Military Plans to Replace Physicians With Self Aid/Buddy Care

[MedicalCorpse]

They finally listened to me! In the only editorial I was able to get published in U.S. Medicine (Issue 88, June, 2006, no longer online), I predicted that a nurse would be appointed Surgeon General of a military department. My final paragraph stated the following:

"The mothers of those brave souls who are right now enlisting to defend our country deserve to know the truth: there will be no military medical system to care for them in a few short years, if current trends continue...and if there is one, it will be so dangerous due to lack of funding and qualified personnel, that self aid/buddy care would prove a far safer option."

Well, a few months later (2007), a CRNA was appointed acting Surgeon General of the Army:
Gale Pollock - Wikipedia

And five years later (2011), a nurse was tapped to be the actual Surgeon General of the Army:
Horoho takes oath as first nurse, female surgeon general

Now, in 2023, here comes LtCol (Dr.) Ross F. Graham, who, in the latest issue of the Journal of Indo-Pacific Affairs, published by the U.S. Air University Press, admits that the military has failed to train and/or retain so many experienced physicians over the past 20 years in favor of less qualified humans, that the only hope of survival our poor troops will have when the balloon goes up in the near future is to be able to manage their own and/or their buddy's tension pneumothorax, obstructed airway, and hemorrhaging by their lonesome using the awesome power of their high school diploma or GED. In order to make it sound less hilarious, the propagandists in the Pentagon are renaming Self Aid/Buddy Care to TCCC ASM (Tactical Combat Casualty Care All Service Members), which has the advantage of inducing the MEGO syndrome in civilians who read about this fiasco in situ (as in, "My Eyes Glaze Over" when forced to read long acronyms).

Accelerating Change to Survive

My next prediction for 2024 and beyond: "How to drill into your buddy's head to relieve his subdural hematoma because we have no more neurosurgeon physicians (vs. Physician Assistant Assistants [PAA] and Nurse Practitioner Assistant Assistants [NPAA]) in uniform. Step one: find a stick* for your buddy to chew on as his sole anesthetic. Step two: ask your implanted DoDGPR DAD (decision assistance device) 'DAD, How do I perform brain surgery in the field under combat conditions?'"

*now renamed WBARS: Wood-Based Anesthesiologist Replacement System for better PR optics

Imagine how much money DoD will save by not having to pay the stick!

Please discuss.

Note: Many of the links on the editorials page have eroded with time. I may or may not get around to fixing them someday.

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[DrMetal]

order to make it sound less hilarious, the propagandists in the Pentagon are renaming Self Aid/Buddy Care to TCCC ASM (Tactical Combat Casualty Care All Service Members), which has the advantage of inducing the MEGO syndrome in civilians who read about this fiasco in situ (as in, "My Eyes Glaze Over" when forced to read long acronyms).

Field medicine is nothing new. If you're boots on the ground, knocking down doors, it stands to reason that initial care (for a massive hemorrhage, traumatic amputation, tension ptx, whatever) will be delivered by a non-physician (an IDC, an advanced medic, etc). This has always been the case. We don't have doctors or even nurses embedded with most operators (nor should we).

Now, in 2023, here comes LtCol (Dr.) Ross F. Graham, who, in the latest issue of the Journal of Indo-Pacific Affairs, published by the U.S. Air University Press, admits that the military has has failed to train and/or retain so many experienced physicians over the past 20 years in favor of less qualified humans,

Here's what's going to happen if the balloon really goes up (ie, we engage in a full combat shooting war, that results in many casualties): We will likely conscript many civilian physicians into the reserves, and utilize them. I'd rather throw a uniform on a civilian CT surgeon (who does several cases a week) and throw him into a field hospital, than rely on a an active duty CT surgeon who hasn't done a case in several months (sometimes years).

We all know this, and this is what's been done in the past. It works well . . . so well, that it makes a good argument that we should all be reservists.

 

[MedicalCorpse]

Field medicine is nothing new. If you're boots on the ground, knocking down doors, it stands to reason that initial care (for a massive hemorrhage, traumatic amputation, tension ptx, whatever) will be delivered by a non-physician (an IDC, an advanced medic, etc). This has always been the case. We don't have doctors or even nurses embedded with most operators (nor should we).

I understand what you are saying. My problem is that the LtCol (Dr.) is proposing that, in lieu of training and deploying sufficient medics (MDs, CRNAs, IDCs, whatever) to manage severe chest injuries and airway disasters, it would be more cost-effective to upgrade the brains of average troops with high school diplomas to perform these functions in austere conditions under fire. This is not a realistic goal.

Quote from the article:
Paradigm Applied, First Example—Shortage of Skilled Hands

"One weakness in the life chain is that there are not enough personnel with lifesaving medical training to address the likely overwhelming number of immediate life threats—such as, massive bleeding, collapsed lungs, or compromised airways. As a countermeasure, the Department of Defense (DOD) is transitioning from Self Aid and Buddy Care to Tactical Combat Casualty Care All Service Members (TCCC ASM) training (Tier 1) by approximately 2023. However, in a casualty scenario in the new operational environment, TCCC Combat Lifesaver (CLS) training (Tier 2) is more effective at preserving the life chain. This is
because the three major preventable causes of battlefield trauma death are extremity hemorrhage, tension pneumothorax (collapsed lung), and airway compromise.42 While Tier 1 training covers the first of these, the skills to address a tension pneumothorax or increased skills to improve an airway are taught at the Tier 2 level, not the Tier 1."

I do believe it is a great idea to teach all military members how to apply tourniquets to stanch life-threatening bleeding.
That's "Tier 1". I have great doubts that the military will take the time to train up all troops to manage tension pneumothoraces and/or difficult airways in austere environments ("Tier 2"). Who will teach them? How long will they be given away from their usual duties to learn these difficult tasks? Will they each have to pass ATLS with a live animal lab, as I had to do at USUHS in 1987? How often will they need to be recertified as capable airway management cooks, pilots, or snipers? By whom?

