GSACEP Lecture Series: Medical Decision Making in Austere Locations

Dr. Regan Lyon and CPT Brian Thebaud share perspectives from their roles on embedded medical teams  in some of the furthest forward medical care in current combat operations. 

Major Regan F. Lyon is an emergency medicine physician and Defense Analysis graduate student at the Naval Postgraduate School in Monterey, CA. Prior to starting graduate school, she served with the Special Operations Surgical Teams, 720th Special Tactics Group, Hurlburt Field, Florida. Major Lyon received a direct commission after graduation from Texas A&M University in 2006. She completed medical school through the Uniformed Services University of the Health Sciences (USUHS) and graduated from the Emergency Medicine Residency at San Antonio Military Medical Center. In 2014, she deployed as the medical director of the 83rd Rescue Squadron at Bagram Airfield, Afghanistan. She served as the Special Operations Surgical Team’s emergency medicine physician in 2017 and Team Leader in 2019 in support of Operation INHERENT RESOLVE. Major Lyon has specific interests in the employment of medicine on the battlefield, extending from point of injury to austere surgery, and its impact on operations. In recognition of her academic contributions, she was appointed an Assistant Professorship at the USUHS Department of Military and Emergency Medicine.

Captain Brian E. Thebaud is a student at the Army Acquisition Professional Education Program in Huntsville, AL. Prior to transitioning to the acquisition career field, CPT Thebaud served as a Special Forces Detachment Commander from 2017 - 2020. CPT Thebaud received a direct commission as an Infantry Officer from the University of Alabama in 2010, prior to attending Special Forces Assessment and Selection in 2014. He has deployed three times in support of operations in the Central Command (CENTCOM) area of responsibility.

For access to the slides and to view the whole lecture, visit:
https://pheedloop.com/GSS21/virtual/?page=sessions&section=SES4HZL7V2023W3RQ

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Transcript

Regan Lyon: 0:00

All right. So my name is Reagan lion. I am a major in the United States Air Force and was recently deployed to operation and inherit results using with the Special Operations surgical team. As the emergency physician, I was asked to give a presentation regarding austere resuscitation surgical care. But I thought the way that we would do this is consider how operations affects medical decision making in those locations. So, I brought on board my counterpart, Captain Brian Thebaud to help me with the presentation. So I'm gonna start out by saying that sauce or explaining I guess that sauce is a six person team. It's designed to bring surgical care and resuscitation as far forward as possible to the frontline. It's damage control stuff, we don't do definitive care. And we primarily serve the special ops community. In our missions, although we can serve a wide variety of people. We are composed of an operation no sorry, our tech, a surgeon, a resuscitation or a resuscitation or critical care nurse, an ER physician, a respiratory therapist and some kind of anesthesia provider. And then we have two people on those teams who lead who one is the tactical team leader, and one is the medical decision maker. And we'll talk a little bit more about how those interact and play into it. I'm gonna let Brian talk a little bit about his team and what his team did while we are on deployment, but kind of set the stage.

Brian Thebaud: 1:40

Right. Yeah. Thanks, Regan. So again, Captain Brian Thebaud. I am a special forces officer, I was the detachment commander for a Special Forces Operational detachment alpha, commonly shortened to an od a. Basically what we are is we're a 12 man Special Forces team, otherwise known as a Green Berets. And we deploy autonomously as a detachment to perform Special Operations globally, the way that we're organized, so amongst the 20 or 12, members of the team, we have specialists in weapons engineering, medical capabilities, and communications. And then we have the headquarters detachment, which is composed of a special forces intelligence sergeant, the senior noncommissioned officer, that is the operation sergeant, a warrant officer, that's the assistant detachment commander, and a captain that is the overall ground Force Commander. So just a little bit of background about how I got to know Reagan and beginning to work with the SOS was we were deployed to Operation Inherent Resolve conducting combat operations against the Islamic State in eastern Syria, the way that we operated was that we would go out Now that pretty much covers it all.

