Page 100 - Journal of Special Operations Medicine - Spring 2015

Only Break Glass in Case of War?

The Difficulty With Combat Medic Skills Sustainment
Within Our Military Treatment Facilities

Cord W. Cunningham, MD

he past 13­plus years of combat have advanced com­ purpose. It further specifies that this should be up to
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Tbat casualty care in significant ways. One area of the level indicated in their respective Soldier’s Manual
great improvement has been in the continued refinement and Trainer’s Guide. These guides list many advanced
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and education of our combat medics and self aid/buddy skills, including parenteral narcotic administration for
aid of non­medics through expert­developed Tactical pain relief, as well as invasive procedures such as in­
Combat Casualty Care (TCCC) guidelines. Even with cision and drainage and chest tube placement. Yet,
these improvements, more than 80% of combat deaths despite this guidance that covers all medical military op­
occurred in the prehospital setting, and more than 25% erational specialties, little evidence shows, in particular,
of those were potentially preventable, as highlighted by that 68Ws are practicing up to the level specified in their
Eastridge et al. Kotwal et al. described a prehospital critical task and skills list in most MTFs in the garrison
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medicine emphasis program that resulted in zero pre­ setting. Many regulatory impediments and obstacles, as
ventable deaths. The difference in these rates illustrates well as hospital cultural perceptions, can prevent an ob­
the importance of a comprehensive prehospital training jective that is clearly of great importance so as not to
and sustainment program with commander emphasis. lose the extensive experience of combat so dearly paid
for in blood.
A comprehensive training and sustainment program
contains many components, including didactic instruc­ The major impediment seems to be in viewing garrison­
tion, task trainers, scenario­based simulation, and ac­ based MTF care as distinctly different from the com­
tual real­life performance of skills. Although Medical bat casualty care mission. Lieutenant General Horoho
Simulation Training Centers (MSTCs), located at many clearly states “our garrison­based healthcare facilities
Army installations, are established, funded, and success­ are an extension of the battlefield,” but the majority of
ful programs, they cannot provide real­life encounters. our MTFs do not conduct usual business in that fashion.
Real­life performance of skills has been in great supply Commanders, clinical leaders, administrators, provid­
during the recent large­scale conflicts due to combat ers, and nurses speak more in terms of workload genera­
sustained injuries, but this will decrease greatly during tion and preparation for the next Joint Commission site
force reductions and projected decreasing deployments. visit and rarely, if ever, about preparing for the next war.
Our medics need continued real­life experiences, and In an environment of budgetary contraction and full
the performance of these skills within stateside Military accountability of cost compared to value, this is unde­
Treatment Facilities (MTFs) is a logical solution. niably important, but our core mission is still “To Con­
serve Fighting Strength.” The majority of direct combat
Lieutenant General Patricia Horoho, as the Army Sur­ casualty care was historically performed at medical
geon General and MEDCOM Commander, issued a centers such as Landstuhl, Walter Reed, and Brooke/
policy memorandum on 14 November 2012 that fur­ ISR; however, their respective garrisons or surrounding
ther stressed the importance of using garrison­based areas have very little Forces Command (FORSCOM)
healthcare facilities as an extension of the battlefield presence. This further separates our smaller medical
to provide skills sustainment for the enlisted military centers and hospitals from the direct and immediate im­
occupational specialty 68 (medical) series as a primary pact of theater evacuation care.

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