what are your DOGE VA, mil med predictions?

[militaryPHYS]

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I'll stick to what I know. Anesthesia. There are plenty of my colleagues that have never operated on a generator run OR, with an oxygen concentrator, without an aline, limited blood, truly dependent on surgical blocks, having to truly triage, and function as the ER and ICU, and experienced a real mascal. And to be willing to do it day after day after day. Those that have are the exception and should be really valued. Most have zero interest in that. Anesthesia is going to be a real problem.

Agree. I've recently done surgery on a ship and also operated in host nation OR's in 3 or 4 different countries where normal conditions are unimaginable for your average U.S. civilian.

Your military trauma surgeons have similar pseudo-austere experience and aren't just hanging out at the MTF with nothing to do. Most are moonlighting or part of a partnership that keeps them handy.

 

[afteranesthesia]

Agree. I've recently done surgery on a ship and also operated in host nation OR's in 3 or 4 different countries where normal conditions are unimaginable for your average U.S. civilian.

Your military trauma surgeons have similar pseudo-austere experience and aren't just hanging out at the MTF with nothing to do. Most are moonlighting or part of a partnership that keeps them handy.

You are assuming the moonlighting isn't being yanked then given back, yanked then given back - never for good reasons - destroying morale.

 

[pgg]

I'll stick to what I know. Anesthesia. There are plenty of my colleagues that have never operated on a generator run OR, with an oxygen concentrator, without an aline, limited blood, truly dependent on surgical blocks, having to truly triage, and function as the ER and ICU, and experienced a real mascal. And to be willing to do it day after day after day. Those that have are the exception and should be really valued. Most have zero interest in that. Anesthesia is going to be a real problem.

I disagree (also an anesthesiologist).

All I can tell you is what I experienced and observed deployed to the busy and well-equipped Role III in Kandahar, and deployed as OIC of a FRSS with just about a dozen people and a couple tents and no other real support.

I graduated from an inservice residency that was solid (albeit dependent upon out-rotations at civilian hospitals) but it had no trauma experience. I had to count elderly hip fractures as "trauma" to get my numbers to graduate, it was that low. Then I went to a small command where I was 1 of 1 + 3 CRNAs and did outpatient stuff for 3 years while moonlighting locally for some sicker/complex patients. No trauma though.

Then I went to Kandahar and the anesthesia was ... easy. Trauma is easy. Access, tube, blood. Maybe some regional. Out the door hours later.

I was one of four US active duty anesthesiologists. We also had one Navy reservist anesthesiologist (essentially a civilian deploying from an academic hospital), and one Australian anesthesiologist (who practiced at a civilian hospital). We all did just fine from day 1.


The truth is that nobody in the military is getting any meaningful trauma experience. Certainly nobody in the entirety of the USA (military or civilian) is getting experience with the kind of combat trauma seen in theater. For all the hype over civilian trauma center gun & knife clubs, it's all handguns and MVAs and falls ... absolutely none of the high velocity rifle wounds or dirt-encrusted blast amputations seen in combat zones. But it doesn't matter, because trauma is easy. Any good anesthesiologist can do it, and do it well.

The difficulty of working in an austere environment is also overblown. Doctors are smart people. They can adapt. At my current job, we do ERCPs in a GI suite with a propofol TIVA, endotracheal tube + Mapleson circuit + wall O2. It might as well be in a tent. Lots of non-OR anesthesia is done without a machine or the usual stuff.

The FRSS I was deployed with had some equipment issues. The oxygen generators were not real reliable and getting FiO2 over 60-70% from them wasn't always possible. The compressor to refill the (tiny) tanks we had didn't always work. But that doesn't make the anesthetic harder - you just make do. It's odd to think that a civilian anesthesiologist would struggle with that.


What makes a good trauma anesthesiologist in any locale is the same thing that makes a good anesthesiologist: experience. Lots of cases, lots of sick patients, lots of big surgeries. Me being a USUHS grad who went to Kerkesner and C4 and NTTC wasn't what equipped me to do well with combat trauma. Me being a prolific moonlighter to double or triple my case load, plus do bigger cases with sicker patients that weren't coming to the Navy hospital - that was the real factor.

