Page 101 - Journal of Special Operations Medicine - Spring 2015

Smaller medical centers do share the load most notice­ Patient safety is another area of friction when dis­
ably in respect to psychiatric and behavioral care, as cussing medics performing TCCC sustainment–type
well as Disease Non­Battle Injury (DNBI) treatment. skills within the MTF. Although patient safety should
The MTFs at large deploying troop concentration posts, always be a foremost concern, our medics safely and
such as Fort Hood, Fort Bragg, Fort Stewart, Fort Bliss, expertly perform complicated interventions in the most
Fort Carson, Fort Benning, and Fort Campbell, expe­ dangerous and most austere locations and conditions.
rience the brunt of day­to­day sick call and dependent As a result, they are certainly capable of providing
care without an apparent link to and importance in the the same level of skill within garrison MTFs, but
proficiency and readiness of combat medics to perform there are additional stipulations. Army Regulation
the full scope of their expected skills. This situation was 40­68, paragraph 5­2, acknowledges delegation of
unfortunately but clearly expressed in a personal com­ tasks and allows for selected invasive and high­risk
munication with a director of hospital education at a tasks and procedures to be performed by unlicensed
FORSCOM post, who stated that providing educational assistive personnel (such as 68Ws) if they have docu­
and clinical opportunities for installation combat med­ mented and formal training, and local policy estab­
ics and the new critical care flight paramedics was not lishes which tasks can be performed and the required
a mission he was staffed to support. But, shouldn’t our supervision. This step requires hard work, diligence,
MTFs be postured to support this important task? and consensus building within the MTF. The essential
pieces are formalized and documented training with
Perhaps there is some reluctance to allow medics to supporting local policy. Although TCCC establishes
perform clinical skills and scope of practice that most the baseline along with the critical skills as outlined in
nurses are not credentialed to perform themselves, STP 8_68W Aug 2013, we must abide by and adhere
due to organizational level of assignment and require­ to AR 40­68 RAR May 2009.
ments. According to US Army doctrine, nurses are not
assigned at Role 1 facilities. Recently, there has been These obstacles are not insurmountable and, while com­
limited experience of critical care flight nurses flying bat medic sustainment should be a goal shared by all
with Medevac units in Afghanistan, which might serve within the AMEDD and Army, we must concentrate
to change existing doctrine. At the maneuver brigade our focus and efforts on continued combat readiness
level and below, medics are expected to perform the and skills sustainment in a period of force reduction
overwhelming majority of both emergent battlefield and planned decreased large­scale combat operations.
care and routine and urgent healthcare, sometimes with Success of this program requires collaboration and
infrequent or offsite medical direction. This is in direct coordination with line units and MTFs, experienced
contrast to the Role 2 and higher setting, where nurses physicians, physician assistants, nurses, and senior non­
are assigned always alongside physicians and surgeons commissioned officers as local advocates and instruc­
and receive their combat experience. This situation is tors, as well as buy­in by local medical command and
further complicated by a large number of government nursing leadership, for it to succeed and flourish. We
service civilian nurses in our garrison MTFs who might must keep combat preparedness as a constant goal, and
be very unfamiliar with the full scope of clinical skills combat medics as the second largest military occupa­
and requirements of combat medics. It is not surpris­ tional specialty within the Army are a major part of this
ing that some discomfort and unease exist with the preparedness.
requirement for medics to sustain their expected Role
1 skills within the garrison system. Medics work daily
and closely with either their battalion surgeon or physi­ References
cian assistant and can be delegated many tasks as an
extension of that credentialed provider up to the level 1. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battle­
that the medic is trained both centrally and through field (2001–2011): implications for the future of combat casu­
alty care. J Trauma Acute Care Surg. 2012;73(6):S431–S437.
unit training programs. This contrasts directly with 2. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating
the garrison facility care model, where the supervisory preventable death on the battlefield. Arch Surg. 2011;146(12):
chain differs from that in combat and the medic is of­ 1350–1358.
ten relegated to other tasks not involving direct clini­ 3. Horoho PD. Memorandum for Commanders, MEDCOM
cal patient care, such as equipment servicing, property Major Subordinate Commands. “Occupational standards and
competency of enlisted Soldiers.”
accountability, and moving or providing basic patient 4. Headquarters Department of the Army. Soldier’s manual and
comfort measures. While these are important tasks to trainer’s guide MOS 68W health care specialist. 2013.
ensure garrison hospital operation, unless they are bal­
anced with more appropriate clinical duties, they will Disclosure
quickly dull the battlefield­sharpened skills that we ex­
pect our combat medics to sustain. The author has nothing to disclose.

Letter to the Editor 91