Category Archives: OpEd

PFC and The Surgical Team Deficit

The vast majority of SOF deployments occur outside combat zones where the SOF Medic is expected to care for the entire team without a credentialed provider.  

Faced with a low level of risk, SOF Commanders opt to accept it.

The team also willingly accepts it due to the confidence that they have in the Medic.

Medics and Corpsmen bear the burden of the risk assumed by the Commander.

There is no Doc. 

No PA. 

No dentist or Vet. 

No surgical team or MEDEVAC standing by.  

What can be done? Hint… It’s training

In 2019 a US News investigation into the readiness of the military trauma system concluded with a series of articles to support what we already “knew” and were moving to address with the development of PFC Clinical Practice Guidelines, training events and tailoring hospital rotations.

A Crack in the Armor: Military Health System Isn’t Ready for Battlefield Injuries

Surgical readiness in the Military Health Service is fraying fast. A nine-month U.S. News investigation has uncovered mounting evidence that military medical leaders are squandering a valuable wartime asset: the surgeons and surgical teams that save lives on the battlefield and back home. The investigation is the latest chapter in a continuing U.S.

One of the PFC Truths is that If you think you need a surgical team or intensivist, you should bring one. If there already aren’t enough to go around to higher risk deployments, bringing one to the lower risk trips may not even be an option. Guys still get hurt on these trips.

Military Surgery in the Spotlight

SAN FRANCISCO – It took two surgeons 92 sponges and two towels to stop the soldier’s abdominal bleeding. To the surgeons’ horror, an otherwise routine exploratory surgery on a trauma patient had become life-threatening, within minutes. Retired Air Force Col.

“No one minds deploying, but it is too often, and since there’s usually not much to do [surgically], I know we lose our skills,” says an active-duty military surgeon.

Even the former Trauma Consultant to the former Army Surgeon General weighed in with a 13-page opinion on the topic summarized in the series:

“The Forgotten Surgeon Warriors.”

Top Army Surgeon Blasts Military’s Capability to Handle War Traumas

The Army’s top trauma surgeon has issued a powerful critique of military surgery, asserting that Army medicine is not “manned, trained or equipped” for the flood of complex battlefield casualties that would occur in even a limited war. “The failure of military medical leaders to acknowledge the critical requirement for trauma surgeons …

Once the surgeons openly (somewhat) established that bringing a whole surgical team, even a small one, to every deployment is just not a plausible solution, many attempts were made to increase the scope of practice of the enlisted clinician. This was a second order effect of the campaign to improve battlefield surgery along with the growing realization of this lack of support. 

What can be done? The first thing that should be implemented more widely is honesty. We need to be honest with ourselves first.  What are our capabilities and limitations relative to our training and experience overlaid onto caring for the complex casualties that we may expect to see? Once we come to terms with that, we need to accurately convey these limitations to Commanders who are charged with assuming the risk.  There should be a frank conversation about doctrinal evacuation timelines and policy compared to the pathophysiology with some of the more dangerous possibilities such as blunt trauma from a vehicle rollover, falls, envenomations, training accidents and other DNBI. “The stuff that keeps Medics up at night.” As stated by JB early on.

If the mission is to include higher risk activity, then a surgical team should rightly be requested.  At the end of the day though, as noted above, there may just not be enough to go around. If given the choice, we would probably all take a small surgical team with us so that we could focus on other aspects of the mission.  This is where honesty comes in again.  Just like the early days of the GWOT when every casualty was “Urgent Surgical” and over triage caused some misallocation of resources, an honest and critical assessment will bear out the actual risks and probability. That still leaves some risk to force that the Commander may assume.  That is the reason that additional training experience is crucial. That is why we are so adamant on being great at the basics but also going a little beyond.  No one is coming, not in time anyway. It is our job to recognize a bad situation early, use telemedicine when possible and temporize to the best of our ability, not to be a one man surgical team. This is instilled through rigorous and realistic training.

Training and Utilization.

Not Stuff.

Prolonged Care and Technology: A PFC Op-Ed

If trained sufficiently, integrated responsibly, and not relied upon, some technology may enhance the awareness of a task-saturated medic dealing with a critically ill patient. However, much of it may be a waste of money, space, and weight without proper consideration, training, and integration. R&D dollars should be spent on training, relevant knowledge, and only on equipment that has a good chance of both improving patient outcomes and actually making it into the aid bag or equipment set.

The stethoscope was invented and perfected in the early 19th century. Before the turn of the century the sphygmomanometer, or BP cuff, was invented. Both of these analog technologies have aided in the bedside diagnosis and treatment of an untold number of patients and are still mainstays of many loadouts . Our modern clinical practice guidelines routinely rely on numbers gathered by the use of technology to guide our decisions and treatment plans. A wristwatch helps this process, another piece of technology. If any one of these 3 pieces of equipment were purposely left behind or disregarded, most medical providers might be considered negligent. Opting to not incorporate some way to record vital signs may also be considered irresponsible.

The ability to record and transmit writing could be considered to be one of the most transformative of early technologies. The TCCC card is a great way to record the first few sets of vitals for a short, doctrinal evacuation. The PFC card and vitals chart can help if caring for a patient for a much longer time without technology. It also should help a weary medic interpret patterns and notice subtle changes over time.

“Yeah, but what about real, digital technology?” Like a Pulse Ox or Emma? Both have been ubiquitous pieces of technology used by modern medics over the course of the GWOT and numerous other non-combat deployments. They are immensely helpful, take up a small amount of space and weigh almost nothing. Like anything else, they may have a small downside depending on the model. A small increase in the electromagnetic signature. Both emit different types and amounts of light. If equipped and switched on, Bluetooth may also be a consideration. In the proper setting, wirelessly monitoring multiple patients via a single device could be hugely beneficial.

Now for the more contentious tech… The vent and the cell phone. As equipment increases in complexity, and/or connectivity, the consideration of electromagnetic signature should be a part of the planning process. This includes all aspects of training: initial and sustainment. An “Autonomous” piece of medical equipment like a SAVE2 bag-valve device that runs at a certain setting, once set, still requires considerable attention by a thoroughly trained and equipped provider. This should include advanced analgesia and sedation training and experience. Just buying the equipment doesn’t cut it. (This may sound obvious but is routinely the case, unfortunately.) You can’t just set it and forget it. It may actually make your job more difficult if you are not ready to manage a vented patient and all of the possible complications.

As ATAK and net warrior proliferate and JMEDIC3 goes through the wickets, clinicians should be familiar with BATDOK and other emerging technologies. If for nothing else, being informed can help steer R&D, acquisition, and training. I have been a huge fan of BATDOK since I first got my hands on an early version in 2015. Despite the potential, here we are almost 8 years later and it is still not implemented across the force. I’ll do another post on that another time. It is googleable though.

Since the majority of deployments are outside combat zones, the use of technology may greatly enhance the quality of care given beyond TCCC and basic sick-call in other austere environments. The 2022 NDAA directs the Secretary of Defense to review “current electromagnetic spectrum emissions control tactics, techniques, and procedures across the joint force.” talk to your S2 and S6 and they may just tell you not to use whatever it is you want to use. Talk to the Air Force and the thing you bought off the shelf may not be considered airworthy. Even if it is blessed off for use in a permissive training environment, take into account these concerns if ever activated into a near-peer LSCO fight.

I’m definitely not recommending to not use technology. Rather realistic integration that begins with adequate training. That means if you are using technology, incorporate the failure of said equipment. This will reduce the reliance on power-hungry or cyber susceptible tech and increase the confidence of the medic in any eventuality, whether telemedicine is available and safe to use or not.