Commander, your Medics need more training. Medics require consistent, progressive medical training in order to maintain their readiness and medical capability. While training for war is an everyday goal of our armed forces, the reality is that support of peacetime priorities can compete with this mission [1]. Between 2001 and 2011 nearly one in four service member deaths from battlefield wounds were deemed potentially survivable had the correct care been rendered at the right time [2].

While the Army Medical Department (AMEDD) trains medical providers, establishes doctrine, and develops medical equipment sets for the prehospital environment, line commanders are ultimately responsible for the medical care of their Soldiers on the battlefield [3]. In this article I’ll lay out a few reasons why you should advocate for better medical training.

Why We Do PT Everyday, or How to PMCS Your Medics

Your equipment is vital to the accomplishment of your mission. You want to ensure you are ready for whatever may come. You order your platoons to conduct preventive maintenance, checks, and services (PMCS) on the equipment assigned to them. PMCS takes time, but it’s worth it if all your trucks roll, all your radios work, and all your guns fire. Medical training is PMCS for medics. Without consistent and progressive medical training, their capabilities begin to corrode like an unserviced truck.

To put it another way, 15th Sergeant Major of the Army SMA Daniel Dailey once said “[physical training] might not be the most important thing you do [in a] day, but it is the most important thing you do every day.” We PT everyday because we are maintaining a level of physical fitness which allows us to do our job, to close with and destroy the enemy. Medical training is PT for your medics. Without consistent and progressive medical training, their capabilities begin to waste away like a muscle.

There is a lack of medical personnel on the line who possess trauma management training and skill. Medics assigned to the line have a hard time receiving and sustaining the appropriate training relevant to current standards for trauma management [4]. Optimal care for trauma patients demands consistent and frequent trauma education and training [5].

Gotta Get Cool to Stay Cool

A small number of key basic skills are important in effectively intervening in life-threatening situations. The ability of military first responders to acquire these skills and sustain their expertise is increasingly limited by the lack of exposure to trauma outside of the combat experience [1]. Common sense argues that medical personnel expected to resuscitate and transport severely wounded casualties should have commensurate training and experience [6]. We expect medics to perform lifesaving treatment under the most difficult of circumstances but invest minimal institutional effort toward training them to a high level or insisting they train alongside physicians and nurses in our fixed military hospitals during peacetime [3].

There has been much advancement in the art and science of battlefield medicine. The Committee on Tactical Combat Casualty Care guidelines for the optimal treatment of war wounded is not only the standard of care for the U.S Department of Defense (DODI 1322.24) but a standard that other nations have employed to a greater extend and to better effect [7]. Best practice guidelines only enable best practice; they do not guarantee it, especially if there are training challenges to be overcome [8].

The key players here are the physicians and physician assistants (PAs) who determine medical capability. Provider knowledge of TCCC, or lack thereof, had a direct effect on their confidence in medics to perform TCCC skills. If providers are not TCCC-trained, or did not have confidence in their own capabilities to perform TCCC skills, it could potentially influence the skills that they both teach and allow their medics to perform [9].

Your medics need to first achieve a high level of readiness before they can maintain that level of readiness. To do this engage your medical staff to determine training requirements.

Mitigating Risk: Don’t Worry, I Got a Guy

When you build your risk assessment you look for ways to reduce or eliminate the potential for bad things to happen. Many leaders will mitigate perceived risks to health and safety by simply placing a medic or corpsman nearby. By doing so you are assuming that when all else fails, the risk will ultimately be mitigated by the capability of the medic. This assumption is based on the medic being trained, equipped, and ready to respond when injuries occur. This may not be the case [10].

If your medics are not able to attend medical training because they are always pulling range or drop-zone coverage, you are proverbially shooting yourself in the foot. Start by truly assessing the risk and whether or not you need a medic available, or whether it can be mitigated in some other way. On many installations, civilian ambulance services are used to transport injured patients, medics will not be able or allowed to perform medic-level interventions, and CLS-level first aid is all that is needed. Many installations have a policy on the level of on-site medical support needed for a given type of weapon system.

Ain’t Nobody Got Time For That

The priorities of running a company or battalion take precedence over the needs of a single group of low-density MOS individuals. Sometimes dedicated time for MOS training must be sacrificed to complete some higher-level mission. How then does a commander balance accomplishment of the mission with the needs of the Soldier? Through the integration of medical training with all other forms of training.

The imposition of casualties during various phases of the mission should be a routine part of rehearsals and training for all missions. It is important to consider not only how the casualty’s injuries should be treated, but also the tactical implications of the casualty upon the ongoing mission [11]. As leaders direct priorities of effort at all levels and can enforce expectations and standards, they play a crucial role in this training strategy [12]. This is true regardless of subject domain. Medics and medical staff can help develop the commander’s intent, but it is the commander who owns the medical program and who has the greatest control over the quality of training.