I don't believe that the argument "Rangers were taught this" is applicable to the entirety of the force. It's all apples and oranges and wishful thinking including mindless, USAFA ring-knocking acronym buzzwords ("ABCD") vs. actual data.

In five years, if I could throw myself down in the shoe section of a BX in a random airbase and the unfortunate enlisted member next to me is able to either place an appropriate-sized LMA or intubate me despite my congenital retrognathia, I'll eat my words. I don't foresee this to be a likely scenario.

As far as the reserves go, the military destroyed all trust after 9/11 by recalling retirees up to age 86 (true story) to
active duty involuntarily. As soon as I left the Air Force and resigned my commission after 15 years of active service (not including USU), I got a big packet in the mail from HQ AFRC in Colorado welcoming me to the reserves. I had to go through many hoops to convince them that I was done and out and not to be sent on the next plane downrange just because the military had managed a retention rate of anesthesiologists beyond their ADSCs approaching 0% for the past twenty years.

As many here have noted, that is by design. Uppity LtCol anesthesiologists are more likely to cancel sexy cases that surgeons want to do in the glorified broom closets that are all military medical facilities outside of the few remaining real medical centers. Uppity LtCol anesthesiologists are more likely to object to requests to violate the Geneva Conventions and the Hippocratic Oath when dealing with "unlawful combatants" who happen to be human. Uppity LtCol anesthesiologists cost money. Brand new O-3 docs fresh off the boat from HPSP or USU can be told to shut up, sit down, and color (quote from one of our prior AF Surgeons General to the chief anesthesiologist of the AF, when the latter stated that the military will be critically short-staffed with anesthesiologists after 2001...which was the Pentagon's plan all along). CRNAs are not doctors, and thus can be cowed much more easily by testosterone-toxic surgeons to do what they are told, rather than what is right for the patient. As one of the senior surgeons I worked with at Travis said with regard to the hemorraging of people from the military medical system that started in the 1990s, especially regarding medical residency programs, apoptosis is more likely than poor planning alone.

There is no way I would advise anyone to join the reserves as a physician in 2023 and beyond, given the 100% chance of random disruption of your civilian practice, your marriage, and your precious time with your children in order to deploy somewhere unimportant strategically where you are guaranteed not to do much of anything for months at a time as you watch your hard-won skills rot away...unless it's WWIII, in which case, well, you'll be dead anyway with the first incoming salvo due to Sheer Poor Planning for force protection downrange. The military is increasingly leaning on the Reserves and National Guard under the Total Force concept that dates to the 1970s...and which requires major changes to cope with 21st century challenges. Since the 1970s, "One weekend a month and two weeks a year" has always been pure propaganda that acted as a "recruiting hook" rather than a reflection of the real demands all services place on their reservists.

Other than inventing a time machine which would overturn the short-sighted and wrong-headed decisions of miltary medical leaders and their line superiors since circa 1995, I'm not sure what else can be done to fix military medicine in this timeline before WWIII erupts somewhere we didn't even predict (as was the case in WWI [Sarajevo] and WWII [Pearl Harbor]).

Wishing everyone sweet dreams after one of my usual upbeat, Rainbow Unicorn posts...

 

[HighPriest]

“Look, it’s not hard. You take the training, you’re qualified to do the job.

Legally, anyway. We’ve done our part. Shut up, now.”

-DoD
(a $350bn organization who’s entire motto is “having a theoretical plan of any kind is the same thing as having a solution.”)

 

[pgg]

I'll readily agree that there are serious problems with retaining physicians, running the MTFs, and planning for future conflicts.

It's a little odd that you zero in on a plan to improve field care at the self/buddy aid area as a problem.

I taught combat lifesaver courses to entire battalions of Marines, from company commanders on down to the newest PFC, and they basically got it. The airway / tension pneumo stuff was a stretch for a lot of them to retain and perform, but hell, that's the truth for a lot of training. And what else can you do? There are a bare handful of causes of preventable battlefield deaths. It's good exposure training. They'll still need corpsmen and medics.

There never has been and never will be a supply of doctors that far forward. Nor should there be. It'd be a criminally incompetent use of physicians to put them with rifle platoons.

It seems like you're stretching pretty hard to criticize and connect this specific plan (which is fine) to larger systemic issues with physician retention and skill growth/maintenance.

 

[MedicalCorpse]

It seems like you're stretching pretty hard to criticize and connect this specific plan (which is fine) to larger systemic issues with physician retention and skill growth/maintenance.

I have no problem with teaching troops basic or even advanced medical techniques. For the last 10 years of my time
in the Air Force, I taught ACLS to hundreds of enlisted medics, nurses, PAs, NPs, physicians, what have you.

I guess the part that bothered me was the philosophical leap from the problem identified in the article:

Paradigm Applied, First Example—Shortage of Skilled Hands

...to the proposed solution: Don't hire/train/retain actual skilled medics at all levels with actual skilled hands (and minds).
We don't need no stinkin' doctors. Instead, make average soldiers/sailors/airmen/guardians responsible for their own or their buddy's airway management, because, hey, if anesthesiologists take 4 years of medical school, 4 years of residency, and maybe 5 years as an attending to get really good at managing difficult airways, we can teach it to high school graduates in a day or two, no problem.

Imagine if you will that the USAF instituted a new training program for all ranks that taught them how to
take over flying multi-seat aircraft in an emergency, just in case their pilot and co-pilot were incapacitated.
I mean, they all have autopilots. How hard can it be? We're not talking vascular/thoracic surgery here.

"So, the CONOPS for project OMGIMGUNADYE is to take two or three days to use simulators to teach
EVERYONE in the military how to fly ALL of our fixed- and rotary-wing aircraft, just in case the aircrew are
rendered incapable, such as from a nuclear explosion blinding everyone in the cockpit, etc. Then we
give them these Reaaaaaaaaaaaly tiny wings they can put on their uniforms to feel better about taking over
as a pilot in an emergency. What could go wrong?"