Regan Lyon: 4:17

So this is a overview of what we're gonna be talking about. We'll go over a little bit about the austere surgical teams and the ADA and the the a little bit more what Brian was talking about how the two interact and work together. We're gonna talk about how the surgical teams are meant to save lives, but not at the expense of operations. So you have to keep that in mind, how to do more with with less and especially the extreme resource constraints that you have in an operational environment, and then getting comfortable being uncomfortable. So just to kind of put everyone in the mindset of being somewhere that's not in the hospital. This is a picture that was taken. We were Actually on a convoy, with Brian's team to very far for location, doing some patrolling, and my surgeon was driving. And we were stuck on the road for a little bit because we were waiting for an obstruction to get moved. And my surgeon had to pee. And he looked out the window, and he was about to step outside of the vehicle to relieve himself. And he snapped this picture because it was a little bit too dangerous. So just to give you an idea, these are all unexploded ordinances that were just outside of the vehicle, and we're talking within a 12 foot radius of where our, our our car was. So it's not the same environment of just practicing in some Trauma Center, there's a lot of other considerations that would have caused a lot of problems for us had he gotten blown up. Alright, so we're gonna start out with a case, a 18 year old male presents to trauma in general, or trauma center General Hospital. And he comes in with a gunshot wound to the left chest, his initial vital signs, when we just do a quick triage of him his heart rate was about 115, a setting 90%. This was with a pulse ox. And the patient actually sits up and takes off his shirt and gets onto the gurney. For us. You do a physical exam and there's a single gunshot wound to left chest no other obvious signs of trauma, he's alert oriented, is talking to us a quick fast exam was negative with the exception of the heart window view. So Brian, you can see my arrow correct? Again, okay, so it's hard to see, because we snap this hastily but, and this is on a handheld ultrasound, but this is heart muscle right here. And then this is a pericardial effusion that we noted, that put us a lot of concern for cardiac tamponade. His full set of vitals then as soon as we got this ultrasound done was a blood pressure of 667 over 39, a heart rate of 127. A saturation of 90% and respiratory rate of 18. So things changed very quickly.

Brian Thebaud: 7:26

Yeah, obviously, you were you were treating this patient in a very austere environment? How would you treat a patient in the US trauma center?

Regan Lyon: 7:34

Yeah, so in the US Trauma Center, this patient comes in, well, first of all, a gunshot wound to the left chest, the trauma team is going to get activated. And so a surgeon is going to be either at the bedside or going to be close to getting to the bedside very quickly. If they're not, or if the patient is in acute distress, there's something that you can do a pair of cardio centesimus, in which you stick a needle into that space and drain the blood. However, in a gunshot wound, when you're having a traumatic tampon on, that's likely due to trauma to the heart vessel. And so just draining that is not going to get you anywhere because it doesn't fix the problem. So they need to go to surgery, and they need to go right away. And they're probably going to be getting extensive procedures done in the operating room. So the patient's going to be in the operating room for a while, it's then going to go to the ICU, and may even have follow on surgeries that they need to get done. Alright, so let's talk about obviously, we're not in the trauma center. So talk a little bit about the surgical teams and what the FDA has. So for any way to start.

Brian Thebaud: 8:46

Yeah, so to just to kick things off, I think it's important to paint the picture of the type of environments that we were living in that type of environment that your team was working in. So when we looked at our operating environments, it was a very different threat than what we have seen, you know, in Iraq or Afghanistan, when we talked about it being somewhat a the linear flight and the hybrid threats. When everyone understand that the type of fight we were fighting was not just guerrilla warfare, you know, we were looking at everything from small skirmishes and harassing attacks by the Islamic State to up to 600 man counter attack by ISIS at the time, using artillery pieces, you know, quadcopter drones, things that you would typically see from a conventional military, while at the same time still having the capability to construct IEDs vehicle borne improvised explosive devices and leave those stay behind. So after the fight was over, they're still effective and like the max amount of violence on our partner force. So the situation itself was extremely chaotic and violence operate. environment. And we'll just go over a few key terms you see on here move with the flock to the flight is a four line of our own troops, you can think of that essentially as the frontline defenses of our partner force, where we would say roughly a kilometer behind them and provide that fire support and the surgical support.

