Page 125 - JSOM Winter 2019

A Case for Improvised Medical Training

Michael R. Hetzler, NRP

ABSTRACT
The hyperresourced, uber-controlled, ultrareactive, constant clinical expertise in oversight, and the presence of ideal condi-
environment that we have come to know in the past 20 years tions. Discounting anything else is unrealistic, unfair, and un-
should not be mistaken as the norm in conflict. In truth, un- professional. A complete understanding of medical support to
realistic expectations of both commanders and systems in re- combat operations is only absolute when seen firsthand.
sourcing is presently being reinforced almost daily. Only in the
past few years of this decade have the majority of allied forces The future of conflict has been analyzed to be mid to high in-
experienced challenge in resupply and support in contingency tensity, political in nature, and with an expected application of
operations. When logistical lines are cut, limited, or untimely, hybrid strategy. Large-scale casualty estimates, a lack of air su-
we must know and exercise other means of providing the high- periority, limited to no casualty evacuation, and complicated
est level of medical care possible—if not with indigenous ways civil–military interaction should be prepared for. Systematic
and means, then by improvisation. History has proved that denial of services means limitations in resupply, communica-
improvised medicine can be capable, professional, and ethi- tion, control, and continuity of care. Intangible effects of legal,
cally sound if practiced properly and to standards, the price social, financial, and media warfare will further complicate ac-
being time, education, and investment in the requirement. tions. Nonpermissive environments and uncontrolled engage-
Most often, these are already time-honored means of care. ments will have affects that cannot be denied although absent
in existence for almost a century of experience.
Keywords: military medicine; environment; equipment de-
sign, unconventional medicine Redundancy is key in planning and preparation. Entering any
surgical case, diagnosis, or therapeutics, the provider should
have a plan for that action and all contingencies possible when
he or she is inevitably deviated from their intent. Operation-
Introduction
ally, improvisation can be part of that redundancy as alterna-
Recent decades have proved rich in resourcing success during tive means of care.
low-intensity conflict. A controlled, methodical, and scalable
conflict has provided almost every known need and cost while The nongovernment community and international organiza-
extraordinary efforts in lifesaving have become the norm. Al- tions in medical service recognize, and implement, care and
though logistics can determine the outcome of conflict, we logistics with improvisation as a matter of expectation. The
must also prepare for proper resourcing when without. Realis- commonalities in mandate-directed, financially limited, and
tic expectations for the uncontrolled operational environment austere humanitarian services offer many similarities to Spe-
must be supplemented with redundant planning and expertise cial Operations, and discussion between our communities
in the manufacture of needs when resupply is not possible or could provide great insight into this subject and more.
pragmatic.
Improvisation will be realized at every level, and many exam-
In terms of medical equipment and supplies, this require- ples have already been seen in the past 4 years. The Syria ex-
ment can be daunting, but encouragement can be found in perience mirrored mid-intensity conflict in weaponry, kinetics,
the knowledge that medicine has been practiced successfully civilian affect, and moving front lines. There improvisation
for many centuries using more primitive and less sophisticated was seen with creativity in the use of technology, optimizing
methods for exceptional care. supplies, and altered therapeutics while medical personnel and
facilities were under constant attack from the enemy. Improvi-
sation was just as invaluable for systems support in preventive
The Requirement
medicine, logistics, and evacuation as it can be in therapeutics
“Amateurs study tactics; professionals study logistics.” and equipment.
—An executive leadership principle
Role 1 care needs may include unique ways of blood collection
In the pursuit of ensuring zero preventable deaths and unneces- and provision, improvised tourniquets and junctional con-
1
sary suffering, we regularly find ourselves focused on the details trol, pelvic binding and skeletal stability, and hypothermia
2,3
4–6
of therapeutics and the rigid application of guidelines while too prevention and maintenance. Rescue capabilities, improvised
often unconsciously applying clinical standards and judgments. litters, and casualty movement continue to provide both re-
This approach demands assumptions of resource availability, quirements and opportunity. Role 2 and Role 3 services have
Correspondence to michael.hetzler@JSOMonline.org
Mr Hetzler provides independent consulting and is currently a lecturer for the University College Cork in Ireland.
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