Trinity says: Let's Go

I mean, that would go over with pilots, right? Because, hey, why take years of hands-on hard work when you can
learn everything you need to know in a few hours of Special High Intensity Training?

Sigh.

It is just that the military seems hell-bent on doing everything except fixing the broken system, including
pushing responsibility for medical care to non-medics in austere environments with artillery shells going
off all around them...as long as we save money by not paying one extra cent for actually-trained
doctors/PAs/corpspeople/medics/AI robot medic dogs to carry tourniquets and whole blood to the front lines.

True story from circa 2004 at Andrews:

Squadron Commander Surgeon: "HQ wants us to cut back on our budget because the line has overspent (on bullets,
missiles, etc. for the Iraq war). They looked at our expenses, and we are being told to cut back on the amount of
sutures we use."

Smart young Surgeon: "Sir, with respect, how much does one deshiscence cost the American taxpayers?"

Squadron Commander: "Oh, so you mean, use the right number of sutures for every patient...oh, OK, I see..."

Nothing ever changes...

 

[pgg]

I don't know man, it just looks like you're really searching for something to complain about. Of all the dumb **** the military medical corps has been doing the last few years - Genesis, "tier 1 buckets", get rid of non-war-critical specialties like OB wait no we won't, the line "buying" physician billets so they "own" doctors that they "lend" back to MTFs ... this is what got you upset enough to return to the forum?


I read the article, and yeah it's full of bull**** buzzwords and stupid acronyms. It's absolutely saturated with the kind of pretentious look-how-smart-I-am language that every doer in the history of doing has heard from middle-management can't-do people.

Still.

I don't see an issue with the overall problem they identify - namely that a near-peer conflict is going to create more casualties more quickly, casevac is going to be unreliable/delayed/unavailable without air supremacy, and that casualties are going to have to rely on far forward medical assets. So maybe expanding self/buddy aid to better cover the 3 main preventable causes of battlefield death is wise.

I don't see where you make the leap from training a Marine or soldier or sailor or airman or my aged grandmother how to use a nasopharyngeal airway is even tangentially related to recruiting or retaining military anesthesiologists. Field care at the point of injury has precisely nothing at all to do with doctors.

 

[MedicalCorpse]

I don't see where you make the leap from training a Marine or soldier or sailor or airman or my aged grandmother how to use a nasopharyngeal airway is even tangentially related to recruiting or retaining military anesthesiologists. Field care at the point of injury has precisely nothing at all to do with doctors.

To quote the article again: "One weakness in the life chain is that there are not enough personnel with lifesaving medical training to address the likely overwhelming number of immediate life threats." The author is proposing that essentially all troops have their brains upgraded to provide "lifesaving medical" care, rather than focusing on the primary duties of their military jobs. I am just questioning 1) how that will work 2) who will teach them 3) how much time will they be given 4) who will recertify them and 5) how often, so that they are not a danger to themselves and others when they attempt to practice medical/nursing/nurse anesthesia care without adequate training, let alone a license.

I am not saying that anesthesiologists should be on the front lines, but other medics/corpsmen (sic)/nurses have fulfilled that role in every U.S. conflict going back to the Revolutionary War. We just need to hire/train/retain more of them, rather than expecting riflepeople or submariners to act as actual medics when the Fit hits the Shan.

No disrespect to your grandmother, but I have seen medical students, residents, and attendings cause alarming, even life-threatening epistaxis when attempting to place well-lubricated, appropriate-sized nasopharyngeal airways. Now comes A1C Smith with a Mac 4 blade, an 8.5 tube without a stylet, and a ton of confidence from his one day TCCC course two years ago on airway management to intubate his buddy with facial shrapnel injuries who just finished chow before the missile hit.

Of course, if he fails, A1C Smith will move immediately to emergency cricothyrotomy via the Seldinger technique he watched on TikTok that one time...

 

[militaryPHYS]

Point is that next conflict has potential for overwhelming number of casualties. In that instance you're either teaching these warfighters how to declare someone Immediate / Expectant and leaving them to die or possibly intervening because they know how to treat some stuff. Will it be a waste of time to train more in advanced TCCC? Maybe, but it probably won't hurt. Just like it can't hurt for me to maintain my rifle/pistol qual in case my role 2 or 3 gets overrun during this overwhelming next conflict and I'm fighting to survive.

I agree with @pgg that there are much bigger problems. DHA needs to cut cost and run efficient hospitals with lots of patients and complexity while also training residents in sub-specialties. The services need to keep physicians busy so that they can be ready to treat down range but they bought all of these billets and don't know what to do with their medical assets. We as physicians are stuck in the middle.

 

[Just Call Me Doc]

To quote the article again: "One weakness in the life chain is that there are not enough personnel with lifesaving medical training to address the likely overwhelming number of immediate life threats." The author is proposing that essentially all troops have their brains upgraded to provide "lifesaving medical" care, rather than focusing on the primary duties of their military jobs. I am just questioning 1) how that will work 2) who will teach them 3) how much time will they be given 4) who will recertify them and 5) how often, so that they are not a danger to themselves and others when they attempt to practice medical/nursing/nurse anesthesia care without adequate training, let alone a license.

I am not saying that anesthesiologists should be on the front lines, but other medics/corpsmen (sic)/nurses have fulfilled that role in every U.S. conflict going back to the Revolutionary War. We just need to hire/train/retain more of them, rather than expecting riflepeople or submariners to act as actual medics when the Fit hits the Shan.

No disrespect to your grandmother, but I have seen medical students, residents, and attendings cause alarming, even life-threatening epistaxis when attempting to place well-lubricated, appropriate-sized nasopharyngeal airways. Now comes A1C Smith with a Mac 4 blade, an 8.5 tube without a stylet, and a ton of confidence from his one day TCCC course two years ago on airway management to intubate his buddy with facial shrapnel injuries who just finished chow before the missile hit.

Of course, if he fails, A1C Smith will move immediately to emergency cricothyrotomy via the Seldinger technique he watched on TikTok that one time...

