USNI article, interested in people’s opinions

[MillertimeUSNA]

Revamp Marine Corps Operational Medicine
Revamp Marine Corps Operational Medicine

Anyone want to share their thoughts on this idea?

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[DMBandFan86]

Not really revolutionary. Replace some physicians at role 1 with PAs and add some PAs.

Sounds good, makes sense.

 

[MillertimeUSNA]

Not really revolutionary. Replace some physicians at role 1 with PAs and add some PAs.

Sounds good, makes sense.

From the article: “With this change, it would require a total of 42 PAs and 63 IDCs to reinforce each battalion to support the OPMED-T structure.”

This is all under the supervision of 1 physician, so this seems like more than ‘some’ PAs correct?

 

[Gastrapathy]

The basic premise that evacuating the injured is “unrealistic” is deeply flawed. The reason we save so many lives is not because GMOs or PAs in Role 1 facilities can do anything important. It’s because we have a system that bypasses them and gets patients to surgeons and anesthesiologists.

 

[DrMetal]

The basic premise that evacuating the injured is “unrealistic” is deeply flawed. The reason we save so many lives is not because GMOs or PAs in Role 1 facilities can do anything important. It’s because we have a system that bypasses them and gets patients to surgeons and anesthesiologists.

Quite true.

The romantic notion of battlefield medicine is really just a movie/Hollywood thing.

The best results come from no 'battlefield' medicine, but rather quick stabilization and medevac to a real hospital. And make no mistake, Medevacing is an operational task, often having little to do with the medical corps (logistics of planes, helicopters, ships, establishing air superiority, suppressive fire, etc )

Also, the whole dilemma with military medicine is, that it hasn't really been tested since Vietnam (the last war, where we actually saw hundreds of casualties at one site, on one day). We did well in Gulf War I and II b/c of our ability to medevac quickly, and we were able to do that well b/c we have a grossly inferior enemy. A land battle/sea battle with China would be grossly different.

 

[DMBandFan86]

Probably more than often the PA may know more trauma care than the physician who could be anyone from an intern to a sports medicine physician. PAs and medics can be trained up for role 1 care with goal to transfer as soon as possible. The focus should be on good evac times even with high patient volumes.

 

[ValeRx]

The basic premise that evacuating the injured is “unrealistic” is deeply flawed. The reason we save so many lives is not because GMOs or PAs in Role 1 facilities can do anything important. It’s because we have a system that bypasses them and gets patients to surgeons and anesthesiologists.

So what happens in LSCO when you can't get that helo to come in and medevac your mascal patients directly to Role 2 or Role 3 because the bird will get shot down?

 

[Gastrapathy]

They don’t survive. And an extra 500 PAs in a role 1 won’t change that.

 

[armytrainingsir]

“So what happens in LSCO when you can't get that helo to come in and medevac your mascal patients directly to Role 2 or Role 3 because the bird will get shot down?”


You either move the patient to the surgeon or move the surgeon to the patient.

 

[ProwlerturnGas]

PA’s replacing physicians in the USMC operational setting be they GMOs or residency trained, would not be a good look for the medical corps. I think it would do harm. IMHO

 

[usma05]

Our medical successes in the war on terror were multi-factorial, but we’re overall dependent on air superiority and a great and timely aeromedical evacuation platform. The military has been preaching for a while for the need to provide sustained care at level ones and twos in future battles that we don’t enjoy that air superiority. Hands help, but experienced has hands help better. With the current retention issues of surgical MOS personnel over last several years leaving the unable to push enough surgical capabilities forward….we’re going to have a lot worse track record in terms of casualties in the next war. Unless we stay out of it till the landscape matures into WWI-like trench warfare like it seems could happen in Ukraine? Then we could have routes for evacuation on land better. I know they were looking at telemedicine options too, but that isn’t a panacea exactly either. I agree these people don’t help substantially. I also don’t have high prospects for our capabilities.

 

[pgg]

So what happens in LSCO when you can't get that helo to come in and medevac your mascal patients directly to Role 2 or Role 3 because the bird will get shot down?

