back to Chiang Mai, Thailand. The return trip through rural Burma and its muddy roads was made much easier by being primarily downhill. TR overnighted in Chiang Mai before flying to Bangkok the following day and engaged in the requisite tourist duties of souvenir shopping and eating fantastic Thai food.

POST-DEPLOYMENT

TR redeployed to the United States through Los Angeles on August 30th. The team stored all team gear in

the LA storage facility, performed a final mission debrief, and departed to their home towns by way of

LAX.

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AREAS OF ANALYSIS

1. Volunteers

2. Logistics

3. Communications

4. Transportation

5. Medical

6. Media

7. Security

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ANALYSIS

VOLUNTEERS

*NOTE: There is no Volunteers section for 2010 Mission to Burma. BURMA 2011:

SUMMARY The volunteers for this mission were chosen primarily for their medical skills and military experience. Medical skills were in high demand due to the nature of the instruction that was performed, while military experience was valuable given the possible risk of reprisal from Myanmar’s central government for educating enemies of the state; the team needed to be “on its toes” at all times as it were. Marc Fiorito, the team’s dedicated photographer, did not fall into either of the medical or military selection criteria, but his past experience in Asia was deemed sufficient to keep him from becoming a security liability.

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Zach Smith, the team lead and California firefighter/paramedic, was a member of Team Rubicon’s 2010 mission to Burma and also had experience with TR in South Sudan, Chile, and Haiti. Navy veteran Dr. Glenn Geelhoed was the only other member of the team who had worked in Burma before this mission. Geelhoed’s lifelong experience of running over 200 humanitarian missions and professorial teaching at George Washington University in the topics of surgery, tropical medicine, and microbiology made him the perfect medical director for this trip. Former Army medic Jason Jarvis, a veteran of Haiti, Iraq, and Afghanistan contributed his Thai language skills and knowledge of Tactical Combat Casualty Care to the mission. Andrew Stevens, a former Marine, Iraqi veteran, EMT-Basic, and the Department of Homeland Security head of security vulnerability assessment team for the state of Alaska, kept our logistics in order, assisted as needed during the medical skills practicum, and ran point for teaching building construction techniques. In addition, Stevens shined as a gifted rapport builder among the indigenous

people. Professional photographer Marc Fiorito’s recent experience in remote China prepared him well for the rigors of living off the beaten path in a foreign country. His array of camera equipment occupied a large backpack, which he used to shoot over 10,000 photos and hours of video.

RECOMMENDATION Given the limited formal medical training that the hill tribe medics have received throughout their careers, there is tremendous potential for the addition of other topics to TR’s teaching curriculum. A short list of these topics might include OB/GYN, pediatrics, dermatology, ophthalmic care, wound care, local and regional anesthesia, etc. If it is decided to offer this increased scope of training then the team roster will need to be filled to support these topics. A five-person team was the ideal sized team for this mission, given that the transport vehicle of choice was the four door pickup truck. Five warm bodies plus a driver and all of the gear filled the cab plus the tail bed of the truck with little wiggle room. Future missions should take this math into account, i.e., 1-5 team members plus gear fit into one truck, 6-10 team members plus gear will require two trucks, etc.

ACTION

The plan for a possible 2012 mission needs to include input from our potential students and their medical supervisors as to what teaching topics they want covered. Once this information is received, Team Rubicon can begin filling the team roster with individuals who best support this.

Army veteran Jason Jarvis trains Shan medics

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LOGISTICS

*NOTE: There is no Logistics section for 2010 Mission to Burma. BURMA 2011:

SUMMARY Logistics for this mission fell into one of four categories:

1. Personal gear (large carry-on bag, TR T-shirt, TAD pants, hiking shoes, sandals, rain jacket, socks,

underwear, foot powder, sleeping bag, sleeping pad, jungle hammock, mosquito net,

headlamps, small knife, multitool, spork, Nalgene water bottle, lightweight coffee mug, water

blivet, journal, pen, pencil, books, laptop,

memory stick, compass, matches, headphones,

cameras, watch, spare batteries, insect repellent,

first aid kit, toilet paper or baby wipes, basic

toiletries, soap, sunblock, hat, sunglasses, dry

snack food)

2. Team gear (multiple duffel bags, satellite

communications <Inmarsat BGAN, Iridium

phone>, Thai cellular phone, cash fund, UV water

purification device, oral rehydration salts, TR

laptop loaded with training Power Points, Power

Point remote slide advancer, memory stick,

personnel beacons, parachute cord, student

certificates of completion, salt and seasoning,

instant coffee)

3. Training gear (suturing materials and surgical

instruments, tourniquets, gauze, pressure

dressings)

4. Donated gear (improvised tourniquets

constructed of nylon webbing, HemCon and

Combat Gauze hemostatic agents, pressure

dressings, antibiotics)

The total loadout was relatively small; all of it fit into two checked bags per team member plus carry-ons. Food and water was paid for in cash to our Karen and Shan hosts. In addition, TR relied upon our hosts for electricity, video projectors, dry erase boards, and dry erase markers.