Regan Lyon: 10:22

Awesome. So as far as what the surgical team has to do, we're kind of expected to bring the same if not better care for our board, because the operational team is in a very constrained situation in which it's going to be difficult to get a patient evacuated, should they get injured. So we are the first line and being able to do damage control, to try to stop non compressible hemorrhage and decrease the mortality rate of, of our troops that are fighting, as well as help the partner nation forces. So when that expectation is, is there that we provide the same if not better care, there's limitations to everything, obviously, we have a six person team, we're very limited on what we can carry with us, especially if we're going out on and constantly moving, we have to pack a lighter, that we can't bring everything with us that a hospital would have. But integrating with the ground forces, you had to be able to communicate that to the to the commander, we had to be able to explain what our capabilities are, but what also what our limitations are, what we need from them. And basically don't oversell it. So I shouldn't be telling Brian, as the commander of the FDA, that we can take care of a ton more patients than what we really can because that doesn't let him know what we're going to need. As far as support. As far as if we get too many patients need to be able to offload them somehow, it it doesn't set us up for success. So our job as a team is to understand how the operations are going and be able to communicate that and keep a good communication between the operational team and an our team. The other thing is that you don't want to be a liability. So integrating with the ground forces and knowing what their problem sets are on what they're thinking about several steps forward. And what's actually going on, is going to help decrease the liability of putting the whole team at risk. For example, if there's a if there's a situation in which we're going to have to move, knowing that what do we have to do we have to pack up because if we have to move the chances are, we're moving because there's a threat. And if we stay put too much that's going to put the whole team at risk. So

Brian Thebaud: 12:51

I think you need to catch up. But no, no, when you were talking about the necessity of clear communication with the ground Force Commander, I think that's huge, because I didn't mention it before. But obviously, your trauma bay is not staying in the same place for very long. You know, as we're pushing the fight for it, we're consistently moving location. So your ability to communicate clearly, to somebody particularly like me, that does not have a medical background so I can understand what you need for your resourcing requirements and how to best support your team, while at the same time considering all the other factors that go into combat situations, is really critical for me to be able to make key decisions, whether that's going to be you know, hey, give you guys more time to work on patients before we move forward or saying you know, hey, we have to go now and you will see later in the slideshow, how that comes into play.

Regan Lyon: 13:40

Right? Anything else to add?

Brian Thebaud: 13:44

No, I think you hit it. Okay.