No offense but it seems like you have very little experience regarding point-of-care medical treatment in a combat situation. As with everyone else, I agree with need to overhaul the military medical system but disagree with the link to providing more medical training to grunts. Logistically, it's difficult to add more medics to a regular platoon/team as since medics are technically 'non-combatants', they would decrease the guns/personnel ratio in a fight. Bullets downrange are the primary prophylaxis to casualties in war. And in combat, a team is often separated on missions such as during CQB in a house, in vehicles during an ambush, or when flanking during a firefight. Often, it may be 10, 15, 30 minutes or more before the medic can reach the patient to provide care. If they have a pneumothorax or compromised airway then they may not survive until then. As the senior medic, I made sure my guys were all trained to provide "lifesaving medical" care with the goal of keeping them alive for the 5-10+ minutes it may take for me to reach them. When one of my teammates in the vehicle behind me got hit in the femoral vein with a round during a complex ambush, it took at least 5-10 minutes for me to get to him after the initial volley and when I could run back the 200 yards to him in the middle of a firefight. Fortunately, I had trained my Marines well and a tourniquet had been placed immediately afterwards which is likely the only reason he survived (still lost almost 2L blood and was hypotensive). My answers to your questions based on my experiences would be 1) TCCC certification for all service members during work-up, 2) MOs, medics, corpsman, nurses, etc 3) hopefully at least 3 days of training but can be integrated with work-up 4) likely recert every work-up with refreshers per MO/medic. The primary duties of a grunt is to complete the mission while keeping their buddies alive. That's why the cook (or MD) needs to qual in rifle even though I wouldn't want them next to me while clearing a house. And while the skill for intubation is likely too advanced to non-medical personnel, I taught my Marines how to place King LTDs and combitubes and do needle decompressions, especially in the case I'm hit and need immediate care. I trusted them to do that because I trained them.

 

[pgg]

To quote the article again: "One weakness in the life chain is that there are not enough personnel with lifesaving medical training to address the likely overwhelming number of immediate life threats." The author is proposing that essentially all troops have their brains upgraded to provide "lifesaving medical" care, rather than focusing on the primary duties of their military jobs. I am just questioning 1) how that will work 2) who will teach them 3) how much time will they be given 4) who will recertify them and 5) how often, so that they are not a danger to themselves and others when they attempt to practice medical/nursing/nurse anesthesia care without adequate training, let alone a license.

I am not saying that anesthesiologists should be on the front lines, but other medics/corpsmen (sic)/nurses have fulfilled that role in every U.S. conflict going back to the Revolutionary War. We just need to hire/train/retain more of them, rather than expecting riflepeople or submariners to act as actual medics when the Fit hits the Shan.

No disrespect to your grandmother, but I have seen medical students, residents, and attendings cause alarming, even life-threatening epistaxis when attempting to place well-lubricated, appropriate-sized nasopharyngeal airways. Now comes A1C Smith with a Mac 4 blade, an 8.5 tube without a stylet, and a ton of confidence from his one day TCCC course two years ago on airway management to intubate his buddy with facial shrapnel injuries who just finished chow before the missile hit.

Of course, if he fails, A1C Smith will move immediately to emergency cricothyrotomy via the Seldinger technique he watched on TikTok that one time...

OK

1) the whole point is that there can never be enough medics to handle the potential casualties from a Pacific theater conflict with China

2) I still don't see where you're making the leap from a NPA to an endotracheal tube or cric. I didn't even let my line corpsmen carry laryngoscopes or tubes because they didn't have room for an ambubag or know what to do after a tube was in, assuming they could do it in the first place, which most can't. Perhaps I missed it but did the article say the plan was to teach soldiers surgical airways?


We're just going to have to agree to disagree that BLS level airway management is beyond them. You're worried about "life threatening epistaxis" from an NPA because a ham-fisted soldier kludged it into an unconscious combat casualty? C'mon. I think you've got an unreasonable degree of angst about teaching field first aid that goes beyond pressure and a tourniquet to soldiers.


A while back some committee of idiot cowboys who sat around MTF ERs thinking their caffeine and adrenalin-fueled fantasy thoughts, wanted to push REBOA to medics and GMOs in the field. THAT is a pants-on-head, clown-shoes, helmet-worthy-r-word, stupid, stupid idea.

This - not so much.

 

[pgg]

Just like it can't hurt for me to maintain my rifle/pistol qual in case my role 2 or 3 gets overrun during this overwhelming next conflict and I'm fighting to survive.

Tangent -

The Pacific Fleet and Navy West rifle and pistol matches are going on at Pendleton right now.

End of next week the Atlantic Fleet and East matches start at Quantico.

They happen every May. All active, reserve, retired, and even civilians can attend. Usually some Coasties, Army, Marines too. Usually not many from the Air Force.

If you're at all interested in marksmanship as a peripheral interest, it's well worth attending one of these while you're on active duty. Get yourself some no-cost TAD orders and spend a week getting coached by some great people. It's precision/service pistol and highpower/service rifle per the CMP rules. No experience necessary - a big part of the fleet-level matches is training and recruitment for higher competition.

I spent 8 years on the Navy rifle and pistol teams and got to go to interservice and nationals most of the years when I wasn't deployed. It's a fun break and it doesn't cost you leave. And I guarantee that after the week you'll be a far better marksman, no matter how new or experienced you are now.

I'm heading to Quantico next week to compete and coach newbies - first year as a retiree.

 

[MedicalCorpse]

No offense but it seems like you have very little experience regarding point-of-care medical treatment in a combat situation.

This is true. I spent my 15 years on active duty as a physician between 1990 and 2005 in hospitals, except for rare FTX adventures in California and Maryland. I got out before I was sent to an actual war zone (although Incirlik AB was in the AOR, I know it's not the same as worse places). I did spend many years teaching ACLS to medics, as I said, in addition to nurses and other "providers", but not where bullets were flying. I will defer to your expertise as eloquently stated in your post.

And while the skill for intubation is likely too advanced to non-medical personnel, I taught my Marines how to place King LTDs and combitubes and do needle decompressions, especially in the case I'm hit and need immediate care. I trusted them to do that because I trained them.

