Navy medicine takes another hit

[armytrainingsir]

'Instructed Not To Call 911': Report Reveals Confusion, Failure and Fear in SEAL Candidate Death

Mullen, who died in California after completing the "Hell Week" portion of the Navy's Basic Underwater Demolition/SEAL training was found to have perished in the line of duty.

www.military.com

‘One doctor interviewed by investigators explained that instead, the command promises to see recruits anytime, though that is typically done over the phone’

‘By the fifth day, Friday, one sailor recalled that Mullen could "barely walk." The investigation said that Mullen received supplemental oxygen that day. A medical form in the report also showed that Mullen was evaluated, and course officials heard crackling in his lungs and his right leg was swollen.

He was found fit to train but told to follow up with post-Hell Week medical checks. Several sailors noted that Mullen's attitude improved after Hell Week finished, though he needed to be wheeled out of the classroom in a wheelchair and one sailor described him looking like the "Michelin man" from all his swelling. A doctor attached to the medical department at the command told investigators that both the swelling and wheelchair were common.’

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[usma05]

This is disturbing. Early intervention by a medical personnel could’ve saved this kid. I’m curious if the cardiac stuff was acute from the combo of hell week stress and pna or an underlying chronic issue that compounded the acute issues. Either way, I can’t imagine the mental gymnastics one has to play to normalize swelling up like a Michelin Man or gurgling in your sleep. I hope for something to be done, but with a good chunk of the nation hypermasculinizing military service they have little face to face interaction with, I don’t have much faith something will be done.

 

[orbitsurgMD]

This should result in a DOD or DOJ investigation, something completely out of the hands of the local and regional commands. What reckless idiot would refuse to allow a call to 911? (Nevermind. I can wait for the investigation.) Focal distal extremity swelling, abnormal lung sounds, hypoxia requiring supplemental oxygen. There is a differential but the most concerning one in the list requires transfer to a proper ED (where peripheral angio-venography and CTPA are available ) and emergency admission.

This is clown-house stupidity.

 

[usma05]

Agreed. I’m skeptical of their answer to make his death not in vain of instituting cardiac screening. He had signs of florid acute decompensation heart failure. Swelling like the Michelin Man, coughing up frank blood and likely pulmonary edema, gurgling in his sleep, supplemental o2, and requiring a wheelchair is not subtle. It sounds like his colleagues try to raise the alarm but institutional norms and command climate dissuaded appropriate evaluation. I don’t buy preemptive cardiac screening will fix culture. I’m all for this training/selection being tough, but to continue as is the question has to be asked if a death here and there is worth the trade off for it?

 

[orbitsurgMD]

Agreed. I’m skeptical of their answer to make his death not in vain of instituting cardiac screening. He had signs of florid acute decompensation heart failure. Swelling like the Michelin Man, coughing up frank blood and likely pulmonary edema, gurgling in his sleep, supplemental o2, and requiring a wheelchair is not subtle. It sounds like his colleagues try to raise the alarm but institutional norms and command climate dissuaded appropriate evaluation. I don’t buy preemptive cardiac screening will fix culture. I’m all for this training/selection being tough, but to continue as is the question has to be asked if a death here and there is worth the trade off for it?

DVT from leg vein phlebitis or injury or undiscovered clotting disorder, PE, and pulmonary infarct and insufficiency and secondary cardiac failure should be foremost in mind with that constellation of symptoms and signs.

 

[DrMetal]

Who were the medical staff? Some poor GMO, or an actual trained physician?

 

[pgg]

DVT from leg vein phlebitis or injury or undiscovered clotting disorder, PE, and pulmonary infarct and insufficiency and secondary cardiac failure should be foremost in mind with that constellation of symptoms and signs.

Probably a GMO set up for failure, like all of us were. There but for the grace of God could I have gone.

 

[j4pac]

Probably a GMO set up for failure, like all of us were. There but for the grace of God could I have gone.

Probably. But honestly you don’t have to have a great differential. You just have to see that its bad…and get him out. There were quite a few times that with my limited knowledge about medicine that I was uncertain about someone’s diagnosis, but I’m surprised any GMO couldn’t determine that this was a dangerous situation. It makes me think that there were command structural problems at play.

 

[pgg]

Probably. But honestly you don’t have to have a great differential. You just have to see that its bad…and get him out. There were quite a few times that with my limited knowledge about medicine that I was uncertain about someone’s diagnosis, but I’m surprised any GMO couldn’t determine that this was a dangerous situation. It makes me think that there were command structural problems at play.

I don't disagree entirely.

It really boils down to whether we think the GMOs phenomenon is good or bad. And I settle on the bad side.

There isn't a July PGY2 resident anywhere in the USA practicing unsupervised, without immediate support available from a senior resident and/or attending. Anyone who has been or has worked with an intern knows that there are gaps in knowledge, experience, and judgment (which necessarily comes from experience). And those gaps are often surprising.

Internships are highly variable in content and autonomy. Transitionals get a very different experience than categorical OB or medicine or surgery. Yet we put GMOs out there and expect the gaps that we KNOW are there to magically not be there.

It's mostly OK in garrison when help is (mostly) accessible. But I couldn't have been the only GMO at Camp Lejeune that was passively discouraged from leaning on the sports med clinic or attendings at the hospital.

And then they deploy, and are in remote locations.

I did some dumb things as a GMO but I don't think I hurt anyone.

But who knows? One of many examples: I was doing the mental health briefings coming home from an Iraq deployment that saw some intense combat, with multiple Marines KIA, 68 wounded badly enough to be CASEVAC'd home, and many more wounded but returned to duty. Me, a GMO who'd done a grand total of a few weeks of psych as an intern and a few more weeks as a MS3. I was grossly unqualified to be counseling and screening 1000 Marines after all that.

I mean, it's not like PTSD, substance abuse, and suicide are problems, right? It's a "low risk, young, healthy, pre-screened" population, right?

GMOs shouldn't exist. That we mostly get away with it and don't see a lot of overt M&M isn't a good defense. Most states won't even license a physician without 2+ years of GME.


So yeah - I agree and I don't think the differential in this case was especially complicated. I also would expect a non-trivial number of interns and July PGY2s to **** it up if pimped about it during morning report at the ol' teaching hospital. I am completely unsurprised when a servicemember who was evaluated by a GMO has a serious issue missed. And I contend those inevitable errors are mostly the service's fault for continuing to use the last millenium's GMO model a quarter of the way through this century.

Do you think any malpractice carrier would agree to insure these glorified interns, at any rate? I don't.

 

[armytrainingsir]

As a side note to the bigger GMO issue.
GMOs should most certainly exist if NPs exist.

 

[orbitsurgMD]

As a side note to the bigger GMO issue.
GMOs should most certainly exist if NPs exist.

Whether NPs should exist as unsupervised primary care providers is a reasonable question to ask. They do, and not in a trivial number of locations. Much of their status is determined not by reason but by political pressure. It does not follow that GMOs should exist, regardless the status of NPs and regardless the greater amount of training or greater difficulty of the process for becoming a GMO compared to a NP. The GMO is still not qualified for independent, unsupervised practice by any organization that certifies trainees for independent practice. State licensure is not that form of certification, even if the military services offer to their beneficiaries the duplicitous suggestion that it is.