And I'm not a surgeon, but I'd rather see a busy civilian vascular surgeon in a combat Role 2 or Role 3 than an active duty vascular surgeon who maybe does a 5 or 6 cases per month.

 

[DrMetal]

We also had one Navy reservist anesthesiologist (essentially a civilian deploying from an academic hospital),

And this---utilizing civilians, throwing a quick uniform on them, making them part of the reserves---is exactly what we will (and should) do during the next peer-to-peer conflict. That's what was done during WWII, Korea and Vietnam.

Me being a prolific moonlighter to double or triple my case load, plus do bigger cases with sicker patients that weren't coming to the Navy hospital - that was the real factor.

Yeah, your experience essentially working as a civilian . . .that sounds about right.

You are assuming the moonlighting isn't being yanked then given back, yanked then given back - never for good reasons - destroying morale.

Meh, people still moonlight regardless of restrictions. They can yank the permission slip as much as they want, plenty still do their own thing.

 

[afteranesthesia]

And this---utilizing civilians, throwing a quick uniform on them, making them part of the reserves---is exactly what we will (and should) do during the next peer-to-peer conflict. That's what was done during WWII, Korea and Vietnam.



Yeah, your experience essentially working as a civilian . . .that sounds about right.



Meh, people still moonlight regardless of restrictions. They can yank the permission slip as much as they want, plenty still do their own thing.

You say this, but heads are rolling at Travis AFB right now....so IDK. I would have said that in the past, but I am 100 percent grateful I am civilian right about now.

 

[militaryPHYS]

I disagree (also an anesthesiologist).

All I can tell you is what I experienced and observed deployed to the busy and well-equipped Role III in Kandahar, and deployed as OIC of a FRSS with just about a dozen people and a couple tents and no other real support.

I graduated from an inservice residency that was solid (albeit dependent upon out-rotations at civilian hospitals) but it had no trauma experience. I had to count elderly hip fractures as "trauma" to get my numbers to graduate, it was that low. Then I went to a small command where I was 1 of 1 + 3 CRNAs and did outpatient stuff for 3 years while moonlighting locally for some sicker/complex patients. No trauma though.

Then I went to Kandahar and the anesthesia was ... easy. Trauma is easy. Access, tube, blood. Maybe some regional. Out the door hours later.

I was one of four US active duty anesthesiologists. We also had one Navy reservist anesthesiologist (essentially a civilian deploying from an academic hospital), and one Australian anesthesiologist (who practiced at a civilian hospital). We all did just fine from day 1.


The truth is that nobody in the military is getting any meaningful trauma experience. Certainly nobody in the entirety of the USA (military or civilian) is getting experience with the kind of combat trauma seen in theater. For all the hype over civilian trauma center gun & knife clubs, it's all handguns and MVAs and falls ... absolutely none of the high velocity rifle wounds or dirt-encrusted blast amputations seen in combat zones. But it doesn't matter, because trauma is easy. Any good anesthesiologist can do it, and do it well.

The difficulty of working in an austere environment is also overblown. Doctors are smart people. They can adapt. At my current job, we do ERCPs in a GI suite with a propofol TIVA, endotracheal tube + Mapleson circuit + wall O2. It might as well be in a tent. Lots of non-OR anesthesia is done without a machine or the usual stuff.

The FRSS I was deployed with had some equipment issues. The oxygen generators were not real reliable and getting FiO2 over 60-70% from them wasn't always possible. The compressor to refill the (tiny) tanks we had didn't always work. But that doesn't make the anesthetic harder - you just make do. It's odd to think that a civilian anesthesiologist would struggle with that.


What makes a good trauma anesthesiologist in any locale is the same thing that makes a good anesthesiologist: experience. Lots of cases, lots of sick patients, lots of big surgeries. Me being a USUHS grad who went to Kerkesner and C4 and NTTC wasn't what equipped me to do well with combat trauma. Me being a prolific moonlighter to double or triple my case load, plus do bigger cases with sicker patients that weren't coming to the Navy hospital - that was the real factor.

