My story

Thank you for sharing your story, sir.

IgD said:

we didn’t have AHLTA.

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whoa, whoa, whoa. did you say you were disappointed in your resources?

Thanks for sharing your story. I don't blame you waiting till had paperwork in hand. I too developed a huge mistrust of the military machine.

At my 4 year point I could have left thoroughly frustrated, angry, dissapointed, incredulous, and depressed. Two more years nearly did me in.

It's a horrible environment to be in where you are fighting to do your job, and then being threatened to do it well. All the adages of officership went out the window when you meet up with some careerist insecure person who holds absolute power over you.

Unfortunately, it seem with the continued decline, more and more of those people stay in, and the ones who come in full of enthusiasm, and vigor to do a doctors work, soon find themselves in situations like you describe.

From your field, you can understand why I post here. This is still therapy to me, and to prevent others from going in blind like I did, I think gives me a modicum of satisfaction. Unfortunately affecting the real change that's needed is a chasm I cannot fathom changing.

Best of luck.

Bullet-pointed b*tch session for the win. Appreciate your sharing.

IgD said:

I'm sorry for giving you a black eye before. I think I was over excited and caught up in the ethos of the Marine Corps.

I think we can drive change and make a difference.

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No worries. I can understand where you were coming from, and its sad that people have to see such a change in milmed to get to the point where we are.

I still would like to make change, but I am not optimistic. I periodically check back on the (I'll call it FEEBLE) attempt to garner information for the Military Health System, and since May, they have had 7 additional comments, all of them practically negative repeating the same things we have been repeating here for years. It does not seem to get better, but worse, and now, as one of the posts states, all the seed corn is gone, and people are starting to understand that military medicine currently is a looser, and not a place to start a medicine career.

I'm willing to listed to any ideas on how to proceed. This is a ripe system for a book, and since Rob seems to have had some restriction placed on his excellent, (harsh) critique of the system, and potentially a book, we need someone else who has the gift of writting expression to put this together.

PS:

Check out the new comments:

http://www.health.mil/Debates/Debate.aspx?ID=9&a=1

Galo said:

No worries. I can understand where you were coming from, and its sad that people have to see such a change in milmed to get to the point where we are.

I still would like to make change, but I am not optimistic. I periodically check back on the (I'll call it FEEBLE) attempt to garner information for the Military Health System, and since May, they have had 7 additional comments, all of them practically negative repeating the same things we have been repeating here for years. It does not seem to get better, but worse, and now, as one of the posts states, all the seed corn is gone, and people are starting to understand that military medicine currently is a looser, and not a place to start a medicine career.

I'm willing to listed to any ideas on how to proceed. This is a ripe system for a book, and since Rob seems to have had some restriction placed on his excellent, (harsh) critique of the system, and potentially a book, we need someone else who has the gift of writting expression to put this together.

PS:

Check out the new comments:

http://www.health.mil/Debates/Debate.aspx?ID=9&a=1

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on the subject of writing a book: wasn't that the goal of the doc that authored medicalcorpse.com ??? I tried looking for his book on Amazon, no joy. Seems like it's still a work in progress, or not published?

Do any of you have bad experiences (or to speak of) regarding milmed in the San Diego area? (i.e. Balboa or other neighboring-MTFs)

I'm not a doc . . . but I am a patient, a customer of milmed in San Diego. I swear to you, I get the royal treatment every time I go in (as does my family, my wife's got a great GP, my kid a great pediatrician). Maybe that's b/c I'm an officer, but I've heard good things from the enlisted as well.

I'm just wondering if all of this animosity towards milmed is geocentric.

IgD said:

I got my DD 214 so here is my story:

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Thanks for sharing your story, IgD. I remember when you first started posting years ago on the board and the old guys would jump on you and doubt your bona fides since you originally seemed very positive about the experience. You always said you'd give out your full background once all was said and done (good decision, by the way).

Sorry that your experience that started out so positive went downhill, as most of the senior posters were expecting. But thanks for sharing the details.

on the subject of writing a book: wasn't that the goal of the doc that authored medicalcorpse.com ??? I tried looking for his book on Amazon, no joy. Seems like it's still a work in progress, or not published?

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I doubt anyone would read it. That guy writes incoherently and hates all parts of the military equally. Heck, the guy hates PT and uniforms, which I thought everyone knew were part of the deal.

Bomberdoc's book would be interesting, though. Galo's too, for that matter.

Anyway, IgD, two more questions:

1) Do you know where you're going next?

2) Would you do it again?

Perrotfish said:

I doubt anyone would read it. That guy writes incoherently and hates all parts of the military equally. Heck, the guy hates PT and uniforms, which I thought everyone knew were part of the deal.

