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information to definitive care facilities and specialist medical specialties and subspecialties. Likewise, out-of-hospital med-
providers, while supplementing facility healthcare workers in icine has developed its own unique and specialized bodies of
the continuity of care. The BATDOK system can also be incor- knowledge with board certifications in critical care, commu-
porated in mass casualty incident (MCI) responses by assisting nity health, and tactical paramedicine. 19
facilities in setting up color-coded tracking systems; this could
lead to improved patient outcomes during triage, monitoring, This expansion of knowledge necessitates a broadening of ed-
and interventions. ucation. While continuing education is a requirement of the
profession, the realities of day-to-day operations often com-
Another lesson learned from the battlefield, which has shown pete with training priorities. In the face of rapidly expanding
promise in civilian critical care, is the use of POI blood trans- and evolving medical knowledge, continuing education hours
fusion. While whole blood is the gold standard for battlefield alone are not enough to keep pace with the standard of care.
POI hemorrhagic intervention, there are noted limitations for Extracting lessons from our everyday practice through reflec-
civilian critical care units such as rotation of stock, cooling tive practice is essential to the progression of the medical pro-
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considerations, and available space for ground and air units. fession. Deriving value from professional practice takes full
To assist in elevating these strains, the addition of freeze-dried advantage of our most precious resource: time.
plasma and packed red blood cells have been shown as effec-
tive interventions when administered in a 1:1 ratio as an ini- Reflective practice supports the development of expertise. 20,21
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tial bolus to suspected traumatic hemorrhage patients. This While a small number of fundamental life support skills are
intervention can reduce the time to transfusions for trauma needed to halt life-threatening conditions, we see that pro-
patients before reaching definitive care facilities. vider expertise produces optimal outcomes. Patients with
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complex or critical presentations, long-duration transports, or
Noncompressible torso hemorrhage (NCTH) is a leading resource-limited environments all demand a greater level of
cause of potentially preventable death on the battlefield and proficiency and latitude in decision making.
a leading cause of death for civilian hemorrhagic trauma pa-
tients. NCTH injuries are identified as vascular disruption In civilian EMS, the Commission on Accreditation of Medi-
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from one or more of four anatomic categories. These include: cal Transport Systems (CAMTS) requires paramedics working
thoracic cavity (including lung), ≥ grade 4 solid organ injury, in critical care have a minimum of three years of experience
named axial torso vessel, pelvic fracture with ring disruption providing advanced life support. This is presumably to ad-
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with the presence of hemorrhagic shock (systolic blood pres- dress the need for expertise. However, as the saying goes,
sure < 90mmHg) or need for immediate operation. To address “Having experiences does not mean you are experienced.”
these devastating injuries, current and future treatments in- We witnessed this in the 2012 study comparing certified flight
clude pharmacologic with tranexamic acid (TXA), arginine paramedics from the California National Guard to active-duty
vasopressin, and electrolytes including calcium and magne- flight medics with EMT certifications. 1,22 Despite both groups
sium. 12–14 With point of care (POC) testing becoming more being considered experts in their respective communities (mili-
widely adopted with increasing number of options, viscoelastic tary versus civilian flight medicine), the paramedics with years
hemostatic assays thromboelastography (TEG) and rotational of consistent practice outperformed the EMTs with limited pa-
thromboelastography (ROTEM) may see their way to the pre- tient care exposure. This conclusion seems intuitive, but why?
hospital setting in helping to guide resuscitation. Controlling Expertise can be viewed as a function of preparation, practice,
NCTH is more challenging. The use of resuscitative endo- and reflection. The combination of providing care for pa-
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vascular balloon occlusion of the aorta (REBOA) is already tients and integrating lessons learned back into practice is the
an option in the prehospital setting. Additional methods of basis for individual performance improvement. 21
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aortic compression and occlusion are being investigated. One
example is the gastroesophageal resuscitative occlusion of the The progression of EMS educational preparation toward
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aorta (GROA), which is a method that does not require vascu- modern standards of medical professionalism is ongoing.
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lar access. Similarly, expandable foams that are inserted into Consistent access to patients of appropriate acuity to maintain
the abdomen can be used without accessing an artery. The a level of practice that lends itself to reflection is largely influ-
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main goal for NCTH injuries is the stabilization of the patient enced by where we work. In the military, medics often lack
until definitive surgical interventions can be reached. exposure to medicine when not deployed, and have inconsis-
tent exposure while deployed. In civilian practice, it is com-
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Administration and Education mon for paramedics to respond to both advanced life support
As our world increases in complexity, it is tempting to turn (ALS) and basic life support (BLS) calls and staff both medical
toward technological advancement to optimize problem-solv- and non-medical apparatus leading to a dilution of exposure.
ing. As we look toward the future of out-of-hospital medi- Across military and civilian out-of-hospital medical practice
cine, both in the military and civilian sectors, we should also there are limited and inconsistent mechanisms for feedback.
be focusing on how we prepare and sustain the provider em- The lack of communication between medical treatment facili-
ploying those technologies. To continue meaningful progress ties and EMS providers regarding patient outcomes limits the
in out-of-hospital medicine, we must optimize our providers. opportunity for reflective practice, quality assurance, and per-
The key to optimizing providers is reflective practice. formance improvement.
Medicine is a science that deals with the probabilistic nature of As the core truths of our profession state, humans are more
complex interdependent biological systems. It is not hyperbole important than hardware, and competent professionals cannot
that the field of medicine learns new things daily. The depth be created after an emergency occurs. The future of out-of-
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and breadth of medical knowledge expand at an astonishing hospital critical care will be defined, in part, by our ability to
rate as evidenced by the increasing number of board- certified optimize provider performance through reflective practice.

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