I just hope our military continues to retain airway experts who can train our troops as well as you did, Doc. I guess what "triggered" me, to use modern parlance, was the idea that anyone can be taught to manage "compromised airways" in a few hours or even days. I heartily endorse TCCC level 1, including especially tourniquet use, given what we learned in the deserts and mountains after 9/11. Ironically, we were taught at USUHS in the 1980s in our Combat Casualty Care Course not to use tourniquets, for fear of causing "nerve damage". I'm glad that doctrine has changed, to the benefit of many of our surviving troops.

I guess I'll wait to see how TCCC level 2 for everyone works out. Insert quote from H. L. Mencken here.

Sitting back down now...corrected, it seems. Peace.

PS I was made aware of this article by an O-6-select Air Evac Squadron Commander who was assigned this as required reading at a leadership meeting. They didn't know what to make of all the acronym gibberish, so they asked for my take. I may have gotten carried away with my initial interpretation that the author was implying that anesthesiologists, intensivists, Emergency Medicine physicians, and other airway experts were no longer needed in the military, if everyone can be trained to perform one of the key roles of our jobs. Sorry.

 

[MedicalCorpse]

A while back some committee of idiot cowboys who sat around MTF ERs thinking their caffeine and adrenalin-fueled fantasy thoughts, wanted to push REBOA to medics and GMOs in the field. THAT is a pants-on-head, clown-shoes, helmet-worthy-r-word, stupid, stupid idea.

Might as well add AEDs to the TA-50.

This - not so much.

I defer to your'all's expertise (yours and Doc's) regarding pre-hospital care.

I guess we'll see how things turn out.

Sitting down corrected.

 

[usma05]

As a fellow uppity O-5 anesthesiologist I think you're reading into this article. I took some time to read it and I'm not seeing much outside what the military has been saying for at least 8-9 years. Even prior to my anesthesia days when I deployed as a flight doc at the height of the Afghan surge this impetus on TCCC skills were there as I had to go TDY to SATX for this as predeployment training. The line talking about airways is in regards to NPAs and BVM. They aren't asking for intubation. Even my flight medics when deployed rarely intubated. Protocols were more driven to trained flight medics to use King LTs and/or surgical airways if only necessary. During the surge and even after when I deployed again as a 60N, there was never enough medical personnel in theater available if what the author describes were to unfold (mass casualty or having far forward assest available everywhere). None of this is new writing.

Honestly, this seems like an ILE paper written by an 0-5 harping on what's been ID'ed as something to work on for years in terms of training for prehospital care and augmenting mascal responses where actual medical resources are but would be overwhelmed. I agree there are a lot of shortcomings for the military medical Corps. I don't think this is it.

 

[MedicalCorpse]

Honestly, this seems like an ILE paper written by an 0-5 harping on what's been ID'ed as something to work on for years in terms of training for prehospital care and augmenting mascal responses where actual medical resources are but would be overwhelmed. I agree there are a lot of shortcomings for the military medical Corps. I don't think this is it.

Roger. I guess my initial reaction was that the author seemed to be recommending reliance on what used to be called Self Aid/Buddy Care in lieu of hiring or retaining actual "skilled hands" with actual medical training, including medics, corpspeople, etc.. However, as I said, my entire time in uniform was at major hospitals, so I am not an expert in pre-hospital care. I've never used a King LT or EOA on a human in 33 years of doing anesthesia, so I guess I'd need some Special High Intensity Training myself.

However, when they start requiring non-medics to perform major surgery in the field with AI guidance ("TCCC Level 4") due to lack of actual surgeons and other physicians, I'll be back...

 

[pgg]

However, when they start requiring non-medics to perform major surgery in the field with AI guidance ("TCCC Level 4") due to lack of actual surgeons and other physicians, I'll be back...

They were serious about REBOA in the field by PAs and IDCs. It pisses me off all over again just to think about it.

I think of all the times I've seen vascular and cardiac surgeons struggle to get femoral access in patients under ideal circumstances, in a well lit OR, with skilled assistant hands, extra supplies, patient on a table at an ergonomic height, ultrasound ....

And those bozos actually thought (think?) that a non-physician in the field is somehow going to
a) get a wire into a vessel in a profoundly hypovolemic patient with clamped down arteries
b) without causing additional bleeding trauma to the femoral vessels
c) while kneeling on the ground
d) with suboptimal lighting
e) and no skilled help
f) using insufficient, incomplete, or otherwise non-optimal supplies
g) THEN get a balloon up into the aorta into proper position and inflate it

There's no place for this any further forward than a role 2.

Idiots.


Fortunately, last I looked, the JTS guidelines for REBOA use still specify a physician at an echelon above role 1.


Edit -

I just looked up the current JTS guideline and under "future considerations" it says:

"Training non-physician caregivers to place REBOAs in the prehospital settings is being investigated."

Idiots.

 

[MedicalCorpse]

They were serious about REBOA in the field by PAs and IDCs. It pisses me off all over again just to think about it.

Idiots.

Yes, well, one of the vascular surgeon contributors to that guideline was a dude I knew from Wilford Hall and Andrews. He was the worst surgeon (not just vascular surgeon) I have ever seen in (mal)practice. How someone gets worse after internship, I'll never know. It does not surprise me to see his name attached to that coprolite.

I wrote a three paragraph explanation with all the gory details, but decided not to post it. I might be evolving some discretion now that I am almost 60. Go figure.

 

[GratefulDoc1]

...Wishing everyone sweet dreams after one of my usual upbeat, Rainbow Unicorn posts...

I always appreciate reading your posts, MedicalCorpse.

I kept up with and read all of your posts in the past/back in the day...and I always appreciated that you took the time to express in such a detailed manner the challenges that so many others of us have witnessed and/or experienced.

I thank you and salute you for your service. It is plainly evident that you were among those who actually CARED...by taking the time and effort to speak up, and to raise flags/sound the alarms...and by also trying to make a positive difference in the system to the extent possible.