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yeah, and his website looks like one of the early bad porn sites . . .(don't ask me why I know that )

i wonder if he ever visits this forum?

If you guys really wanna exact change in milmed, here's what you gotta do (coming from the perspective of an officer that's dealt with many staffs, but not milmed):

1. Form an action group, a non-profit for example. (I think somebody here suggested that). If effective, that group could be more powerful than a book (although books certainly help too). The group should be comprised mainly of members that are currently civilian (but have prior service), such as yourselves. Of course, you could have active-duty members, but they'd probably be hesitant to act for fear of repercussions. In any case, the leadership of the group should definitely be civilian and prior-service.

2. Come up with detailed, realistic ideas for change. Don't propose a 4-fold pay increase just yet. Do propose alternative to MD GMOs, etc etc.

3. Find out exactly who (in milmed) has the power to make your ideas a reality, and then target that person persistently. This is much easier said than done. Sometimes, it takes great effort to just find out who the decision-maker really is. Make sure your "target" person is really a major player, someone who can create long-term policy. That's probably not an 0-6, not even a one-star. This getting to the level of two- and three-stars, and they're important b/c they can actually get face time with the Secretaries of each service, who in turn can make policy and get the POTUS to sign off on it (usually). Interestingly enough, it's easier to approach a 3-star as a civilian than an active-duty member! (which is why the leadership of the group should be civilian).

4. Get the media--the most powerful tool in American politics and govt--on your side.

its a lotta work, but it can happen . . . .there's plenty of examples (maybe not in milmed yet).

Tired said:

I see a lot of mental health issues, and most of them don't go to psych. Uncomplicated depression, people with situational issues who need counseling; I probably only send 1 in 3 to psych. The rest I either treat myself or refer to MilitaryOneSource.

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Is it really best practice for a GMO with intern-level training in a non-psych specialty to be diagnosing/treating folks for their psych issues?

This isn't a slight on you, Tired. The thought of intern-level psych folks doing surgeries doesn't play well with me either. It's just why the whole GMO thing just smacks of bad business...

notdeadyet said:

Is it really best practice for a GMO with intern-level training in a non-psych specialty to be diagnosing/treating folks for their psych issues?

This isn't a slight on you, Tired. The thought of intern-level psych folks doing surgeries doesn't play well with me either. It's just why the whole GMO thing just smacks of bad business...

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As a GMO I completely agree with the question above. It's one I've asked many times to many "sirs" and "ma'ams" at my clinic/MTF. One honestly said "oh, you'll figure it out"

My answer to my patients is that first, I read alot about things I struggle to be motivated to read about otherwise. I mean, how can a wannabe surgeon really care about depression as much as colon cancer, for example?

But for the patients I know I'll be seeing, I would have a hard time caring about many things I see in our little clinic. So I read alot in the evenings, read alot before seeing pts in the room if I can spare the time, and then have a LOW THRESHOLD to refer pts downtown for ANY specialty care that I think needs that standard of care.

The beancounters never seem to like us GMO's referring but I know for a fact there's a board-specialty trained clinician who way outranks me that refers considerably more pts out of spite and professional slothfulness, so as long as he keeps doing that I'm safe to refer as I see fit, which again, is reasonably often.

I make an honest effort to do the best I can with my limited training as a oneyearwonder, but its a challenging position and I have been counting down the days OUT of GMO-land since the day I arrived.

Someday soon I hope to share my story as you have, IgD.

crazybrancato said:

I'm not a doc . . . but I am a patient, a customer of milmed in San Diego. I swear to you, I get the royal treatment every time I go in (as does my family, my wife's got a great GP, my kid a great pediatrician). Maybe that's b/c I'm an officer, but I've heard good things from the enlisted as well.

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The care the troops get is often wonderful, in spite of the system not because of it. Many people in military med go the extra mile to make sure the patient isn't affected by our dysfunctional system. Sounds like you've found a couple of those people. Congratulations. I go to church with about 2 dozen military families, all of whom have bitched to me about the way they've been treated at my MTF (sometimes in my own department). Many complaints are without merit (I had to wait an hour and a half to be seen at the urgent care etc.) but many are (I couldn't get an appt with Peds for two months!)

Tired said:

It's a reasonable question.

It really comes down to your perception of your own abilities and your opinion on how medicine should be practiced.

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Well, true, but if you really didn't think doing a residency would make you better as a doctor, why bother? We train to become better. And the consensus in the profession today--not the way the military wants to see things or gets to have things, but how the much larger civilian world does things in medicine--more training is needed to make you ready, even for the most general type of practice.

