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Journal of HospitalLibrarianshipPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/whos20

Providing Library Servicesto Deployed Army MedicalProviders in Iraq andAfghanistanJill Anne Lynch aa Lane Medical Library , Evans Army CommunityHospital , Fort Carson, CO, USAPublished online: 07 Sep 2008.

To cite this article: Jill Anne Lynch (2008) Providing Library Services to DeployedArmy Medical Providers in Iraq and Afghanistan, Journal of Hospital Librarianship, 8:2,218-229, DOI: 10.1080/15323260801928555

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Journal of Hospital Librarianship, Vol. 8(2) 2008Available online at http://jhspl.haworthpress.com

© 2008 by The Haworth Press. All rights reserved.218 doi:10.1080/15323260801928555

WHOS1532-32691532-3277Journal of Hospital Librarianship, Vol. 8, No. 2, March 2008: pp. 1–17Journal of Hospital Librarianship

TECHNOLOGY

Providing Library Services to Deployed Army Medical Providers in

Iraq and AfghanistanJill Anne LynchJOURNAL OF HOSPITAL LIBRARIANSHIP Jill Anne Lynch

INTRODUCTION

We are an Army at war. Military units deploy to combat zones withvehicles, machinery, and weapons. Military hospitals also deploy withequipment. X-ray machines, oxygen tanks, and medical supplies are thepart of equipment used by soldiers providing medical care to other sol-diers. Library materials are part of the equipment to be available to thesehealthcare providers. Sending an entire print collection of journals andmonographs is not feasible; therefore home libraries in the United Statesand at other noncombat locations are tasked with fulfilling the informa-tion needs of these soldiers remotely. These needs are met through a

Jill Anne Lynch is Medical Librarian, Lane Medical Library, EvansArmy Community Hospital, Fort Carson, CO 80913 (E-mail: jill.lynch@amedd.army.mil).

Comments and suggestions should be sent to the Column Editors: SorayaAssar (E-mail: n4matishun@yahoo.com); Nicole Mitchell (E-mail: nmitchell79@gmail.com); Barbara Platts (E-mail: bplatts@mhc.net); and Steven Van Houten(E-mail: svanhou@lumc.edu).

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Jill Anne Lynch 219

variety of means such as electronic databases, e-mail services, and CD-ROMs. This article details the library services provided to deployedArmy Medical Department (AMEDD) personnel by evaluating the resultsof two surveys, and discussing difficulties involved in the transfer ofinformation to remote locations.

BACKGROUND

Military medicine faces unique challenges. In addition to providing state-of-the-art, sophisticated healthcare, they must provide care to soldiers, civil-ians, and enemy combatants in “virtually any location on the planet and in themost chaotic, difficult, and hostile circumstances imaginable” (1). Combatmedical care is performed in a continuum of echelons or levels. There are5 levels of combat care, from first aid care performed on the battlefield tocomplex rehabilitative care at hospitals in the United States. Level 1, the firstlevel of care, is performed by the combat medic assigned to an infantry unitand at a Battalion Aid Station (BAS). The combat medic’s range of dutiesincludes first aid, bleeding control, splinting fractures, wound dressing, andadministration of pain medicine (1). The BAS is an aid station that providesadvanced trauma life support, where patients are stabilized for transport to ahigher level of care. The next level of care, Level 2, or Forward SurgicalTeam (FST), is located in the maneuver phase of the combat operation.Staffed by a 20-person team including 4 surgeons and 2 anesthetists (2),FST’s primary function is to provide stabilizing surgical procedures topatients who cannot survive transport to a Level 3 facility. Examples of inju-ries seen at an FST include burns, broken bones, shrapnel, and crush and blastwounds (2). FSTs are 100% mobile and follow closely behind the battle (1).