 

[MedicalCorpse]

I thank you and salute you for your service. It is plainly evident that you were among those who actually CARED...by taking the time and effort to speak up, and to raise flags/sound the alarms...and by also trying to make a positive difference in the system to the extent possible.

Honestly, thank you very much. It's kind comments like these that make getting up the morning worthwhile. I'll never forget my late father saying he was proud of me for deciding to walk away from all retirement benefits to put my money where my mouth was regarding the death of the physician in military "health care", decades after he pinned on my 2LT bars in front of John Harvard's statue on 5 June 1985 (ROTC Det 365 ftw).

With my three year 1099 locum tenens gig drying up, and paychecks getting smaller and fewer, I'm looking for a new job that won't drive me crazy (to quote Pat Benatar). May I use you as a reference? Just kidding, sort of...

[Edited by author]

 

[pgg]

So many others who are O-5 and above just coast for years trying not to make waves until retirement, just so they can ensure their place at the turgid belly of the government to suck up taxpayer dollars for the rest of their worthless lives, after doing exactly zero to improve care for our troops and retirees during twenty-plus years in uniform.

That's obnoxious.

Practically every physician on active duty is providing the best care they can to our troops and retirees, despite a broken system that breaks a little more each day. There isn't really much room for any person to improve anything at a systemic scale, but most work hard at making their local environment a little better.

Around 2014 I was the DSS at a smaller Navy hospital and helped oversee a round of downsizing. It was such a miserable experience of helplessness in the face of bigger Navy decisions, that for the rest of my career I studiously avoided other administrative positions. I declined to be considered for a number of positions ranging from my department to the directorate level over the next few years, instead putting all of my collateral efforts into the residency program and some other projects that have benefited anesthesiologists in the Navy.

Dozens of threads here emphasize that the better financial decision is to take out loans instead of accepting HPSP. There's a window of a bare few years in which it makes financial sense to hang on for the pension. (Especially now, in our specialty of anesthesiology, with the insanely good job market right now, leaving service at the first opportunity is almost always going to be the greediest financial choice.) If you think people are staying purely for a bit of government cheese you're bad at math.

So good for you, I guess, to proudly walk away at 15 years, but there's no need for you to **** on the doctors who stayed.

 

[MedicalCorpse]

That's obnoxious.

At least you know I'm not an AI. They don't make an AI that can "trigger" people so effortlessly while just trying to speak the truth as I saw and experienced it first hand over 19 years in uniform.

So good for you, I guess, to proudly walk away at 15 years, but there's no need for you to **** on the doctors who stayed.

It was never my intention to insult you personally. I apologize if you feel that it was. Please see my PM.

V/R

Rob

PS Offending sentence redacted in the original post. Sorry.

 

[pgg]

I think we're 100% on the same side in wanting the best for military patients, and in wanting a capable medical corps to care for them when sent into damger. Together we've witnessed 30+ years of the decline wrought by poor leadership and it makes both of us sad and angry.

But the main thing holding it together and keeping patient outcomes positive (and for the most part, the care patients got at my MTFs was quite good) is the people in the system doing the actual clinical work. I think we should be careful when levying broad criticism at everyone who stays beyond their initial commitment. There are many reasons people stay, and laziness, malice, and incompetence aren't a big piece of the pie.

 

[MedicalCorpse]

But the main thing holding it together and keeping patient outcomes positive (and for the most part, the care patients got at my MTFs was quite good) is the people in the system doing the actual clinical work. I think we should be careful when levying broad criticism at everyone who stays beyond their initial commitment. There are many reasons people stay, and laziness, malice, and incompetence aren't a big piece of the pie.

I'm glad that was your experience in the Navy. It was not my experience in the (smaller, more inbred) Air Force.

I would add "greed", however, as a Fourth Horseman of Dysfunction in the military system. I sincerely believe that the brass ring of retirement is detrimental to the ethical conduct of everyone in the military who is determined to stay in, when all it takes is one bad OER/EPR by toxic superiors to get you passed over, kicked out, and robbed of all retirement benefits up until and including 19 years, 364.9 days of honorable service. This makes even the best of us feel the need to shut up and not say something when we see something.

It's almost as if that's an intentional part of the system. Hmm.

As Upton Sinclair said: ""It is difficult to get a man to understand something, when his salary depends upon his not understanding it."

"Patient safety, what? Standards of care, eh? Doctors commanded by nurses...gah, you're speaking gibberish, son....I don't understand a word you say. Now get along and fill out your time sheet, finish your CBT on hand washing, then get ready for your Friday at 1630 Mandatory Fun Run."

 

[militaryPHYS]

@MedicalCorpse

Opinion: The risks of prolonged casualty care for conventional forces in large-scale combat operations

The prolonged casualty care construct of “hold and treat” as a standard approach is inappropriate for large-scale combat operations.

taskandpurpose.com

How about this article?

 

[pgg]

@MedicalCorpse

Opinion: The risks of prolonged casualty care for conventional forces in large-scale combat operations

The prolonged casualty care construct of “hold and treat” as a standard approach is inappropriate for large-scale combat operations.

taskandpurpose.com

How about this article?

I think that's an excellent article.

Correctly identifies the elephant in the room - that in a peer conflict, the Role 2 and 3 facilities our current doctrine describes will be smoking craters about 15 minutes after they get set up. And so scoop & go is the only answer: field care by medics and troops, followed by some kind of rapid, low visibility, survivable transport asset with en route pre surgical care but NOT surgery. And surgical care far from front lines.

My last deployment was as the OIC for a "mobile" role 2 / FRSS and it was obvious to everyone in the line command that even our barebones team was too fat, too slow, too visible, too noisy, and just too vulnerable to go anywhere quickly, or to pack and move quickly, or to survive a contested location. And that was for a mission in which uncontested air supremacy was a given. We required multiple transport aircraft - and that didn't even include lift for all the Marines and equipment needed for security, setup, litter bearing, comm, patient tracking, and utilities.