Regan Lyon: 13:48

Okay, so, we're going to talk a little bit about flexibility. So, Mark, our surgeon that works with us said all the time, when people ask us like, how do you do it? Like, what's the tricks? What's the, what's the key medicine, things that I need to know? And then it's not about the medicine, the medicine is easy. A patient that comes in and needs a chest tube needs a chest tube? The key is that do you have all the chest tube equipment, or can that chest to wait until the next location doesn't, they may need a chest tube, but does the chest you have to happen now. And if they do need a chest tube that you put in the test tube the same way that you put in any other test tube, you just have to know the the environment and the situation in which you're making those decisions. So one of the key things were our surgical teams is that we have to remain light fast and mobile, which you kind of hit on Brian as far as like being able to move being able to move with the troops like we can't just stay in one place and that staying in one place. We may have to move in minutes versus have an hour notice versus knowing, you know, like we may be in one spot for days. And so tailoring What are packages and what the plan is. A movement is based off of the operations in the mission is, is important because as you get lighter, meaning able to pick up and move things quicker, you can't bring as much stuff with you. And if you can't bring as much stuff with you, you have decreased resources, which obviously play into what, what kind of capabilities you have as a surgical team. This fixture is actually one of our vehicles that we utilize downrange for our surgical teams, we actually had two of them and this one is right next to it. So we have three different configurations for our teams one's by backpack. So if if we are by backpack, each one of us carries with like a backpacking backpack that's full of medical equipment, and then has one pocket that we can put like extra undergarments or food or whatnot for us. But otherwise, like we're basically it's medical gear. And that's pretty much it. Or we can go to a truck model. So basically, we have those backpacks. But we also have the ability to bring a couple of other things, but not much, because we have to be able to pack the back of these, these vehicles with patients potentially for evacuation. And then the last one is what's called a house model. And that means that we set up shop in a house, we're not planning on moving for a while we have a whole lot of resupply. And those different models vary based off of the mission planning that we do with you ahead of time for whatever it is that we're trying to accomplish whatever our mission, our objective is for that. So as that model changes or capability changes, and again, I have to be able to communicate that with the ground force commander and explain that, because our need for support is going to change. If I'm just on backpacks, I'm going to need a lot more resupply than if I have am living in a house where I can keep our like an extensive supply with us. So that changes that changes everything. But no matter what we have, as far as what level we're operating at, we have limitations as far as our medical decision making. And those limitations are diagnostic capability, we aren't going to have x rays, we're not going to have a CAT scan. And even potentially, if you're working out of a backpack, you may not have a Doppler like a pencil Doppler. That's something that we use to check for pulses. It's different than an ultrasound, we used to have that when we operated in one set location and not moving a lot. But that's even though it's a small object, that's a couple of pounds that we don't necessarily need to pack on our back. We don't have monitored holding capability. I mean, we could hold one patient. But if there's six of us and that one patient is there and is pretty critical. That's not something that we can sustain for a long period of time, our supply chain is going to change like how are we getting our resupply for our medical supplies, our disposable supplies, electricity and power, we're not likely going to have that regardless what we're going to be but if we're on backpacks are we going to be able to bring a generator versus trucks, we bought a generator for that. And then blood products blood products, that holding capability versus the demand is one of the biggest challenges that we have in this. In this situation, we just don't have we need a lot of blood. In order to have a lot of blood, you have to have a lot of cooling capability, which means power, usually some kind of fridge. But that means we take up space. So if you decrease the amount of space that we take up to be able to hold more patients, that means we have decreased blood products, which means that we aren't able to treat as many patients and all those things go back and forth and and create variables which affect our capability and therefore affect Brian's mission and how he's going to conduct operations. Any questions? I

Brian Thebaud: 18:50

apologize. Yeah, I apologize. We're gonna address this later in the slideshow, but the the issue of sterilizing your medical equipment, and that type of environment. How did you guys handle that?

Regan Lyon: 19:02

Yeah, um, the best way we could. And there are different ways of doing it. So in the hospital, it's very different than in austere locations in the hospital use autoclaves, which are extreme heat, basically, and you put in, you put it through hours of extreme heat. There were chemical ways of sterilization. And so we brought chemicals that we mixed with our bottled water to dilute it like we brought concentrated chemicals. And then we soaked the instruments in there and hand sterilized them. That was the best way that we could do it because in order to bring an autoclave out autoclaves use a extreme amount of power. And that's a perfect example of, you just have to balance it like you can't have a generator that runs a autoclave because it requires too many amps. In order to have a generator that would do that. You have to have a very large generator that you can't fit in a truck and therefore your mobility is decreased.

Brian Thebaud: 20:03

Yeah, so it really is just about balancing those, the medical requirements versus the operational ones that you have, right.