People with injuries that don't demand prompt surgery or resuscitation will probably survive, the others will die.

You either move the patient to the surgeon or move the surgeon to the patient.

Easier said than done.

For all the effort that has gone into creating the forward Role 2 / FRSS scheme ... its success is absolutely dependent upon a 100% secure location to put it, which implies 100% air supremacy and 100% suppression (or absence) of accurate enemy indirect fire. These are things we've had since our threat shifted from Cold-War-turning-hot, to bombing the everloving **** out of Saddam's Iraq before screaming into Kuwait with half a million troops, to chasing insurgents. But we won't have them in a conflict with a peer or near-peer adversary.

These "mobile" forward surgical units really aren't that mobile. And they're hard to hide, and they're fragile. Even a 9-person FRSS has an absolutely huge logistic footprint. Multiple C130 aircraft to move all the stuff and people ... which needs a runway. Or a LOT of rotary wing aircraft. Don't forget the people and stuff for security, comms, utilities, even basic manual labor. And don't forget that if things are really that dicey out there on the line, those logistic assets are going to be moving trigger pullers, not us.

With practice and frequent drills, a team can unpack a basic 4-tent FRSS in a few hours and be ready to accept casualties. Packing up to leave is marginally quicker. But it's not fast enough if the enemy has artillery or aircraft. And of course, "ready to accept casualties" might mean only one casualty before resupply is needed (blood being the biggest consumable for these trauma patients).

AND ... it's not like that patient isn't going to have to get CASEVAC'd promptly anyway - role 2s don't have much holding capacity to speak of, and the idea is damage control surgery and prompt CASEVAC.

I spent my last deployment as the OIC for a FRSS parked in Italy as part of a "quick" response team for crisis response in Africa. I learned that there's a lot of magical thinking going on when it comes to the capabilities some folks in the line think a mobile role 2 has.

There will be no moving the surgeon to the patient in the next non-insurgency conflict. We will either move critically wounded casualties to secure locations promptly or they will die.

 

[pgg]

PA’s replacing physicians in the USMC operational setting be they GMOs or residency trained, would not be a good look for the medical corps. I think it would do harm. IMHO

I don't think there's much risk of that. PAs don't grow on trees. There aren't enough of them in the civilian world either. There is exactly zero chance of the military recruiting/training and then retaining the number of PAs being talked about.

Short of a wartime draft, that is. Then all bets are off.

 

[pgg]

Revamp Marine Corps Operational Medicine
Revamp Marine Corps Operational Medicine

Anyone want to share their thoughts on this idea?

I think their scheme as depicted in Fig 2 has merit ...

... but not for the reasons they think. I'm supremely skeptical that adding some PAs or IDCs at the company level will really improve survivability of combat casualties.

But IDCs are really excellent assets to have at the company level in a Marine infantry battalion. I had one, who we kept in the H&S company when at home. For one deployment we got augmented with a second. When deployed, and our battalion was spread out over multiple locations, they were super useful in that they could handle most sick call issues independently. And being better trained and more experienced, they were great for triaging more mundane illnesses and injuries in the field into "stay here" vs "routine medevac" categories, and providing frequent training for ordinary corpsmen.

That's where they really shined: elevated medical knowledge.

Combat casualty care is pretty easy stuff. Dangerous and demanding, but intellectually and procedurally easy. Corpsmen do an outstanding job of managing casualties with survivable battlefield injuries. (No secret what the top 3 are: blood loss from extremities, basic airway issues, tension pneumo.) An IDC, PA, or board certified trauma surgeon aren't going to improve on Corpsman-level field care to a degree that justifies risking those assets so far forward.

The basic issue with all of this "push higher trained people to the front" is that there comes a point where the extra training isn't going to change outcomes if prompt transport to R2 or R3 doesn't happen. Many times in Afghanistan and Iraq I'd talk to other GMOs and hear about them riding along on convoys because their COs felt better knowing a doctor was along - but not really understanding that the doctor with a backpack full o' goodies really wouldn't be able to do much more than a corpsman with the same backpack.