Tired said:

If you believe (as many do here) that all medical problems require subspecialty training to deal with, then obviously the GMO is medical heresy. Only BC/BE Surgeons and ER docs should sew up lacerations. Only psychiatrists should treat depression. Only IM docs should treat hypertension. Only Orthopods should put on splints.

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You are building a straw man. Many problems don't necessarily require specialists, but clearly some do. And knowing which ones they are, and how soon they should be treated by specialists is part of what you learn in a supervised GME setting, and that learning can't be done in a year. The military medical services either believe that you can train someone to that level in a year, or they just don't want to hear or see the arguments why you can't, because doing differently means change, and work and expense.

Tired said:

But for me, I just don't think most issues in medicine are that complicated, and I think the increasing reliance on subspecialists is a waste of our patients' time.

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In the best sense, what you refer to is judgment. It is a funny thing, but time has a lot to do with developing good judgment, seeing outcomes, learning from your mistakes and those of others, reading, listening to your teachers, thinking, much of which takes place in residency. It is asking too much of medical school graduates to be ready to practice with only what you can get out of a single year of even the best internship (and the military struggles to be good). It is unreasonable to expect this level of competence anymore. Maybe 50 years ago, the case could be made that one year was sufficient training, but not today. And just because you can handle 95% of the problems that you see doesn't mean you should be seeing those problems with that level of experience without the support of fully trained attendings. If a second-year IM, ED or FP resident is expected to be under direct daily supervision of attending teaching faculty, what is it about you as a GMO that makes you think you should be working with less than that?

Tired said:

If I can sit down with someone, spend a good 30 minutes talking to them, screen out serious underlying psychiatric disorders, and end up with uncomplicated depression as a diagnosis, why shouldn't I give them an SSRI/SNRI and followup with them to assess its efficacy? Similarly, if they're having isolated marital issues, why shouldn't I refer them to a marriage counselor instead of a BC/BE psychiatrist?

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I guess I will turn this question around and ask, if you were in the outpatient clinic of your residency in FP or psych, what is it about your experience and knowledge that makes you think you shouldn't have to discuss your plan with an attending where a second-year resident might have to?

Tired said:

I don't want to give the impression that I take a cowboy approach when it comes to treating Marines. I refer all the time; sometimes because I don't feel qualified to rule out bipolar disorder, sometimes because I think people need more specialized followup than I can offer, and sometimes just because I get a hinky feeling about the dude and want a better-trained opinion.

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I think you are taking this personally. Your judgment sounds good in this case. It seems you have a handle on what you know and don't know. That's good. But let's get back to that 5%, those cases where you know that you don't know but also possibly those cases where you don't know what you don't know. I am not singling you out here, because that is the challenge to all of us, trained and untrained, to make that number as small as possible particularly the part of not knowing what you don't know.

Tired said:

But what you're going to find out either sometime during internship or right when you start GMO is that 95% of medical visits are really simple. The sprained ankle is really just a sprained ankle, not a subtle syndesmotic injury. The adjustment disorder is really just adjustment disorder, not early schizophrenia. The gastroenteritis isn't Whipple's disease. And so on and so on.

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It is that 5% that gets you.

Tired said:

And if you're worried at all, you have way more options than your average civilian primary care provider. You can see them back every day (I've done this) to reassess.

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Not true. Civilians do this too. ERs do this. Private docs do this. No you can't order someone back, but you can see them.

Tired said:

You can call specialists to get curbside input. You can call your Regimental Surgeon to take a look at them. You can send them to the ER. You can refer emergently.

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Unless you don't have a "regimental surgeon" on call. Unless you are the ER.

Tired said:

The funny thing is that everyone on this board who says, "All GMOs should be converted to FPs" aren't actually FPs. Making an FP a GMO is just as much a waste of skills as making a General Surgeon a GMO. No matter how much specialty training you have, you're not going to provide any more treatment in a BAS than I am, because you don't have the facilities, staff, or equipment. And now you took a doc who should be doing vasectomies, stress tests, managing diabetes, and delivering babies, and put them in charge of managing the sniffles and cellulitis.

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The civilian world has no use for GMOs. Yet, all the same problems are cared for just the same, by NPs, FPs, by internists and others. Sure a FP could spend lots of time on high-value surgical activity, but most see the sniffles and cellulitis too.

Tired said:

Seriously, being a GMO is the easiest job you will ever have, from an academic/intellectual standpoint. Other than this board, just about everyone in Navy medicine will confirm this fact. As long as you approach it with a sense of humility, recognize when something seems funny, see you patients back if you have the slightest doubt, and consult when necessary, there's really nothing to it.