A lot of medical personnel and casualties with survivable injuries are going to die if they don't change (abandon) this doctrine of forward surgical capability before a peer conflict kicks off. It's nice to see that the authors of that piece get it. Hopefully someone with power reads and understands it.



Related note - this paragraph especially resonated with me:

Currently, military physicians, surgeons, and nurses frequently struggle to maintain clinical currency and competency in trauma management given the lack of critically ill trauma patients presenting to most military treatment facilities. While the 2017 NDAA attempted to address this, thus far we cannot find any data substantiating a system-wide improvement. To address this challenge, hospital personnel seek off-duty employment, military-civilian partnerships, and robust live-tissue and simulation-based training despite full-time employment in a medical facility.

Yep. The need to address this issue is a hell of a lot older than the 2017 NDAA, but even if we grant them the benefit of the doubt and assume that they didn't start trying until then, their complete and utter failure to make the slightest bit of progress on this problem since 2017 is damning.

Six years removed from that NDAA, the fact that the only functional mitigation strategy is for physicians to just go moonlight a second or third job is absurd.

 

[Just Call Me Doc]

There are a lot of heavy hitters on that article and Andy Fischer was a Ranger PA (now a surgery resident) so has extensive operational experience.

One bit of hope is legislation named MISSION Zero Act that hopes to establish grant programs for eligible trauma systems and centers to incorporate full military trauma teams or individual military trauma providers into their hospitals. Lobbied a bit for that during the ACS Leadership and Advocacy Summit in DC last month. Hopefully it continues to get traction.

 

[DrMetal]

"Currently, military physicians, surgeons, and nurses frequently struggle to maintain clinical currency and competency in trauma management given the lack of critically ill trauma patients presenting to most military treatment facilities."

Then these folks should be honorably discharged from active duty service (maybe even some debt forgiven), transitioned into the reserves (if they so desire it, or if needed for some payback), and allowed to assume civilian lives.

There was a time in this country, when the Active Duty military would do just that: discharge members (whatever their profession), if their services were no longer needed or there was no way to utilize them. And there was no shame in this, it was certainly not a punitive discharge. Said members were more than welcome to continue serving in the reserves.

 

[pgg]

"Currently, military physicians, surgeons, and nurses frequently struggle to maintain clinical currency and competency in trauma management given the lack of critically ill trauma patients presenting to most military treatment facilities."

Then these folks should be honorably discharged from active duty service (maybe even some debt forgiven), transitioned into the reserves (if they so desire it, or if needed for some payback), and allowed to assume civilian lives.

There was a time in this country, when the Active Duty military would do just that: discharge members (whatever their profession), if their services were no longer needed or there was no way to utilize them. And there was no shame in this, it was certainly not a punitive discharge. Said members were more than welcome to continue serving in the reserves.

One deal-killing issue there is that although there is insufficient caseload to maintain specialty or subspecialty competency, the physicians' services would always still be useful and needed, albeit at a more basic "medical provider widget" level. There is plenty of operational demand for such people, and a vascular surgeon sure could perform the tasks of an infantry battalion GMO quite satisfactorily, and a pediatric endocrinologist sure could be the SMO on a big gray ship.

I can't imagine a scenario in which the services ever decided to release a licensed physician under an ADSO ... the widget is too useful and too reasonably priced to just let go.

 

[DrMetal]

and a vascular surgeon sure could perform the tasks of an infantry battalion GMO quite satisfactorily, and a pediatric endocrinologist sure could be the SMO

Which is Waste Fraud and Abuse. Taxpayers paid to have you trained in Vascular Surgery, now you're paying the gov't back by doing essentially urgent-care type work? Sounds like a 60 Minutes piece.

I can't imagine a scenario in which the services ever decided to release a licensed physician under an ADSO

I know you're right, but it can and should happen. There is precedent for it from other communities (pilots, SWOs, etc).

You're a trauma surgeon with 11 years in, you have 2 years left on your ADSO? Go home. You're not close enough to retirement. Your 2 years ADSO has now been converted to a 4 year reserve obligation. Pursue your civilian practice. We'll happily recall you when Taiwan is invaded.

You have 19 years in service. Ok, we allow you to serve 1 more year to hit 20, then go home.

Such programs could be voluntary at first . . .but we are a militant organization, we're allowed to cut orders and decide peoples' fate.

 

[usma05]

Which is Waste Fraud and Abuse. Taxpayers paid to have you trained in Vascular Surgery, now you're paying the gov't back by doing essentially urgent-care type work? Sounds like a 60 Minutes piece.



I know you're right, but it can and should happen. There is precedent for it from other communities (pilots, SWOs, etc).

You're a trauma surgeon with 11 years in, you have 2 years left on your ADSO? Go home. You're not close enough to retirement. Your 2 years ADSO has now been converted to a 4 year reserve obligation. Pursue your civilian practice. We'll happily recall you when Taiwan is invaded.

You have 19 years in service. Ok, we allow you to serve 1 more year to hit 20, then go home.

Such programs could be voluntary at first . . .but we are a militant organization, we're allowed to cut orders and decide peoples' fate.

Destroying and rebuilding a Medical Corps seems like a bad idea to me. I know they have a legal means to do the doctor draft in a pinch, but knowing what's out in civilian world there are many that have zero interest in complying with that law. At the minimum it'll be a more timely endeavor than what's warranted when the right flash point of a war develops.

Also, having no clinically experienced grey heads is a recipie for poor decision making by a mix of non-clinical, line, and junior medical officers in the next war. Good doctors need top cover from stupidity.

 

[DrMetal]

Destroying and rebuilding a Medical Corps

Okay okay. All good points. Sorry, I often go for the nuclear option. It's so much simpler.

 

[militaryPHYS]

How many well trained trauma surgeons did we have in 2001?

I’m truthfully asking. Do we think it is ten times worse now or have we just sunk back to the mean?