And I'm not a surgeon, but I'd rather see a busy civilian vascular surgeon in a combat Role 2 or Role 3 than an active duty vascular surgeon who maybe does a 5 or 6 cases per month.

Some civilians have a mindset and resilience that aligns with many military members. Some military physicians have a mindset and entitlement of some civilian docs.

Would I love it if we all had a ton of cases or were civilians and made a ton of money? Sure! But that will never happen. Thankfully we have systems in place to mitigate some of it while things are slow. How many civilians are practicing operating in poor conditions with half of the instruments they are used to using? How many are building resilience to lack of autonomy or learning how to accomplish initiatives in the military system?

We won’t be perfectly prepared for the next conflict. Military or civilian. Most of the early boots on ground and receiving hospitals weren’t prepared for OIF/OEF but they adapted, learned and taught…just like we will do for the next one.

 

[usma05]

I disagree (also an anesthesiologist).

All I can tell you is what I experienced and observed deployed to the busy and well-equipped Role III in Kandahar, and deployed as OIC of a FRSS with just about a dozen people and a couple tents and no other real support.

I graduated from an inservice residency that was solid (albeit dependent upon out-rotations at civilian hospitals) but it had no trauma experience. I had to count elderly hip fractures as "trauma" to get my numbers to graduate, it was that low. Then I went to a small command where I was 1 of 1 + 3 CRNAs and did outpatient stuff for 3 years while moonlighting locally for some sicker/complex patients. No trauma though.

Then I went to Kandahar and the anesthesia was ... easy. Trauma is easy. Access, tube, blood. Maybe some regional. Out the door hours later.

I was one of four US active duty anesthesiologists. We also had one Navy reservist anesthesiologist (essentially a civilian deploying from an academic hospital), and one Australian anesthesiologist (who practiced at a civilian hospital). We all did just fine from day 1.


The truth is that nobody in the military is getting any meaningful trauma experience. Certainly nobody in the entirety of the USA (military or civilian) is getting experience with the kind of combat trauma seen in theater. For all the hype over civilian trauma center gun & knife clubs, it's all handguns and MVAs and falls ... absolutely none of the high velocity rifle wounds or dirt-encrusted blast amputations seen in combat zones. But it doesn't matter, because trauma is easy. Any good anesthesiologist can do it, and do it well.

The difficulty of working in an austere environment is also overblown. Doctors are smart people. They can adapt. At my current job, we do ERCPs in a GI suite with a propofol TIVA, endotracheal tube + Mapleson circuit + wall O2. It might as well be in a tent. Lots of non-OR anesthesia is done without a machine or the usual stuff.

The FRSS I was deployed with had some equipment issues. The oxygen generators were not real reliable and getting FiO2 over 60-70% from them wasn't always possible. The compressor to refill the (tiny) tanks we had didn't always work. But that doesn't make the anesthetic harder - you just make do. It's odd to think that a civilian anesthesiologist would struggle with that.


What makes a good trauma anesthesiologist in any locale is the same thing that makes a good anesthesiologist: experience. Lots of cases, lots of sick patients, lots of big surgeries. Me being a USUHS grad who went to Kerkesner and C4 and NTTC wasn't what equipped me to do well with combat trauma. Me being a prolific moonlighter to double or triple my case load, plus do bigger cases with sicker patients that weren't coming to the Navy hospital - that was the real factor.

And I'm not a surgeon, but I'd rather see a busy civilian vascular surgeon in a combat Role 2 or Role 3 than an active duty vascular surgeon who maybe does a 5 or 6 cases per month.

1. Thanks for your service, but you took a tangent with my discussion. I'm not pushing the trauma angle. I largely agree with what you said about trauma in the US (minus there's no stateside military trauma experience....there is at BAMC). Everything else I agree with. My point was more about being in austere environments, and I think your barometer for austere isn't the same as mine. I'm not talking KAF (I've been there twice and even worked in the ORs a bit there before my residency) nor am I talking about medical care at the height of GWOT.