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You are taking the example of the best-supported GMO and generalizing. Sorry to say, there are GMOs who function far closer to the limits of their experience and training than they should be asked to do, with far less support than you are describing. I found that a lot in my experience of the Navy, the leadership holding up some exceptional person or facility as if it were representative of the whole enterprise. It is wrong and deceptive and shrugs the obvious duty to change a system that should have been changed a long time ago.

Minor medical problems don't end at the base fence. Civilians deal with them fine, and without resorting to using GMOs.

Tired said:

It's fun, it's easy, and if you have to do it (at least with the Corps) you'll probably really enjoy it.

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Not the point, really. Fun or not, it isn't right anymore, and that is not a good thing.

orbitsurgMD said:

It is a funny thing, but time has a lot to do with developing good judgment, seeing outcomes, learning from your mistakes and those of others, reading, listening to your teachers, thinking, much of which takes place in residency.

[...]

I guess I will turn this question around and ask, if you were in the outpatient clinic of your residency in FP or psych, what is it about your experience and knowledge that makes you think you shouldn't have to discuss your plan with an attending where a second-year resident might have to?

[...]

But let's get back to that 5%, those cases where you know that you don't know but also possibly those cases where you don't know what you don't know.

[...]

It is that 5% that gets you.

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It's interesting that you write all of this. I'm almost 2.5 years into residency now after a 3 year GMO tour where I nearly always had backup immediately available. On the whole I still think most GMO physician billets could be converted to midlevel billets provided appropriate supervision was available.

There are a few instances that I look back on now and am grateful that I didn't get into trouble or hurt someone. Two cases specifically come to mind, both during the same deployment to Afghanistan at a time when I was out on the Pakistani border and had no local backup - just a radio and 2 hour (at best) medevac times. Both cases worked out very well, and I don't think I'd handle them too much differently now, but it sure would have been nice having more experience.


The first was a local national who got his hand caught in some kind of machine at a factory. The hand was done - shredded and about 1/2 detached. No way it could be saved. He'd already bled a lot and looked shocky. A medevac request was denied (not life/limb threatening because the loss of his hand was a foregone conclusion). We gave him some IV fluids, put a tourniquet on him, gave him some ketamine. Our only monitor was a pulse-ox. Got the local SF team's surgical instruments (I still have no idea why their PA had all that stuff), opened up an ortho textbook, and Spies-Like-Us style looked back and forth between the book and the patient as we sawed of the distal 2 cm of his radius & ulna, tied off his radial & ulnar arteries, tried to wrap some of the periosteum around the end of the bones, and sewed up a nice stump. Woke him up, gave him some Keflex and Vicodin, and sent him on his way. Saw him again a few days then a couple weeks later and he looked great. (Minus a hand, but great.)

The second was a local national kid whose uncle was burning some trash with gasoline and set her on fire. Burns over about 35% of her body, about half of them 2nd or 3rd degree. Medevac again denied. We saw her every other day for dressing changes and debridement (no kid-sized IVs in stock, so we used IM ketamine, again with just a pulse-ox) for about 10-12 days until one day she showed up obviously septic. At that point a medevac was finally approved because she was almost dead, and she was flown to Bagram where she got a series of skin grafts. She did very well in their hands.


As a current CA-3 anesthesiology resident I'm pretty thoroughly appalled at, among other things, my anesthetic technique and the risks I didn't fully appreciate. But I knew both patients might die, and I was in the unpleasant corner of treating them myself (well outside my appropriate scope of practice) or sending them home to die. These were both cases that deserved a residency trained physician though.


Third/last story. I saw a young Marine who came in with a sore throat and lumps on his neck. They appeared to be reactive lymph nodes, just another case of pharyngitis, so I sent him off with Motrin. Don't remember if I also gave him the USMC-cureall-Z-pak. Three weeks later he was back complaining that the nodes were still swollen, but he looked thinner and paler ... I sent him over to the local AF surgical team for a CBC. Hct 22 with 95% immature lymphocytes, same day medevac, chemo within a week. To this day I don't know if I should have picked up the seriousness of his condition the first time he came through the BAS. Probably not; visit #1 was a pretty uninspiring URI presentation. But I do remember thinking at visit #2 that everyone in the battalion had lost weight climbing the mountains over the previous 5 months, so his 30 pound weight loss probably meant nothing, and that it wasn't unusual for lymph nodes to stay enlarged for a while after a URI resolves ... I almost sent him back to the hills.


Anyway, point being, after 2.5 years of residency I now look back with some nervousness at some of the things I did - and moreover, felt comfortable doing as a GMO. I don't know if that means that the whole GMO concept is flawed, or if I was just too confident in my skills and knowledge, or something else.