 

[pgg]

I'll throw out a slightly tangential and contrary opinion here -

I think the focus on TRAUMA experience and currency is vastly, vastly overrated. What we need are competent general surgeons who are busy in a varied practice, taking care of sick and otherwise complex patients. Two main reasons:

1) Trauma is pretty easy. Not to slight the trauma fellowship trained people out there, but trauma isn't complex. A good surgeon, particularly one with vascular or thoracic experience, who regularly does major cases can handle most trauma just fine.

2) The "trauma" experience at a US level 1 center is wholly unlike combat trauma. It's all motor vehicle accidents, falls, stabbings, and the gunshot wounds are 99.73% low velocity handgun wounds. Most combat trauma is blast injury, and the gunshot wounds are high velocity rifle wounds.


All the well-publicized efforts to get "trauma" into CONUS military hospitals are missing the point so hard it makes my head ache. There's little to no "trauma readiness" value to bringing fender bender neck pain, drunken bar fight jaw fractures, garbage the police drag over for an en-route-to-jail medical clearance, or playground distal radius fractures into the MTF ER.

The experience that matters is the experience that makes surgeons busy and well rounded clincians. There is no substitute for sick, old, complex, high volume case load.

On the anesthesia side, the lack of need for "trauma" experience is even more stark. I did ZERO trauma for the three years preceding my deployment to the Kandahar role 3, and had no trouble managing blast and GSW injuries on day one. It's just a hypovolemic unstable hypothermic person who needs access, blood products, and a general anesthetic.

I was good at those things because I had been moonlighting my ass off and had done a ****load of cases on nights and weekends and leave, not because the Navy gave me a 2 week refresher course on clinical practice guidelines at NTTC before I deployed.


A year ago when I left active duty my MTF was just starting to take some civilian trauma. It was good in that it was going to add a handful of cases to keep the ER a little busier (actual surgical cases resulting from these ER visits will of course be negligible). But as a solution for surgical skill atrophy, it's essentially pointless.

Good surgeons can handle trauma. Sick, old, complex, voluminous case load is what makes surgeons good. Civilian trauma work is 95% NOT THAT and medical corps leadership is barking up the wrong tree by focusing so much on it.

 

[Trefoil]

"Currently, military physicians, surgeons, and nurses frequently struggle to maintain clinical currency and competency in trauma management given the lack of critically ill trauma patients presenting to most military treatment facilities."

Then these folks should be honorably discharged from active duty service (maybe even some debt forgiven), transitioned into the reserves (if they so desire it, or if needed for some payback), and allowed to assume civilian lives.

There was a time in this country, when the Active Duty military would do just that: discharge members (whatever their profession), if their services were no longer needed or there was no way to utilize them. And there was no shame in this, it was certainly not a punitive discharge. Said members were more than welcome to continue serving in the reserves.

The other reason this won’t happen is that billets determine the needed number of physicians. Currently, with poor retention, we seem to be entering a period where there are many empty billets. Eventually, these may close, but it takes an HRC review to close them in my understanding. That design means there is a lot of inertia to overcome to redefine how many physicians of a certain specialty are needed. HRC doesn’t seem to think in terms of competence. ICTL’s would be the best tool to make that argument; however, I have found that leadership sees ICTL’s as another box that needs to be checked, and the burden to check that box is placed on the individual rather than the organization. It may give you a little bit of leverage to argue for ODE if the command is resistant; however, ODE is still a burden on the individual to find a place that can provide good variety while sacrificing their leave to stay current in a dysfunctional system. Also, the paperwork for ODE itself can sometimes take a year to get squared away while you may only be in that location for three years making it a time intensive and costly investment that may or may not pay off.

 

[DrMetal]

The other reason this won’t happen is that billets determine the needed number of physicians. Currently, with poor retention, we seem to be entering a period where there are many empty billets. Eventually, these may close, but it takes an HRC review to close them in my understanding.

You guys are throwing very accurate 'reality' bombs into my plans to dismantle the active duty MC.

 

[DrMetal]

I'll throw out a slightly tangential and contrary opinion here -

I think the focus on TRAUMA experience and currency is vastly, vastly overrated. What we need are competent general surgeons who are busy in a varied practice, taking care of sick and otherwise complex patients. Two main reasons:

1) Trauma is pretty easy. Not to slight the trauma fellowship trained people out there, but trauma isn't complex. A good surgeon, particularly one with vascular or thoracic experience, who regularly does major cases can handle most trauma just fine.

2) The "trauma" experience at a US level 1 center is wholly unlike combat trauma. It's all motor vehicle accidents, falls, stabbings, and the gunshot wounds are 99.73% low velocity handgun wounds. Most combat trauma is blast injury, and the gunshot wounds are high velocity rifle wounds.


All the well-publicized efforts to get "trauma" into CONUS military hospitals are missing the point so hard it makes my head ache. There's little to no "trauma readiness" value to bringing fender bender neck pain, drunken bar fight jaw fractures, garbage the police drag over for an en-route-to-jail medical clearance, or playground distal radius fractures into the MTF ER.

The experience that matters is the experience that makes surgeons busy and well rounded clincians. There is no substitute for sick, old, complex, high volume case load.

On the anesthesia side, the lack of need for "trauma" experience is even more stark. I did ZERO trauma for the three years preceding my deployment to the Kandahar role 3, and had no trouble managing blast and GSW injuries on day one. It's just a hypovolemic unstable hypothermic person who needs access, blood products, and a general anesthetic.

I was good at those things because I had been moonlighting my ass off and had done a ****load of cases on nights and weekends and leave, not because the Navy gave me a 2 week refresher course on clinical practice guidelines at NTTC before I deployed.


A year ago when I left active duty my MTF was just starting to take some civilian trauma. It was good in that it was going to add a handful of cases to keep the ER a little busier (actual surgical cases resulting from these ER visits will of course be negligible). But as a solution for surgical skill atrophy, it's essentially pointless.

Good surgeons can handle trauma. Sick, old, complex, voluminous case load is what makes surgeons good. Civilian trauma work is 95% NOT THAT and medical corps leadership is barking up the wrong tree by focusing so much on it.

You should really write the next article, this is spot on.