Page 126 - JSOM Winter 2019

already seen three-jar and gravity-driven negative suction, im- just as sound. As leaders and mentors, we are required to de-
provised wound vacuums and dressing theory, sterilization, mand more than is expected under normal circumstances; only
and the reuse of material and equipment in the most Spartan then will we enable success with expectations and standards.
conditions of Operation Inherent Resolve. Recovery and criti-
cal care needs will increase with pain control, critical care, and An example is often used in prolonged field care (PFC) train-
nutrition and hydration. ing. Standard expectations are the use of a “critical care set”
that includes equipment and diagnostics such as monitors,
Surgical care in mass casualty, nonpermissive environments, bed side lab values, ultrasound, and telemedicine. Through-
or operational medicine has required and will continue to re- out a long exercise in PFC, take the opportunity to remove
quire, improvised medicine. Successful but extreme examples equipment from the care provider. Asking medics what they
of these requirements can be realized from the Southeast Asia could sequentially give up through the exercise and taking
POW experience during the Second World War. 7–15 Here in the those things away as they choose demands critical thought
camps of Burma and Thailand, surgery was affected for years and a fuller appreciation of redundancy in planning, appreci-
with makeshift instruments, primitive sterilization, and even ation and stewardship of equipment, and doing without when
blood transfusion without anticoagulants—all with a surgi- forced to. These lessons take on even greater dimensions when
cal mortality rate of 2%. 16–18 Even primitive, hand-fashioned looking at the 18D and SOIDC scope of practice in nonper-
prosthetics from the camps proved more effective than com- missive environments where surgical care, anesthesia, rehabil-
mercial products after the war. 15 itation, and animal husbandry are needed or in the Pararescue
role of rescue under adverse and time-sensitive conditions.
Ethically, improvisation is just. First, as leaders in our commu-
nity, we owe it to the next generation to instill those qualities Improvisation is directly supported by the applied imagination
of creativity, ingenuity, and problem solving as a professional approach to problem solving described by Alex Osborn in the
responsibility. We should also ensure that pragmatic and real- mid 20th century, himself illustrating the process as “storm-
istic expectations are understood with humility; duty to both ing the problem in a commando fashion.” His four rules for
the future patient and to the taxpayer requires that we recog- creative problem solving set the path for ‘thinking outside the
nize the need and mentor the proper mind set of stewardship box,’ and this educational theory even included methods to
and standards. personally become more comfortable with discomfort in the
consideration of nonstandard processes and actions. 31–33 These
Second, as healthcare providers, the patient will be the most principles form the very structure in culture and mindset for
important beneficiary of ensuring that solutions can be found SOF and operational medicine and only recently have creative
when resources cannot. The operating mindset of the care studies been recognized as an academic subject. 34–36
provider has to be adjusted to work under the most extreme
conditions of need. Self-reliability, ingenuity, initiative, doing Mindset is probably the most necessary trait of all. The ability
more with less, and perspectives need to be cultivated in all of a provider to adjust, adapt, and overcome obstacles in med-
medical communities. Conversely, we should also be vigilant icine and operations is rare in this age of technology, expecta-
in the research, evaluation, and best practices of improvised tion, and resources. When those benefits are absent, who will
medicine. 19–29 Recognizing the need will encourage study for still be able to perform? The mindset of accomplishing with-
best practices and integration into training and exercises. Suc- out must be recognized and exercised now for the future, and
cess in recognition of the requirement will ultimately provide culturally we should develop problem solving attributes and
quality research, reference, and recommendations. provide tools for solutions. Planning and redundancy cannot
be facilitated simply by supply lines in the future environment.
Training
Conclusion
“Technology is important . . . the best instruments
on the battlefield are your hands, fingers, and brain, “We improvise only when we have to, not because
trained for optimal use. They seldom break, they are we can.”
hard to misplace, they can be upgraded continuously,
and frequently invent new solutions.” Improvised medicine is a requirement for the future battle-
—Dr John Holcomb 30 field—mission analysis, command guidance, and history all
validate the need. Culturally, we should always plan for the
The first step to future success is the realization of the require- worst-case scenario operationally just as we do in patient care.
ment. The “realpolitik” of future medical challenges is already We should identify those needs in equipment and supplies
secured in command guidance, mission analysis, and history, most at risk and begin educating the solutions possible while
where we can find many solutions with time-honored success accountability should be enforced to the best professional and
and these pave the way for plans and preparation. ethical standards of care. Mindset is paramount; the ability
to practice medicine successfully without resources still meets
In the most professional sense, the next challenge may be the the requirement to practice medicine. The references provided
acceptance of improvisation, often critically thought of as a with this editorial are only a trace of proven methods and ex-
conscious sacrifice of clinical standards. It is important to rec- periences for care—the rest is up to leadership, preparation,
ognize and enforce that care outside of hospital walls should and responsibility. 37–54
be held to the same standards while also understanding that
adaptation comes with limitations. This can be too easily dis- Acknowledgments
missed to the charge of clinical standards, but the same demand I have great appreciation for MK, KS, PT, and PB for their
is required of combat arms and our obligations in conflict are review and support.

124 | JSOM Volume 19, Edition 4 / Winter 2019