As medical training and readiness becomes a leadership priority, it creates another cultural opportunity for cohesion that primes the organization for a robust battlefield casualty response system [12].

What’s a Commander to Do?

There remains considerable overlap of authorities and responsibilities between the services, the Geographic Combatant Commanders, and individual combat units with respect to training and equipping troops in battlefield trauma care [3]. This diffusion of responsibility leads to medics being left without clear leadership and advocacy. This situation is ripe for the Commander to take the reins and develop a casualty response system able to save his or her Soldiers from potentially survivable death.

Current literature shows training, leadership, and organization have made the most significant documented improvements in survival. Several examples illustrate the potential for capitalization: 

  1. The U.S. Army Rangers, with their command led casualty response system, are able to document no potentially preventable prehospital deaths after more than a decade of combat. 
  2. Staffing a forward battalion aid-station with emergency medicine trained providers showed a 30% reduction in deaths, and 
  3. Adopting current civilian air ambulance standards during helicopter evacuation in Afghanistan showed a 66% reduction in the risk of dying.

To achieve a lower rate of preventable death in your unit, both your officers and senior enlisted, who must know what to expect from their medics on the battlefield, need an overview in TCCC. Line leadership buy-in is the sine qua non of sustained advances in the military. Likewise, military physicians and other medical department personnel who are assigned to combatant units, who supervise combat medical personnel or who will be deploying in support of combat operations, all need to be trained in TCCC [8, 9].

Commander, your people are counting on you to integrate quality medicine into your training program. If you can do it with PT, preventive maintenance, and battle drills, you can do it with medical training. Lives depend on it.

References

  1. Sohn VY, Miller JP, Koeller CA, et al. From the combat medic to the forward surgical team: the Madigan model for improving trauma readiness of brigade combat teams fighting the Global War on Terror. Journal of Surgical Research. 2007 Mar;138(1):25-31. DOI: 10.1016/j.jss.2006.09.006
  2. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma and Acute Care Surgery. 2012 Dec; 73(6 Suppl 5):S431-7. doi: 10.1097/TA.0b013e3182755dcc.
  3. Mabry RL, DeLorenzo R. Challenges to improving combat casualty survival on the battlefield. Military Medicine. 2014 May;179(5):477-82. doi: 10.7205/MILMED-D-13-00417.
  4. Freel D, Warr BJ. Surgical and Resuscitation Capabilities for the “Next War” Based on Lessons Learned From “This War”. Army Medical Department Journal. 2016;(2):188-191
  5. Committee on Trauma, American College of Surgeons. Resources for Optimal Care of the Injured Patient: 2014. Chicago: American College of Surgeons; 2014.
  6. Gerhardt RT, Delorenzo RA, Oliver J, Holcomb JB, Pfaff JA. Out-of-Hospital Combat Casualty Care in the Current War in Iraq. Annals of Emergency Medicine. 2009;53(2):169-174 doi:10.1016/j.annemergmed.2008.04.013
  7. Savage E. Tactical Combat Casualty Care in the Canadian Forces: lessons learned from the Afghan war. Canadian Journal of Surgery. 2011;54(6). doi:10.1503/cjs.025011
  8. Butler FK, Blackbourne LH. Battlefield trauma care then and now: a decade of Tactical Combat Casualty Care. Journal of Trauma and Acute Care Surgery. 2012;73(6) Supplement 5:S395-S402. doi:10.1097/TA.0b013e3182754850
  9. Gurney JM, Stern CA, Kotwal RS, et al. Tactical Combat Casualty Care Training, Knowledge, and Utilization in the US Army. Military Medicine. 2020;185(S1):500-507. doi:10.1093/milmed/usz303
  10. Schauer SG, Naylor JF, Uhaa N, April MD, De Lorenzo RA. An Inventory of the Combat Medics’ Aid Bag. Journal of Special Operations Medicine. 2020; 20(1): 61-64
  11. Butler FK, Hagmann JH, Richards DT. Tactical Management of Urban Warfare Casualties in Special Operations. Military Medicine. 2000;165(10) (Supplement 1). doi:10.1093/milmed/165.10.via
  12. Kotwal RS, Montgomery HR, Miles EA, Conklin CC, Hall MT, McChrystal SA. Leadership and a casualty response system for Eliminating Preventable Death. Journal of Trauma and Acute Care Surgery. 2017;82(6),Supplement 1:S9-S15. doi:10.1097/TA.0000000000001428