Page 135 - Journal of Special Operations Medicine - Spring 2016

that we could train on. We got a grant from the [US Army] with the medics. Some captains, lieutenants, or platoon ser-
Surgeon General to purchase some high-end simulators; geants, they wanted their medic with them all the time; other
we [at 3/75] took these and immersed [ourselves] inside a ones said, “The hell with him; let’s keep him at the flagpole.
shed that we could make brilliant light, zero light, or in the He can read magazines and eat until we get an injury.” So
middle. A guy would run 200m, breach two obstacles (agil- some were integrated. So what we had to do was change
ity, strength) then request permission to enter the simulation that; it was too varied. So we developed the CRRL, the Ca-
room, “Mike 03, coming in.” He would start working on the sualty Response for Ranger Leaders. What we did was talk
simulator. What we found was that we couldn’t just take a about the expectations, limitations, and employment strate-
guy and thrust him into that. We had to stop, because guys gies of your available assets.
were killing the manikin constantly. We had to start from the
ground up which was tabletop. Can you do these procedures Hooah on.
in ideal conditions? Can you do these procedures in less- One of the biggest problems we had was that we med-
than-ideal conditions (which would be on the ground with ics had a different language than the tactical operator. We
all your equipment on, working out of your aid bag or as- spoke transient brain injury, tension pneumothorax, cardiac
sault vest)? Can you do these things in low light, high noise? tamponade; they don’t give a shit about that. You know what
What’s feasible? What’s not? We started to find out a lot of they speak? Cost-benefit analysis, added value, risk manage-
different things like you can’t really do a venous cut-down. ment. So what we had to do was change how we did things
It’s very difficult to do a surgical [cricothyrotomy] without a to get them involved. So we started this course and, again,
tracheal hook to anteriorly displace the cricoid cartilage, and expectations, limitations, and employment strategies of all
make a draw bridge and open it up and put a tube in real the assets you have available, but then how they are em-
easy. We learned not only about the procedures we could ployed on the battlefield. What their capabilities are, what
and could not do, we learned about how to pack equipment [medical] resources we have that are outside [the unit].
so that it was optimal when you got there.
And the second part of this is an interactive, scenario-driven
The last thing we learned was that working in two-man buddy event. And that really gets their attention. One I remember
teams with guys that were trained the same; they comple- was we picked out a lieutenant or a captain coming back to
mented each other. Things went a lot faster versus the lone the [Ranger] Regiment and he’s all motivated as shit: “Oh,
medic by himself. And then what we did was we pumped we got dressings that instantly clot blood, they got these
that lead—because we videotaped all these—so your peers platforms and litters and, man, this is great!” And then OK, I
would watch you go through these high-end trauma clinics. could just tell they just clicked it out of their brain, you know,
And them seeing you make a mistake—because we were all “Great, this is good stuff,” but it wasn’t really sticking.
trained from the same core—for some reason, it resonated
with them; they would not make the same mistakes going So the second part of this thing was that I would pick one
through the simulator themselves. We’d talk about it. of them and say, “OK, now you are the Assault Team Leader
for the initial breach. You’re going in on a MH-47 [modified
From there, what happened was that there were three pro- Chinook helicopter], you got 20 guys with you. You have two
grams that were born out of this thing—the Ranger First Re- breaches to make. If you cannot make both those breaches
sponder Course, which focused on six critical tasks that had in 35 minutes, you need to radio and [exfiltrate]. You will be
a direct correlation with decreasing potentially preventable picked up, cycled in and out on [MH-]60s [modified Black-
death—those were owned by the individual warfighter be- hawk helicopters], and, if you can make it, then the remainder
cause, as we learned, the medic can’t be everywhere at the of the assault force will be coming in and will utilize the pri-
same time. And so the days of you kicking in the door and mary and alternate breach to [infiltrate] . . . the target. Do you
someone getting shot and lying in the doorway and yelling, understand your mission? Right. OK, do you want everyone
“Medic!” are over. Those days were over. So we changed the to have their Bleeding Control Kit?” “Yes.” Ding-ding-ding-
way he did business. Every guy carried a bleeding-control kit. ding: the number would go up because the individual had
the stuff in there to decrease about 70% to 80% of prevent-
Then we had the medics be ready to assume operational able deaths inside the bleeding-control kit, which had chest
cycle. It was called Ranger Medic Assessment and Validation, seals, needles for [pneumothorax] decompression, nasal pha-
and they had to have book knowledge and hands-on experi- ryngeal airway, and bleeding-control stuff—it was more than
ence, go through an oral board, and they would be blessed [just] a [bleeding-control kit]. “Do you want a Ranger Medic
off to go to that [cycle]. with you?” “Hell, yeah. I want the Ranger Medic.” Ding-ding-
ding-ding: the number would go up. “Man, we’re close to
And the last thing we found was that infantrymen go through 100%!” “So do you want to bring an extra medic who has two
several pillars of education that are built around each other. Pelican cases out of the 47 after we push the primary breach-
Well, everywhere in there it was either they didn’t deal with ing package off, so he converts that [aircraft] to a casevac
medical at all or it was extremely subjective like, “Check with platform? You want that?” “Um, oh, er, I want to bring extra
Brigade Surgeon.” So we went back and interviewed warf- shooters; can I do that?” “Sure.” “Here comes the 47.”
ighters and leaders, and again we were able to confirm the
hypothesis that everything was subjective. That was how he It’s zero-moon 30 in the morning. Everybody’s standing up,
based his relationship to the medical stuff on what his rela- getting ready to exit the aircraft, taking a knee, unhitching,
tionship was when he first came in the Army and had contact to land and go conduct business. Next thing we know, [on

Interview: Rob Miller on Changing Trauma Care 119