Page 91 - Journal of Special Operations Medicine - Winter 2015

Providers Face Challenges

Maintaining Deployment-Ready Skills at Garrison Hospitals

Steven G. Schauer, DO; Shawn M. Varney, MD

s the US military drawdown proceeds in the Afghan- Similar to training for sporting events, successful teams
Aistan Theater, challenges to maintaining procedural invest more resources in the athletes themselves than
skills for emergency physicians will continue. Every in the equipment they use. Physician procedural skills
medical specialty has developed based on the need for are similar: they require repetition, which is why many
a special knowledge base, procedural skill set, or, more specialties require a minimum quantity of procedures to
commonly, both. Emergency physicians are trained to graduate residency and become board certified. It is
1,2
develop a broad diagnostic acumen and to possess the reasonable to infer that procedural skills will perish if
treatment capabilities to resuscitate and stabilize pa- not maintained.
tients until definitive care is available. In the setting of
combat operations, it is simply not feasible to place a Several modalities have been evaluated to gain and
trauma team in all corners of the combat theater. Thus, maintain procedural competency, including simulation,
emergency physicians are specialists well fit to labor in live-tissue models, and off-duty employment. Simula-
far-forward areas where the proper application of their tion models are the method most widely used. How-
special skill set sustains Soldiers’ lives until definitive ever, simulation is not without its own challenges. Little
care is possible. data exists correlating the use of simulation models to
3
patient outcomes, although there appears to be some
Significant challenges persist in maintaining procedural confidence gained following simulation. These models
4–7
skills at a level ready for deployment. The current op- come at significant cost, with some high-fidelity manne-
erational tempo (OPTEMPO) has reached a steady-state quins priced in excess of $300,000 (personal communi-
where predeployment training can often be attended just cation). In addition, they often need trained, dedicated
prior to deployment to “retune” those essential skills. staff to manage the simulators. This may be cost limiting
However, as seen early in the Joint Combat Operations, when small MTFs may have only one or two active duty
the OPTEMPO was often unpredictable and resulted in emergency medicine (EM) physicians who will use them.
short-notice deployments. If the past is a predictor of Further research is needed to determine how the high-
the future, it is likely that we may face the same chal- fidelity training simulators can support the EM physi-
lenge again. Thus, our emergency physician force must cians to maintain a deployment-ready status.
stay in an always-ready status.
Live-tissue models provide advantages over the simula-
The current model for procedural skills maintenance tion models, since they create a real-time sense of ur-
assumes that working at military treatment facilities gency that may not be experienced with simulators.
(MTFs) is sufficient. With our colleague Kristin Cox, However, recent Department of Defense changes have
we conducted a survey study that questions whether the limited the ability of this modality for training, and its
current model is accurate or adequate based on the per- use will likely continue to decline. 8
ceived needs of the physicians who may actually have
to perform these technical skills in a resource-limited The most cost-effective method for skills maintenance
environment. The majority of the MTF emergency de- may be the use of off-duty employment (ODE). ODE
partments are often low acuity, and as evidenced by the costs the military virtually nothing, yet provides EM
data presented, low in procedural volume, including the physicians the opportunity to evaluate and treat higher-
larger medical center. All 47 physicians surveyed felt acuity patients, and encourages (even demands) the use
their current position at an MTF was insufficient to stay of resuscitative skills. However, ODE is not uniformly
procedurally ready. supported throughout the military. Broader support for

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