2011 Burma TL Zach Smith sits with TR supplies

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Overall the logistics ran very well; TR’s preparedness ensured that the team lacked for nothing once on the ground. Future team members need to ensure that they adhere to the Team Rubicon individual packing list.

RECOMMENDATION TR should up the ante on donated gear for future missions. The 2011 donated gear focused primarily on trauma patients; this is not the hill tribes’ primary problem. Donated gear in the future needs to focus more on what will do the most good, i.e., mosquito nets, antibiotics, oral rehydration salts, etc. Looking at some of the medics’ kits, TR realized that the typical hill tribe medic is woefully undergeared for dealing with field trauma. TR could help bridge this gap by donating manufactured tourniquets, elastic pressure dressings, hemostatic agents, nasopharyngeal airways, 14 gauge intravenous needles, chest seals, buddy transfusion bags and tubing, and field blood typing cards.

ACTION

COMMUNICATIONS

SUMMARY Burma 2010: TR utilized four modes of communication during the 2010 trip to the Thai/Burma border. These included:

Internet available on publically available wi-fi sites

Cell phones when networks were available

Satellite phone

BGAN satellite uplink for our PC

TR found that each mode of communication was appropriate during different times in the trip.

RECOMMENDATION Multiple lines of communication: Multiple team members had cell phones on this trip. Because of this, multiple lines of communication between the team and stateside members of Team Rubicon were happening simultaneously during the trip. For example, when the team was in transit to Thailand, the floods started in Pakistan. Several team members were in contact with stateside members of Team Rubicon, and rumors started that our team would be diverted to Pakistan for flood relief. This happened several times during the trip and caused confusion that was unnecessary. One official line of

Find out from prospective students what their equipment needs are and attempt to bring some of these supplies to them.

Solicit donations of the desired logistic items or buy them outright.

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communication should have been set up between the team leader or his designee and one stateside or alternate stateside Team Rubicon member. Communication policy: We were incommunicado with the United States for approximately 2 days while on the Thai/Burma border due to weather conditions, terrain and remoteness of our location. Stateside personnel developed great apprehension during this time due to no contact with the team. TR needs to develop a more comprehensive lost comms plan. Equipment: BGAN Satellite terminal: TR could get by with a less expensive model. The team did not utilize all of the features that were included with the deployed model. The BGAN was also affected by the humidity. After being shut off and charged, the BGAN turned on spontaneously due to humidity near or at 100%. This allowed the BGAN to discharge without the team knowing. In one instance when we climbed 45 minutes up a mountain to get reception for the BGAN, the team discovered that the BGAN battery had discharged and thus could not communicate with the satellite. Satellite phone: The team had issues with cloud cover and terrain such as trees and mountains obstructing signal to satellite. The team found it easier to get signal with Sat phone than the BGAN.

ACTION

BURMA 2011:

SUMMARY The team was well-equipped for satellite communication with both the Iridium phone and the Inmarsat BGAN satellite uplink via laptop. Team Leader Zach Smith sent messages to TR headquarters at regular intervals. For communication with the locals the team relied on a Thai cellular phone purchased in Chiang Mai. Two team members carried beacons that could be activated in the case of an emergency.

RECOMMENDATION

Develop stricter communication policy about official communications with a designated stateside TR contact; team leader or designee communicate on regular intervals with stateside contact. This will reduce rumors, misinformation, and keep safety concerns of team addressed.

Reevaluate which BGAN unit is appropriate for TR use.

Utilize dry bags in humid conditions to keep equipment working properly.

Develop information packeting strategies to reduce transmission costs of pictures and video back to states.

Send back higher volume of pictures and information with less emphasis on high quality of pictures.

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Each time a TR mission is launched all team members need to learn how to operate all of the team’s communications devices. This learning can be strengthened in the field by using a rotating roster of responsibility for transmitting situation reports.