I also wonder what other dumb things I did without realizing how dumb they were, without an attending there to step in. I'm pretty sure I didn't hurt anybody with substandard care, but if I did and didn't notice, it was probably during a deployment.

I'm glad to see GMO billets going away, but I also don't think replacing them with BC/BE physicians is necessary. The main problem I see with the current system are the short periods when help is not easily available, and with the "clinic/ER" billets all but gone, these periods are going to be during deployments now. I think this problem could be appropriately solved by staffing units with midlevels in garrison, and augmenting them with a single BC/BE primary care physician for deployments. In garrison they wouldn't be abusing the physicians with garbage duty; on deployment there'd be no risk of a glorified intern getting stuck in the wilderness without backup, even for a short time.

My turn:

I'm in a VERY fortunate and unusual GMO position. I'm on a large deck ship with a SMO who is an IM doc for 15 years. We also intermittently have the FST with us which includes an FP, Surgeon, CRNA, etc.

I'm a fairly independant practicioner, I even was as an intern, but there have been several times that I've wanted/needed another set of eyes or another opinion and I've been able to walk down the p-way and get it. All of these weren't necessary, but I'm not really sure until I ask. That's kind of the point: if I were absolutely alone, what would I have done?

I've said it before and I'll say it again. I think a good experienced PA would do my job just as well or better than I do. There are still plenty of situations that a Peds intern and an IM attending are in over their heads (dysfunctional uterine bleeding? ectopic? Serious abscess with no surgeon around? seen it). But 95% of the time it's routine. And a good PA would have the experience to probably know their limits better than I know mine. They have the experience.

Just my 2 cents.

The trendy answer to this problem is to fill the billets with FPs. Or at least that's the trendy answer among those of us who aren't in FP, trained at MTFs where FP didn't exist, and have only a limited view of what FP actually does.

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Is this the plan? I thought the plan was to replace pre-residency GMO's with post-residency GMOs selected equally from all specialties. So you would have an equal chance of being a batallion surgeon with the Marines if you were an FP, EM, GS, or Psyche resident. Isn't this the plan now?

Perrotfish said:

Is this the plan? I thought the plan was to replace pre-residency GMO's with post-residency GMOs selected equally from all specialties. So you would have an equal chance of being a batallion surgeon with the Marines if you were an FP, EM, GS, or Psyche resident. Isn't this the plan now?

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This is a very interesting discussion. At least in the Army, many of the GMO billets will be filled with pediatricians. In many ways, a transitional intern would be able to do the job better than I would as a BC pediatricians. From my perspective, a former ortho intern might be the best choice (assuming he hasn't had his ritual ortholobotomy yet and forgotten all his non-surgical knowledge ). 75% of what I see is ortho. Most of it is very simple, however.

I will say one thing. There is a difference between a doc with one year training and three in a GMO billet. Generally, there's a maturation of the thinking process. This is not an issue of knowledge base or technical skill, its an issue of temperament. Of course, there are some fully trained BC physicians that are boneheads and some internship trained docs who are very mature.

Ed

Tired said:

This is an interesting argument to hear from a surgeon, because essentially you are predicating your entire claim on the notion that we go to residency to learn to practice medicine, and I whole-heartedly disagree.

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I'm confused. Are you saying that medical school is sufficient to become a great general doctor? Or is there something in the intern year that gets you up to that level of skill? I'm suspect about the second, since an intern year in Psych, Medicine and Surgery are sufficiently different, yet both seem to be suitable to fill the GMO slot.

Tired said:

I also think that your broad brush-strokes hide the underlying details: for 95% of patients in a BAS, a transitional intern is all they need.

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The 95% thing is true of anything in any field in medicine, no? 95% of most anesthesia cases can be run by a nurse anesthesist, but it's the 5% they're underqualified for. If an intern is sufficient for 95% of the cases, I find it very hard to believe that they're somehow qualified to discern the other 5% when they see it.

Tired said:

But what about the guy with depression who gives you that "hinky" feeling? Would you rather have an FP or a Psych intern? I'd take the intern. Or when the IED injury gets dumped in a BAS prior to CASEVAC (and you know this will continue to happen as our wars expand and change scenery), you really want a board certified FP instead of a fresh surgery intern?

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The problem with this logic is that you don't have Psych interns just managing easy Psych cases or Surgery interns managing easy surgical cases and Medicine interns managing easy medicine cases. The problem is when the Psych intern is handling the medicine case and the Surgery intern is handling the Psych case. That's the rub with what's problematic about the GMO model.