They could put a PA in every rifle platoon, but if there isn't a helo to get the casualty to surgery promptly, it won't matter. And if the helo is there ... then what do we need all these PAs for?

 

[Gastrapathy]

Well said.

 

[armytrainingsir]

Easier said than done.

Never said it was easy, or even possible.
Just the simple fact that if a patient needs life saving surgery, the surgeon et al and the patient have to meet. Or the patient dies.

 

[pgg]

Never said it was easy, or even possible.
Just the simple fact that if a patient needs life saving surgery, the surgeon et al and the patient have to meet. Or the patient dies.

Agreed though I've watched with concern as senior medical corps leadership (maybe with encouragement from the line?) have persisted with their idea that pushing care forward to the bleeding edge of the battlefield is either workable or wise.

Everything from a FRSS flying forward which I covered above, to the absolute lunacy of pushing reboa to medics and PAs in the field. I honestly believe there's a massive disconnect between these planners and reality that's going to get people killed if they ever actually try this stuff in a real fight.

 

[backrow]

Agreed though I've watched with concern as senior medical corps leadership (maybe with encouragement from the line?) have persisted with their idea that pushing care forward to the bleeding edge of the battlefield is either workable or wise.

Everything from a FRSS flying forward which I covered above, to the absolute lunacy of pushing reboa to medics and PAs in the field. I honestly believe there's a massive disconnect between these planners and reality that's going to get people killed if they ever actually try this stuff in a real fight.

Which was glorified by this….

 

[fhockey13]

I would argue that the huge expansions in telemedicine moonlighting + PA/NP job options during COVID make it nearly impossible to sell deployments, long field assignments, military med after ADSO etc. to any one other than those in GMO or IDC role. Simply because other options don't really exist for non board eligible/cert physicians or IDC's. Both in and out of military med. At the very least, additional training/GME is required.

Most people pursue PA degrees knowing they don't want the additional stresses/quality of life burdens that come along with MD/DO practice in todays practice. Job satisfaction speaks for itself in the number of PA's that decide to go back to school to become physicians (zero that I knew personally, but I'm sure they exist. I'm just willing to wager they exist in far fewer numbers than those who don't). Another drawback mil med has for PA's is the advancement/promotion opportunities in MSC vs. the medical corps. Which is why I think this model is flawed-- this endless pool of PA's waiting to get operational assignments may only ever exist in things like Fig 2. Also funding for PA degrees is available through the VA which I'm not sure was always around.

 

[Traumahawk]

Agreed though I've watched with concern as senior medical corps leadership (maybe with encouragement from the line?) have persisted with their idea that pushing care forward to the bleeding edge of the battlefield is either workable or wise.

Everything from a FRSS flying forward which I covered above, to the absolute lunacy of pushing reboa to medics and PAs in the field. I honestly believe there's a massive disconnect between these planners and reality that's going to get people killed if they ever actually try this stuff in a real fight.

Agreed, and that mindset has apparently not changed in the present day. I would also point to the fact that a lot of med planners are not in any wise clinicians. Most of the people doing POMI stuff are MSC officers with healthcare administration degrees and absolutely no experience in patient care. They get suckered in by the buzzwords and moto videos, and don't have the clinical acumen to ascertain how many fragile, irreplaceable moving parts (both personnel and equipment) it takes to deploy thus-and-such a capability. They then promulgate this glorified view to the line, who also doesn't have the experience to call BS, and then the line makes it our problem.

You can make a pretty good argument that PAs are a clinically equivalent replacement for all the PGY-1 GMOs we aren't going to have in the future. You can't in good faith argue that replacing each of your senior line Corpsmen with an IDC is going to improve your trauma resus capability. At the end of the day, all you're trying to do is maintain as much hemostasis as you can till that patient gets to surgical care. You don't need a physician, or a PA, or an IDC to put on a tourniquet, or needle a chest, or even give blood in the field (see: ROLO). After that, the patient either gets CASEVAC'd or dies. No amount of gee-whiz is going to change that calculus.