ACTION

TRANSPORTATION Burma 2010:

SUMMARY Team Rubicon secured travel arrangements from the United States to Chiang Mae, Thailand. From Chiang Mai to the training site, 4th Wall International secured transportation. Team members traveled from Illinois, Wisconsin, Florida, Washington, DC and California. The team rallied in Los Angeles before traveling overseas. This allowed us to accomplish multiple goals:

Assemble and repack supplies.

Distribute capital among members so that one member didn’t carry all cash for trip.

Meet with stateside personnel to go over SOP’s for trip.

Brief members and train on communication equipment in a user-friendly environment.

The team originally utilized the help of a travel agent in arranging travel plans. The team found that by going through travel websites they could secure

cheaper airfare than found using the travel agent. TR ultimately used the travel agent to secure the tickets due to the ease of having one source for all the tickets. Airline tickets from Bangkok to Chiang Mae, Thailand were booked by the team due to a significant savings over the travel agent prices.

RECOMMENDATION

Assemble all satellite communications devices well in advance of mission launch and test them.

Cross-train all team members on the different devices before mission launch and keep their skills up during the actual mission.

TR crosses into Burma on a longboat

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Apply for frequent flier programs. By applying for a frequent flier membership with the Thai airline the team was able to double the allowed weight of carry on luggage. One of the team members had priority status on Philippine Airlines that allowed all of the team members to bypass an hour-long line at the Los Angeles airport. The team had planned on carrying back packs to avoid losing any luggage in transit. However, the backpack on the personal gear list is slightly larger than some airlines allow for carry-on bags. The team had no problem on this trip with stowing the bag in the overhead compartments; however, a slightly smaller backpack should be considered for future missions to avoid problems with airline regulations. One problem we did encounter was the solar panel battery pack. We stowed our solar panel/battery pack in our carry-on luggage. This triggered an inspection in every airport because it looked like an IED when seen in the X-ray machine. The battery was also very heavy to carry. An alternative energy storage source should be considered to lighten the load.

ACTION

BURMA 2011:

SUMMARY The transportation details for this mission were fairly simple. TR took commercial fixed-wing aircraft on Philippine Air from Los Angeles to Manila to Bangkok. TR took Bangkok Air from Bangkok to Chiang Mai. From Chiang Mai, TR was picked up by a local driver with a pick-up truck. TR used the pick-up truck to transit from Chiang Mai, to Mae Sariang, to the Thai border, and to the Shan State and back.

RECOMMENDATION Transportation during the entirety of the mission was smooth; no need to change this in the future.

When pricing tickets, use several resources. If a travel agent is used, check prices on the internet travel sites for cheaper tickets.

Have team members join frequent flier clubs for additional perks such as added weight limits of luggage and priority movement through lines etc.

Reassess sizing of team approved carry-on bag and downsize if necessary.

Do not carry battery packs in carry-on luggage due to similarity to bomb design. Assess all equipment that will be carried on board a plane to see if it will trigger luggage searches.

TR arrives in Mae Saraing

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ACTION

MEDICAL Burma 2010:

SUMMARY This was Team Rubicon’s first proactive training mission and TR did not send the right team for the mission. The team lacked enough qualified medical personnel to train the Karen medics. Once training began, TR found that the medics were more advanced than previously thought, and the course curriculum that TR prepared to be grossly inadequate for the students. Fortunately the Chief Medical Officer for the mission, Dr. Glenn Geelhoed, filled the gaps. During the mission, TR conducted training in the classroom setting, in a live tissue lab with an anesthetized pig, and during clinics for local villagers. During clinics, the team observed the treatment of patients - intervening only when necessary. Dr. Geelhoed is very experienced in third world medicine and training. He was TR’s greatest asset during the mission. Among other things, TR volunteers learned on this trip that tropical medicine in a third world country has many aspects not encountered in the United States. For example in the United States right lower quadrant pain may be a sign of appendicitis, which is a surgical emergency. In the population TR was treating and training, due to the diet of the Karen, appendicitis is almost nonexistent. Right lower quadrant pain would typically be a sign

of a parasitic liver abscess which needs to be treated, but is not an immediate surgical emergency.

RECOMMENDATION TR learned that equipment we take for granted in first world countries is not available in most third world countries. Therefore training must be geared to the equipment available in the target population. For example, equipment taken for granted in the United States such as Oxygen sensors and Cardiac monitors are not available. Training on watch signs and symptoms of the patient to clinically evaluate these parameters must be emphasized. Higher levels of care are not readily available to most rural third

Book flights for future missions well in advance to save on costs.

Explore alternatives to Philippine Air and Bangkok Air.

Coordinate with the hill tribe points of contact for ground transportation.