The Combat Support Hospital or CSH (pronounced CASH) is the thirdlevel of care. A CSH is constructed of “composite endoskeleton modulartentage with climate control, lighting, and water and power systems” (1).This is a self-contained and self-sufficient hospital with radiology, labora-tory, and pharmacy operations. A CSH can be of various sizes including a44-bed, 84-bed, and 164-bed or 248-bed layout. The largest CSH configu-ration, the 248-bed layout, serves as the next level of care in the contin-uum. These Level 4 hospitals are located far outside combat operations,usually in the communication zone and have a number of advanced medi-cal care departments including a head and neck team; renal dialysis andinfectious disease units: and pediatric, family practice, preventive medi-cine, OB/GYN, and pathology departments. Landstuhl Regional Medical

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220 JOURNAL OF HOSPITAL LIBRARIANSHIP

Center in Germany serves as a Level 4 hospital. The final destination inthe continuum of care for soldiers unable to return to duty is a Level 5hospital located at Army Medical Centers such as Walter Reed ArmyMedical Center in Washington, DC (1).

LIBRARY SERVICES WHILE DEPLOYED

For the combat medic, the use of library resources can be limiteddepending on the level of care offered at the duty station. A medic assignedto an infantry unit must be as mobile as an infantry solider and therefore canonly take what can be carried on the back. Typically this consists of an aidbag containing tape, bandages, dressings, catheter and needle units, oint-ment, splints, and scissors (3). A combat medic may be assigned to a BASwith variable computer and Internet availability dependent on the unit andthe location. At one such BAS, one combat medic stated that only one com-puter with intermittent Internet access was available for staff use. However,there were several medical reference print books brought over by the physi-cian and physician assistant assigned at this unit.

As the level of care increases, so does the availability of medical equip-ment and library services. At a Level 3 CSH, which is generally morestatic than a Level 1 BAS, more computers and networks will providemore consistent Internet access. Medical education programs includingCME, CE lecture series, and advanced cardiac life support courses areroutinely offered at this level (4).

METHODS

In order to measure library services offered and used, 2 different sur-veys were created and disseminated (see Appendix A and Appendix B)The first survey was designed for the deployed library user and consistedof 12 questions. The participants of this survey included any Army medi-cal personnel who had previously been or currently were deployed to Iraqor Afghanistan. The surveys were e-mailed to Evans Army CommunityHospital personnel and were available as hard copies in the Lane MedicalLibrary located at Evans Army Community Hospital. Subsequently, thesurvey was converted to electronic form, and the hard copy surveys previ-ous completed were manually input into this version. A total of 45 sur-veys were completed.

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Jill Anne Lynch 221

The second survey was designed to be completed by Army medicallibrarians and included 6 questions asking about the type and availabilityof library services provided to deployed personnel, type of predeploymenttraining or handouts, difficulty of providing service, and type and fre-quency of correspondence received from deployed personnel. Seventeensurveys were returned from Army medical libraries located in the UnitedStates and Europe.

RESULTS

Deployed Library Patron Survey Results

The majority of respondents to this survey were nurses 20 (47%). Physi-cians accounted for 13 (29%), and other job titles reporting were allied healthprofessionals, combat medics, and a laboratory technician. Half of respon-dents reported using their home base medical library for assistance including6 (27%) for help in expert searches and 11 (50%) requesting materials suchas a book or journal article. Direct patient care 17 (57%) was the top reasonfor using library services while deployed. Other reasons for using library ser-vices included training 16 (53%), CE or CME credits 10 (37%), research7 (23%), and information for the patient 5 (20%).

The Army Medical Command provides resources for deployed person-nel such as the Army Knowledge Online, Deployment Medical ResourceCD-ROM, Army Medicine’s AMEDD Virtual Library, Army Medicine’sAMEDD Deployment Readiness Portal, and electronic textbooks of Mili-tary Medicine. Survey respondents were asked if any of these serviceswere utilized. The Army Knowledge Online (AKO) My Library Web siteprovides access to a variety of commercial databases accessed through auser ID and password, and was used by 14 (42%) respondents. The sec-ond most popular electronic resource was the Deployment Readiness Por-tal 11 (33%), which includes resources and information organized bylevel of care and medical functional areas. Another valuable resourceused was the Army Medicine’s AMEDD Virtual Library 9 (27%), whichis the portal for databases, e-journals, e-textbooks, and subject guides. TheDeployment Medicine Resource CD also garnered selection by 9 (27%)respondents. The last frequently used item was the Borden Institute’se-textbooks of military medicine, accessed by 6 (18%) respondents.