After listening to a lot of folks who've done GMO tours and then finished their training (residency), you mostly hear the fact that though they felt okay at the time, they shudder at some of their decisions and luck back in the day. The 95% that they are qualified to handle can be handled by a mid-level and the 5% they can't required them to have more training than they had.

I think what ultimately bothers me about the whole discussion is this: we're allowing a standard of care for our servicemen that we wouldn't dream of allowing in civilian sector. In all honesty, how many of us would allow our spouse to be use an intern as their Primary Care Provider. Not me. And if it's not good enough for my spouse, it's not good enough for my military.

The first was a local national who got his hand caught in some kind of machine at a factory. The hand was done - shredded and about 1/2 detached. No way it could be saved. He'd already bled a lot and looked shocky. A medevac request was denied (not life/limb threatening because the loss of his hand was a foregone conclusion). We gave him some IV fluids, put a tourniquet on him, gave him some ketamine. Our only monitor was a pulse-ox. Got the local SF team's surgical instruments (I still have no idea why their PA had all that stuff), opened up an ortho textbook, and Spies-Like-Us style looked back and forth between the book and the patient as we sawed of the distal 2 cm of his radius & ulna, tied off his radial & ulnar arteries, tried to wrap some of the periosteum around the end of the bones, and sewed up a nice stump. Woke him up, gave him some Keflex and Vicodin, and sent him on his way. Saw him again a few days then a couple weeks later and he looked great. (Minus a hand, but great.)

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This story is a great example of why we should not be utilizing GMO's as independent practitioners. Judgements about limb salvage and amputation level for a mangled extremity, and particularly an upper extremity, are some of the most complex decisions in combat medicine. I'm board certified in a surgical subspecialty and limb salvage is my business, but I still find the decisions challenging. And even after residency, I really didn't know what I didn't know until I worked with a hand surgeon in Iraq and saw some of the complex reconstructions he was doing. Why are we putting a GMO who did a psych or IM residency in a position to make those decisions?

Some of the wounds that I thought looked pretty horrific and unsalvageable as an intern look a lot different to me now as an attending. I didn't see the hand, and don't know what "half-detached" means, so obviously I can't second-guess your particular case, but rarely is the decision about limb salvage and amputation level a "no-brainer."

I think you probably did the right thing, since you were obviously in a uniquely austere environment with minimal backup, and you probably saved the guys life. But on the other hand, someone with more experience and/or rank would probably have pushed back HARD when that air-evac was refused. The right answer to the clinical scenario you described is virtually always tourniquet--air evac. I have never heard of air-evac being refused in the situation you described during my time in OIF. If anything, it was the opposite, with lots of civilian air-evacs for relatively minor injuries.

mitchconnie said:

The right answer to the clinical scenario you described is virtually always tourniquet--air evac. I have never heard of air-evac being refused in the situation you described during my time in OIF. If anything, it was the opposite, with lots of civilian air-evacs for relatively minor injuries.

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This was Afghanistan 2004, and CASEVACs for local nationals were routinely denied. Far fewer aircraft were available, and they covered much larger areas than in Iraq. Time from first call to the patient arriving back in Bagram was always over two hours: 50-55 minutes out, refuel at the FOB, pick up the patient, 50-55 minutes back. Nothing like the 30 minute round trips in Iraq. CASEVACs for US/coalition forces were always approved, but for local nationals they had very rigid life, limb, or eyesight criteria plus other availability criteria (two helos already out? troops in contact somewhere? operation imminent?).

Tired said:

If the GMO weren't there, the guy would have been even more screwed, possibly died. And it was a great chance for the GMO to use some skills and figure some stuff out. Sounds like a win-win to me.

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I thought it was great at the time and we were all happily self-congratulatory after he turned up not-dead and not-infected for followup a few days later. I'm less thrilled about the whole thing in retrospect ... not so much the amputation because we really didn't have any options there. It's the full-stomach room-air general anesthetic with ketamine, morphine and a pulse-ox that I'm not so proud of. It's the fact that at the time I didn't really recognize that once he'd had some volume and the tourniquet was on, the anesthetic (provided almost as an afterthought) put him at more risk than the procedure, and we had better options. Just one case where I didn't know what I didn't know; there were others.

IgD said:

That is pretty concerning to me IMHO. We had a pediatrician who was a battalion surgeon in our unit. He was a good guy and competent but is that crossing professional boundaries when you use a pediatrician as a GP? You do what you are trained to do and what your skills are sharp on.

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Oh, it's all adolescent medicine with the USMC.

it was a great chance for the GMO to use some skills and figure some stuff out. Sounds like a win-win to me.

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Hopefully you aren't arguing we need Orthopaedic Surgeons with Hand Fellowships in every FOB, just in case a local factory worker gets their hand caught in a machine.