TR teaches CPR to Karen students

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world populations. Unlike the United States, one cannot call an ambulance to have the patient transferred from a clinic to a hospital in 30 minutes for an emergent surgery. In the third world, an emergent surgical condition such as a C-section delivery needs to be performed locally by a trained person. There is usually not time to transport a person 2-3 days through the jungle to a higher level of care facility. If no one with surgical skills is close by, the patient has a high probability of dying. Therefore, training medical personnel to a level where they can perform four or five basic emergent surgeries will save many lives. The language barrier was an issue with training. All of the trainees spoke Karen. A few of the more advanced medics spoke some English, and they translated for their comrades. Medical lectures needed to be slowed down so they could be translated to Karen. Many medical terms used in lectures didn’t have readily available Karen translations. Sometimes lectures were given too quickly and five minutes of lecture was translated with two sentences. Lectures were best understood when using medical terminology then explained in terms that were easily understood by the trainees. Asking frequent questions verified that the given message was actually understood by the trainees. Dr. Geelhoed trained the KDHW medics about the World Health Organization’s (WHO) medical model. This included education on the classification of different types of medical facilities such as community health care clinics up to the requirements for being a hospital. These distinctions on the surface seem very academic. In reality, if a facility could be classified as a hospital, supplies and medicines for the facility could be donated or bought very cheaply from the WHO. Getting these classifications for third world facilities would then provide much needed medical supplies and meds for the facility. It was noted that the medical record for patients was always written in English by the Karen medics and trainees. Therefore it was imperative that correct English terminology was taught to the trainees. Utilizing the senior medics to train the junior medics was a very effective practice. For example, when a lecture on suturing or surgical knot tying was given, the senior medics then trained the junior medics with the trainers observing and giving instruction when needed. This practice also carried over to surgical training when the senior medics taught the junior medics surgical techniques on an anesthetized pig. The senior medics walked the junior medics through the training they had just received themselves. This method of training was very beneficial, and set up a self-sustaining training model.

ACTION

Most TR medical personnel are trained using first world medical resources in a temperate climate. TR members who are treating or training personnel in tropical third world countries need additional training in tropical medicine and third world medical techniques in order to be effective.

Compile a training document that will explain ways to maximize effectiveness of communication when using a translator during training.

Train TR members on the WHO medical model and terminology.

The medics we trained were of differing levels of training. We as trainers need to adapt to their needs.

Develop an outline of lesson plans applicable for third world counties for trainers to be able to reference. Trainers need to be flexible to the needs of the trainee group and adjust as necessary.

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BURMA 2011:

SUMMARY In addition, TR carried enough first aid supplies for any minor illnesses or injury. The plan for anything serious was to move the patient to the hospital in Mae Sariang via pickup truck. As it turned out, throughout the mission TR required nothing more invasive than a band-aid. Medical lessons were taught by way of an interpreter translating English into the local dialect. Instructors took their lesson cues from PowerPoint presentations displayed on a Macintosh laptop (the projector had a bad bulb). The presentations, visible to all in the small room, were copiously interspersed with pictures and charts to add visual impact to the talking points. Dr. Geelhoed favored the dry erase board and spelled out his points chalkboard-style with practiced ease. Occasionally the students had an opportunity to work with our training aids, to include a variety of tourniquets, pressure dressings, and suture materials.

TR trained with four popular tourniquet types: the ratchet strap, the Combat Application Tourniquet (CAT), the Special Operations Forces Tourniquet (SOF-T), and the North Atlantic Treaty Organization (NATO) tourniquet. The ratchet strap tourniquet is used by many US EMT organizations; it is an intuitive design but the ratchet mechanism does not function well in the presence of mud and debris. The CAT

Dr. Geelhoed lectures Karen students on surgical techniques

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tourniquet is widely used by conventional US military forces, law enforcement, and some NATO countries; it is an intuitive design but has a well-documented history of breaking in the hands of operators under duress. The SOF-T is favored by some military special operations forces as a more robust version of the CAT; the SOF-T is intuitive and rarely breaks, though it is more bulky and heavy than the CAT. The NATO tourniquet is carried by some in the US and Scandinavian special operations forces; it is the least intuitive tourniquet ever devised (in this author’s opinion), though it is virtually unbreakable by virtue of using low technology and the fewest possible number of moving parts. As for pressure dressings, TR demonstrated some of the many application techniques available to the medic equipped with an ACE elastic wrap, Cinch-Tite, or Emergency Bandage (formerly known as the Israeli Dressing). Most medical courses that train their students on pressure dressings practice the simple circumferential wrapping technique then stop. Team Rubicon realized that a junctional injury (high on the arm or leg) requires a technique more sophisticated than a simple wrap, as these parts of the body do not lend themselves towards easy