The most frequently used commercial databases reported wereMicromedex® 13 (42%), MD Consult® 10 (32%), PubMed® 8 (26%),

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UpToDate® 7 (23%), and OVID® 6 (20%). Access to computers was eitherby a shared computer 30 (73%), private computer 11 (27%), or a personallyowned computer 8 (20%). Sixteen respondents (40%) reported that a com-puter was usually available and wait time was not excessive. Nineteen (47%)respondents reported having to wait periodically for a computer, and 5(13%) found computer access difficult with frequent waits common. Printbooks were available to 24 (58%) respondents.

Learning about the existence of library services was another questionposed on the survey. Learning about the services on their own was reportedby 14 (36%) respondents, while 10 (26%) learned about them from a fellowsoldier, 7 (18%) from a supervisor, 4 (10%) from library personnel, and 3(10%) learned about library services through this survey. See Table 1.

The final question on the survey was a comment block asking respondentsto provide any feedback on problems or difficulties involved with usinglibrary services. There were 16 comments with the overwhelming complaintof slow, unreliable Internet services. Some notable responses were as follows:

“Not widely advertised, most resources are unknown to staff thatneed it. Computers have slow Internet, so web based resources arenot very practical.”

“I think we need to link with our TOE units early in the deploymentprocess so that the library assets are known in advance of deployment.”

“Most of our library at the hospital was from the Saddam era, andexcept for books mailed in from doctor’s wives, was pretty old.”

“We deployed with our own medical resources, books, etc. We didnot always have access to a computer or time to spend on computerwhen dealing with a trauma.”

“Unless the articles were available in full text through OVID orMEDLINE, I was unable to obtain them in a timely fashion.”

Despite the enormous amount of negative comments there were twopositive comments:

“They are very useful. I thought that it was easy to get the infoI need via the Internet.”

“I found MD Consult and STAT!Ref very useful when deployed.Thanks for all you do.”

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TABLE 1. Deployed Library Patrons Survey Tally

Position titlePhysician 28.9% (13)Nurse Practitioner 2.2% (1)Physician Assistant 0.0% (0)RN/LPN 46.7% (21)Allied Health 4.4% (2)Medic 8.9% (4)Other (please specify) 8.9% (4)Did you use any of the following services from your home library?Emailed library for search assistance 27.3% (6)Requested materials (books or journal articles) 50.0% (11)Other (please specify) 40.9% (9)Did you use library services while deployed for

any of the following reasons? (Select all that apply)Direct patient care 56.7% (17)Training 53.3% (16)CE or CME 36.7% (11)Research (other than patient care) 23.3% (7)Information for the patient 20.0% (6)Other (please specify) 16.7% (5)Did you use any of the following resources?(Select all that apply)AMEDD Virtual Library 27.3% (9)Lane Medical Library webpage 6.1% (2)AKO My Library Databases 42.4% (14)AMEDD Deployment Readiness Portal 33.3% (11)e-Textbooks of Military Medicine 18.2% (6)Deployment Medicine Resource CD 27.3% (9)DeployMed Resource Link 12.1% (4)Deployment Health Clinical Center 3.0% (1)Other (please specify) 21.2% (7)What databases did you access while deployed? (Select all that apply)OVID 19.4% (6)MD Consult 32.3% (10)Nursing Consult 12.9% (4)PubMed 25.8% (8)EbscoHost 0.0% (0)Micromedex 41.9% (13)UpToDate 22.6% (7)Stat!Ref 12.9% (4)Other (please specify) 22.6% (7)How did you access electronic services?Shared computer 73.2% (30)Private computer (computer used mainly by you) 26.8% (11)Personal computer 19.5% (8)PDA/Smart Phone/other handheld 0.0% (0)