2. I also graduated from a solid in service residency plused up with great civilian rotations. Prior to that I was a flight surgeon that deployed to KAF in 2011 which mostly was primary care clinic, but also involved a fair amount of MEDEVAC and time in the hospital there. That was functionally the equivalent of a high end community hospital stateside. After residency I spent almost 9 years at BAMC seeing its capability wax and wane but never seeing its trauma mission diminish. The Army sent me to Honduras 3 times to work in local hospitals on pediatric patients (on machines that barely worked, had no ETCO2, and staffing ratios and local practices for PACU and wards were scary so you optimized the patient more than you do stateside or sat with them until you were comfortable leaving) and one more trip to Afghanistan in Kabul in 2015 (largely in another functionally high end community hospital stateside that was next to an airport), but the also sent me out with with the OGA/ODA folks functionally camping as an anesthesia asset. I left AD 3 years ago for the USAR, peds fellowship, and working both peds/adults at a level 1 academic center now.

3. I got small tastes of true austerity between my 2nd deployment being sent out as a functional split FRST having to plan and pack everything anesthesia myself and set up a functional OR in whatever warehouse or hut we could find for DCR. The medical footprint that existed elsewhere, while retracting, where it existed resembled stateside. Where I was did not. Also the trips to Honduras while going to existing local institutions did not resemble anything stateside. Since going civilian, I've spent more time in Central America and Africa in environments that don't have near the resources, infrastructure, or manpower taking care of a number of sick patients. KAF wasn't that, and I imagine the numbers for your FRSS weren't enough to stress the system or induce true moral injury (if it dealt with the occasionally kinetic ISIS fight since GWOT).

4. Also, if conflict does break out I think we dissolved most good will between the actions of the last 20 plus years with only 1% serving and now recent actions with the current admin that intentionally or not have targeted academic center budgets. I won't guarantee it, but I don't think you'll see the willingness to sign up. It'll be like WW3 needs met the fight against serving seen in Vietnam and Korea. Even without that, I don't think most of my colleagues are remotely interested in signing up for working in the conditions that exist in such a situation, not making their normal income, and not having their usual trappings of modern life.

5. I'd encourage you to look at ICMOP. They're forecasting 1000+ patients a day being dropped off stateside for prolonged hospitalized care. Initial capacity was MTFs and VAs then civilian centers that's now going to largely fall on civilian centers with the cuts. Civilian centers that don't just have that many open beds available. It's going to be a huge operational challenge that I don't think many are considering.

 

[Trefoil]

Getting fat people to lose the first 100 pounds is nearly impossible. So you get them to lose three pounds by the next visit.

Same as DOGE


And those programs aren’t untouchable.
They are touched every year.

For example:

Is your ‘full retirement age’ 65? Why not? It was touched.

Are the Medicare/Tricare/VA/Medicaid formularies the same in 25 as they were in 22? More touching.

Restrict access to those programs to American citizens. More touching that >50% of America want.

Biologics make up merely 2% of prescriptions yet 37% of the cost of prescription medications. Pretty easy to convince 95% of the population to go along with curtailing that pesky problem.


You can kill Medusa. You just can’t attack her with a simple frontal assault.

Political third rail mythology is just that. Myth.

It’s all meaningless nonsense. If you give 4 trillion and tax cuts while cutting 30 billion dollars of middle class workers, you just end up with a bunch of rich people and a larger deficit.

DODGE is essentially the private equity of the government. They are coming in, selling all of the assets, and running it for broke. The only difference is those of us who don’t have a private residence in Greece or Portugal will be stuck here as the infrastructure crumbles around us.

You can’t meaningfully fix spending without basically getting rid of social security, which isn’t what they are doing.

 

[militaryPHYS]

Thankfully this isn't a political forum where we debate politics or fiscal responsibility initiatives because none of what you said makes sense.