dressing application. To this end, the students practiced the “axillary wrap” for high arm/shoulder/armpit injuries, and the “femoral wrap” for injuries of the upper leg, groin, and buttocks. The amputated stump dressing was also practiced - a particularly valuable technique for medics faced with landmine casualties. TR noted that the student medics do not carry elastic pressure dressings in their loadout; TR strongly encouraged them to acquire ACE wraps (the cheapest of the elastic dressings). If Team Rubicon revisits the Karen we will endeavor to bring gifts of tourniquets and ACE wraps. Suture technique was performed on pig skin. The students learned the simple interrupted technique as well as the running continuous and running interlocking techniques. TR explained the pros and cons of each technique, when a given suture technique would be appropriate, the particulars of thread size and composition, and when the field medic would choose either a primary intent closure versus performing a delayed primary closure. Other field medicine techniques taught but not actually practiced: nasopharyngeal airway placement, IV therapy, administration of pain medication, and austere-resource wound debridement.

RECOMMENDATION Ensure first aid kits brought in the future are sufficient (analgesic medications, foot powder, skin repair, bandaging, oral rehydration salts, and an ample formulary of over the counter medications) and locations, routes, and contact numbers for all nearby medical facilities are known by all team members.

TR conducts surgical training in Shan State

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ACTION

MEDIA

*NOTE: There is no Media section for the 2010 Mission to Burma. BURMA 2011:

SUMMARY News of our mission was posted to the TR website after our return from Burma. This included journal entries, videos, and copious photos. TR decided to wait until the end of the mission to post media due to lessons learned from the 2010 mission. The training sites are encumbered by both geography and weather, making it difficult to establish a satellite link with the inmarsat BGAN.

RECOMMENDATION The after-the-fact media approach worked well and probably increased our safety margin vis-à-vis Myanmar. We recommend following a similar format in the future.

ACTION

SECURITY BURMA 2010 & 2011:

SUMMARY Physical security was provided by either our Karen or Shan hosts. TR was far enough away from the front lines and Myanmar forces that we were not overly concerned about any imminent threat.

RECOMMENDATION

Conduct a pre-deployment inspection of first aid kits.

Research healthcare facilities in the area of operations both before and during future missions.

If we are indeed aiming for as little interference as possible from the Myanmar government on future missions, team members need to keep the mission (particularly dates) out of social media during the time leading up to the mission.

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Research the local and regional security situation before future missions and couple this information with the local geography to formulate an emergency evasion plan.

ACTION

KEY LESSONS LEARNED Burma 2010: Team Rubicon developed lasting relationships with 4th Wall relief group in Thailand and the Karen Department of Health and Welfare (KDHW). This will pave the way for future missions to this region for training of medical personnel that will treat internally displaced persons (IDP’s) in Burma. This mission has also shown areas where improvement is needed for training. These include:

Tropical medicine training for TR personnel.

Training on the World Health Organization (WHO) medical model.

Developing training outlines to be used in future training missions.

Develop guidelines for the use of a translator during training. Burma 2011:

1. The Karen and Shan medics working in the field are sorely underequipped. The two items they don’t have that would make the most substantial difference in their load out would be elastic pressure dressings and tourniquets. TR should endeavor to gift some of these items to the trainees next year.

2. Medical logistics donated in the future need to focus more upon “unglamorous” items along the lines of mosquito nets and oral rehydration salts. These items will likely have a bigger impact on overall mortality and morbidity than any amount of trauma management kit.

3. The medical topics we covered in training were probably just the tip of the iceberg of what can potentially be covered in follow-on missions.

4. The security situation in the Shan State is quite good. TR should feel confident that it can deploy to this region and work in a relatively safe environment. Despite this perceived safety, TR should always have an emergency evasion plan in place anytime it deploys outside of the United States.

Research the local and regional security situation before future missions.

Devise an emergency evasion plan that incorporates the local security situation, friendly points of contact, geography, and emergency beacons.

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KEY ACTIONS Burma 2010 & 2011:

1. Raise awareness of the plight of the hill tribes living along the Thai-Burma border and fundraise in order to support future missions to this region.

2. Learn from prospective students and their medical directors what teaching topics they wish to have covered during future training missions.

3. Build a team of volunteers tailored to the training topics to be taught in the next mission. 4. Solicit donations of medical equipment (or purchase outright) needed by the hill tribe medics

and CHWs.

Documents

2010-2011 Burma AAR