(Continued)

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Medical Library Personnel Survey Results

Army medical libraries located throughout the United States andEurope completed the 6-question survey. All but one library reported pro-viding library services to deployed Army medical personnel 16 (94%).The services provided were access to electronic databases 15 (94%),expert searches 13 (81%), interlibrary loans 10 (63%), and print mono-graphs 4 (25%). Predeployment handouts or training was provided from13 Army medical libraries, with formal or informal training taking placeat 9 (69%) libraries and handouts being provided by 11 (85%) libraries.Most respondents 9 (64%) found providing remote services to be rela-tively easy. Those finding it difficult blamed e-mail transmission as thesource of frustration. All libraries reporting that they provided servicesalso received correspondence from deployed patrons. The frequency ofcorrespondence varies, and was reported as more than once a month by 5libraries (31%), once a month by 4 (25%), every 2 to 3 months by 3(19%), and every 6 to 12 months by 4 (25%).

Several comments were recorded on the surveys referring to examplesof how library service was provided. A few respondents stated thatCD-ROMs of the electronic database UpToDate are issued and highlyregarded. The medical library in Heidelberg, Germany sends 500 UpTo-Date CD-ROMs every quarter to deployed providers. UpToDate has giventhe Army special permission to disperse CD-ROMs of their product todeployed providers. Librarians support these remote patrons by respondingto e-mail requests for database passwords, articles in PDF format, extendedcirculation of print books, and literature searches. See Table 2.

TABLE 1. (Continued)

How convenient was it to find computers to use?Easy (computer was usually available) 40.0% (16)Moderate (had to wait periodically) 47.5% (19)Difficult (had to wait frequently) 12.5% (5)

Did you have access to print books?Yes 58.5% (24)No 41.5% (17)

How did you learn about library services to deployed soldiers?From a fellow soldier 26.3% (10)From library personnel 10.5% (4)From a supervisor 18.4% (7)Self 36.8% (14)Other (please specify) 18.4% (7)

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DISCUSSION

This study was performed to determine how library resources areemployed in a remote setting such as Iraq or Afghanistan. It wasexplored from two sides; the individual libraries providing theresources and the individual patrons using those resources. Theseresults indicate that libraries are actively providing services, despitethe geographical distances; however, unreliable Internet access in thefield is hindering the use of electronic databases. An answer to theunreliable Internet access is the use of CD-ROM and DVD productsfrom vendors such as UpToDate and STAT!Ref®, as well as the

TABLE 2. Libraries Providing Resources Score Sheet

Do you provide library services for deployed Army Personnel?

Yes 94.1% (16)No 5.9% (1)

What services do you provide to deployed personnel?

Print books 25.0% (4)Electronic databases 93.8% (15)Searches 81.3% (13)ILL 62.5% (10)Training 31.3% (5)Other (please specify) 18.8% (3)

Do you offer and pre-deployment training or handouts on accessing library services while deployed?

Formal/informal training 69.2% (9)Handouts 84.6% (11)

Do you find it difficult to service deployed personnel at a distance?

Yes 35.7% (5)No 64.3% (9)

Do you receive correspondence from deployed personnel asking for assistance with library services, such as searches or ILL requests?

Yes 94.1% (16)No 5.9% (1)

How often do deployed personnel contact you for assistance?

More than once a month 31.3% (5)Once a month 25.0% (4)Every 2–3 months 18.8% (3)Every 4–6 months 0.0% (0)Every 6–12 months 25.0% (4)

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e-textbooks of Military Medicine provided by the Borden Institute.Print books still appear to have a place in the hospital settings, butrapidly deployable levels of care such as Level 1 and Level 2 cannottravel with large reference collections. Another area of concern discov-ered from this study is that most deployed medical personnel are not awareof any library services. This can be addressed by providing bettervisibility of library services such as coordinating with deployableunits and providing handouts and information sessions.