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Umm.....No.

The current set-up with subspecialists at a centralized CSH works fine--if people with some training and experience know how to work the system.

And I don't know what your experience in-theater was, but my observation is that the relationship with host nationals is quite complex. Our guidance regarding, life, limb, and eysight was clear--U.S. standard of care for initial stabilization to include air-evac. But after that, the situation becomes very nebulous and hard to figure out.

On the one hand, untrained personnel doing surgical procedures on host nationals for the purpose of practice, or "figuring things out," as you put it seems grossly inappropriate to me. As ppg points out, its probably not even the surgical procedure itself that is most risky, but the general anesthetic. One can only imagine the PR disaster if it were publicized that a host national died during a "routine appendectomy" which was done by an IDC. On the other hand, we all agree that the DoD can't be delivering full-on first-world medical care to every Afghan guy who gets hurt at work.

Bottom line is that these are tough judgement calls. Who should be treated and to what extent? Whose standard of car applies in this situation? Are we creating a more life-threatening situation with our untrained personnel delivering general anesthetic? Should we fib a little and sell the situation to the air-evac control officer as a limb/life threat?

I think these questions are well above the level of a psych intern, but maybe you've been more impressed with the psych interns than me.

I mean really, no disrespect intended to mitchconnie, but if you hear the story of an Afghani with a mangled hand, and your first thought is, "I bet we could have salvaged some function there, if only he had gotten to a specialist", you don't really have the appropriate perspective on the issue.

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I guess I will go along with this, and don't mean to imply that limb salvage is more important than saving a life. However, I think that ppg's post-hoc analysis of the situation is extremely insightful. The fact is that once a tourniquet was on and fluid resuscitation was started, the situation was no longer life-threatening or even urgent. If you are giving up on limb salvage (which is not unreasonable), a tourniquet could stay on for 24 hours and it wouldn't matter. And in that 12-24 hours, there would lots of better options.

But as someone with very little clinical experience, ppg didn't realize that a full-stomach, no intubation, no experienced person monitoring, no oxgen, general anesthetic on an underrescuscitated patient WAS life-threatening. After completing residency, he clearly does recognize this.

So I would agree with you that a properly supervised GMO in garrison may not be different than a mid-level provider. However, in the described situation, I think that the extra training in a residency would be extremely valuable.

Tired said:

Better options as in what? You had oxygen but didn't use it? You think you should have intubated him instead?

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An axillary block would have been a safer, better choice. No special equipment needed, and it would have been easy on that thin guy (even learning on the fly from a book).

Short of that, standard of care would have been GETA after a RSI. Naturally attempting that as a GMO would have been begging for disaster - everything from induction to intubation to maintenance to wakeup to extubation.

I was ill prepared to deal with lots of things that could have gone wrong but didn't

• he didn't aspirate - should've OG tubed him as soon as he was out
• he didn't obstruct - should've put an OP or NP airway in from the start; if he had obstructed, without a dedicated anesthesia provider paying attention my first clue probably would have been the sound of his sats dropping through 80
• he remained hemodynamically stable - should've had (at least) some ephedrine or phenylephrine ready
• he didn't wake during the procedure and freak - didn't know enough about the practicalities of a ketamine TIVA than to do anything more than just give a hit when he started moving
• after the procedure, he didn't wake from the pure ketamine anesthetic and freak - should've given him some midazolam but I didn't think of it at the time

I'm sure there are more but the details of that day are fading.

Tired said:

I'm a little leery at the idea of applying American standards of care in a situation like this, at least in a retrospective fashion, which is what everyone is doing here. There was no hand reconstruction for this guy, your facilities and personnel were minimal, his options were you or death, and his followup was going to be nil no matter what you did or didn't do.

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Right, we were stuck in an uncomfortable corner, did our best, and it turned out as well as anyone could have hoped. I absolutely agree that any US-trained GMO, even one straying far outside what would be an appropriate scope of practice within the US, was/is much better than anything a lot of these patients could/can get locally. And once the CASEVAC is denied, your hand is forced.

But the main point of the story was that my perspective has changed somewhat since starting residency. At the time I felt comfortable doing what I was doing, and part of that was because I didn't appreciate how risky it was.

This leads me to question whether there were other things I did for local nationals or US Marines, and felt comfortable doing, that were riskier than I understood. That's all.

mitchconnie said:

If you are giving up on limb salvage (which is not unreasonable), a tourniquet could stay on for 24 hours and it wouldn't matter. And in that 12-24 hours, there would lots of better options.

But as someone with very little clinical experience, ppg didn't realize that a full-stomach, no intubation, no experienced person monitoring, no oxgen, general anesthetic on an underrescuscitated patient WAS life-threatening. After completing residency, he clearly does recognize this.

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Well, to my (small) credit we had, I think, appropriately volume resuscitated him. At least, he was less tachycardic. We had supplemental O2. You're dead on with the rest of it though, except maybe having better options after 12-24 hours.

The CASEVAC was denied, and the next routine "ring flight" was 2 or 3 days away. No ground convoys to that FOB, ever. There was nowhere for him to go, so waiting beyond basic fluid resuscitation didn't offer anything. We could have waited for a longer NPO time but trauma patients don't reliably empty their stomachs anyway, so that's of dubious value.

But yes, you see what I mean and I agree with your overall assessment of what happened. My perspective has changed somewhat after some time as a resident.

You have quite a story to tell and I am very glad you have!

I have been forever changed from the experiences I have had and been a part of from the medical industry. It is leading me into a desire of a Master's in Health Administration and PH.D in Clinical Psychology. I have seen too much to not do something!

IgD said:

The LTCOL NPs were telling the MAJ board certified anesthesiologists what to do by using their senior rank and position as department heads.

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This is the all too common reason why rank structure should have no place in medical care. Based on many conversations with many physicians across the services in many varied locations, this occurs everywhere. Nurses (and occasionally others, PA, MSC, etc) use rank inappropriately to influence and often subjugate the decision making process of vastly more qualified physicians.

IgD said:

When you send Marines to your MTF are they always seen by a psychiatrist or other mental health provider like a social worker or NP?

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Most of my sailors have ended up being seen by a psychologist. If the psychologist thinks they're really messed up then they have to come back to the psychiatrist like 2 weeks later.

IgD said:

There is a lot more to my story. Maybe I'll let more out

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im sure im not the only one you've got chomping at the bit for more stories.

BomberDoc said:

This is the all too common reason why rank structure should have no place in medical care. Based on many conversations with many physicians across the services in many varied locations, this occurs everywhere. Nurses (and occasionally others, PA, MSC, etc) use rank inappropriately to influence and often subjugate the decision making process of vastly more qualified physicians.

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Something here doesn't quite make sense. In the military, it's not the rank that gives you authority. It's the current situation and the particular job-function that grants one authority.

For instance, once upon a time when we were flying UAVs, I was the officer on the beach collecting data. The actual UAV pilot was an E-6. Now, although I out-ranked him by several pay-grades, I could not order him around (tell him how to fly, how to navigate, etc etc). Because for that particular situation, he (the E-6) was in charge of that mission (as deemed by someone above both of us). Likewise, in another example, an E-6 piloting a ship can kick a JO off of the bridge, if said JO becomes distracting in someway. If that E-6 has the conn, s/he has "situational" rank.

So, you're telling me that an O-5 NP can order around a BC O-4 ??? And when I say "order", I really mean it. The O-5 NP can issue a direct order ("carry out such and such medical procedure"), and the O-4 BC must comply, otherwise he/she can be prosecuted under UCMJ ??? [Or rather, is it just more like an O-5 NP trying to throw his/her weight around, but not really dishing out serious orders, just trying to influence???]

IgD said:

I specifically recall reading about anesthesiologists and NPs in the military butting heads. The LTCOL NPs were telling the MAJ board certified anesthesiologists what to do by using their senior rank and position as department heads. The NPs and physicians I've seen in the civilian world work side-by-side and get along great.

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Sounds like my MTF. One guy who was probably going to make a career of it is now getting out mostly because of the above issue.

IgD said:

What I've seen generally is the highest ranking officer in the department regardless of professional experience gets designated the department head by the CO. For example, an O5 fresh out of residency gets named the department head over a double boarded O4. Another situation I saw is a non-physician with a higher rank would be named the department head. These characters control the department policies and filter communication to the CO to protect themselves. They have tremendous power because they have your fitness report over your head.

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ok, but there must be reasons for that. it's not always the case that person with most experience (a double boarded O4) gets put in charge. suppose that person is a real introvert , can't lead, can't make good decisions at a departmental level. Suppose that O-5 is really good with people, can make good decisions, etc etc.

In any case, that O-5 can't walk into an OR and tell that O-4 surgeon where to make an incision, right??? In other words, that O-4 surgeon has situational rank in that OR, during that surgery, right?

(Of course, I'm aware that the O-5, being the dept head, can make policy decisions that obstructs the O-4's performance).

IgD said:

Sounds like you have no idea what you are in for Welcome to military medicine my friend.

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Thanks, for NOT answering the question. And spare us the "holier than thou" attitude.