The Lane Medical Library now provides a deployment packet, whichincludes contact information for the library; an online search request form;a table of contents request form; a breakdown of the available databaseswith instructions on how to access them; quick reference cards provided byvendors on products such as OVID, UpToDate, First Consult®, andSTAT!Ref; and a laminated credit-card sized card with the Web addressesof the most popular databases. The library also advertises deployed servicesduring the hospital’s monthly Newcomer’s Orientation sessions.

This survey resulted in an increased awareness of library services todeployed Army medical providers. Many of the respondents wereunaware of library services until after participating in the survey.Although the online Web forms mentioned above have not increased inusage, more deployment packets are being distributed and numerousUpToDate CD-ROMs are still being sent to providers already deployed toIraq or Afghanistan. Lane Medical Library is now on the out-processingform that is given to deploying providers. This means that as they preparefor deployment and are sent to various departments throughout the hospi-tal to temporarily check out of the system, they are also sent to the libraryfor a brief on how to access library resources and to pick up the deploy-ment packet. Future study will be needed to determine the results of thiseffort to increase awareness and use of library services.

REFERENCES

1. Hetz SP. Introduction to military medicine: a brief overview. Surg Clin N Am.2006;86:675–-688. doi:10.1016/j.suc.2006.02.011.

2. Tick E, Hill F. “MASH” today: medicine, war and writing. J Sci Heal.2007;3(1):59–61.

3. Pueschel M. (2003). Army transforms combat medic role. http://www.usmedicine.com/article.cfm?articleID=586&issueID=47). Accessed 27 Oct 2007.

4. Beitle AL, Wortmann GW, Hofmann LJ, Goff JM. Operation enduring freedom: the48th Combat Support Hospital in Afghanistan. Mil Med. 2006;171(3):189–193.

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APPENDIX A

Library Services to Deployed Soldiers (Soldiers Version)

1. Position title2. Did you use any of the following services from your home library?___Emailed library for search assistance___Requested materials (book or journal article)___Other (please specify) _______________3. Did you use library services while deployed for any of the following

reasons? (Select all that apply)___Direct patient care___Training___CE or CME___Research (other than direct patient care)___Information for the patient___Other (please specify) _______________4. Did you use any of the following resources?___AMEDD Virtual Library___Lane Medical Library webpage___AKO My Library Databases___AMEDD Deployment Readiness Portal___e-Textbooks of Military Medicine___Deployment Medicine Resource CD___DeployMed Resource Link___Deployment Health Clinical Center___Other (please specify)_______________5. What databases did you access while deployed?___OVID___MD Consult___Nursing Consult___PubMed___EbscoHost___Micromedex___UpToDate___Stat!Ref___Other (please specify)_______________6. How did you access electronic services?___Shared computer___Private computer (computer used mainly by you)

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___Personal computer___PDA/Smartphone/Other handheld device7. How convenient was it to find computers to use?___Easy (computer was usually available)___Moderate (had to wait periodically)___Difficult (had to wait frequently)8. Did you have access to print books?___Yes___No9. How did you learn about library services to deployed soldiers?___From a fellow soldier___From library personnel___From a supervisor___Self___Other (please specify)_______________10. Were there other problems or difficulties involved in using library

services while deployed?

APPENDIX B

Library Services to Deployed Soldiers (Library Version)

1. What is your location?2. Do you provide library services for deployed Army personnel?___Yes ___No3. What services do you provide to deployed personnel?___Print Books___Electronic databases___Searches___ILL___Training___Other (please specify) ____________4. Do you offer any pre-deployment training or handouts on accessing

library services while deployed?___Formal/informal training___Handouts5. Do you find it difficult to service deployed personnel at a distance?___Yes___No

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Jill Anne Lynch 229

6. Do you receive correspondence from deployed personnel asking forassistance with library services, such as searches or ILL requests?

___Yes___No7. How often do deployed personnel contact you for assistance?___More than once a month___Once a month___Every 2–3 months___Every 4–6 months___Every 6–12 months8. Additional comments you’d like to add regarding other services or

support your library provides to deployed personnel?

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