Regan Lyon: 20:10

And so that's obviously going to play into what you can and can't do medically, it doesn't change the fact that someone may need a treatment, it just changes how you handle that patient at the time. So perfect segue into far forward medical decision making. So because of all this, you have limited diagnostics. So all we had was a handheld ultrasound with a dual probe. So we could do use a linear probe or a curvilinear probe, to be able to do fast exams, that was our diagnostic capability. Everything else was, it was kind of old school medicine, it was really nice, being able to get back to, you know, looking at the patient and taking vital signs and what happened to them and kind of figuring out what's most likely going on. with very limited tools, we don't have labs available to us, we can't check their blood count, we can't check and see whether or not they're bleeding out. And we certainly can't watch and wait. So there are certain conditions with trauma in which you may decide not to go to the O r, and just wait for a little bit to see whether or not they start to get worse or better with vital signs, you know, sometimes they come in too early. And so you just like, well, let's just see, for four hours how they're going to do, you can't do that we don't have four hours, because say we're our three, all of a sudden, you come to me saying there's a counter attack, and we have to pick up and move and now we have a patient with us that we can't operate on because we're going to be on the move. And that puts the patient at risk that it's just not, it's not good medical practice for us. So you have to make those decisions, what you see is what you get. The other thing is transport time. So in 2017, when I was deployed to the same Asr, our transport time to the next location was anywhere from four to six hours. And so we were doing a whole lot more, when someone came in with a tourniquet and have a vascular injury, we would do amputations. And we would do a lot of that the differences is that when we were deployed with you, the next level of care was about an hour and a half to two hours away. And if that's the case, then they can have a tourniquet on because they're not reaching the point of where their limb is going to, to be lost for having a tourniquet on that long. So we were able to ship them. And that decreased the amount that we had to do surgically, which actually freed our team up to be able to take care of the really critical ones and not get overrun so quickly. So that is something to keep in mind. And the other thing is

Brian Thebaud: 22:35

resource wise, that was easier on you guys to sustain yourself for longer periods of time as well.

Regan Lyon: 22:40

Absolutely, absolutely. So it helps us decrease the amount that we use, which helps in the end. The other thing is the receiving facilities capability. So in the partner nation or in the nation that we were working in, the partner forces had a hospital that would do surgery, the problem is, is that we found out they don't have ventilators. So the only ventilator that they had was in the O r, if we sent a patient to them on a ventilator, then that meant that they would have to take the ventilator out of the O R and put the patient on the ventilator, which they can no longer do surgery at that point. Or we would set them up where they had to be excavated. So it was better for us to try to excavate the patient and potentially transfer them even with an open abdomen that's that's packed, excavated with adequate pain control, to be able to get to the next hospital because they don't have any capabilities doing that. Now if a patient had to be intubated, then they would just have to be bagged the whole way and just have that and someone would just have to bag them for the transport and while they're in the hospital, but we try to avoid that as much as possible. And then obviously, operations of you know, whatever is going on around us we have to make those decisions. So yeah, my question.

Brian Thebaud: 24:06

Now, so we'll touch on a little bit later. But you know, as far as I believe, during the first example, when we started looking at balancing operations versus medical requirements, at the time, we can go pretty in depth there.

Regan Lyon: 24:18

Yeah. So the The last thing I kind of want to touch on is this idea of there's no luxuries. So again, I kind of mentioned it, there's no electricity or power, that means everything is generator based. So anything that he elements has to be minimized, you don't have a bogey, but or colorization, which is a very common practice for surgical techniques. And when you're in fact most surgeons are getting they're used to having a bogey or colorization. You don't have that anymore. You don't have the the bear huggers that we put on patients for extreme hypothermia. You have limited equipment. And then on top of it because you're doing generated generator based, you may not have the correct or enough fuel, like, are you bringing a generator that requires unleaded unleaded or mo gas. Because if you do and you're operating in a place that only has diesel, it may be very difficult for you to find the fuel that you need for your generator and then you get one use out of it. And then next thing, you know, you can't use it anymore. The other thing is, in some of our places that we had, we had our own generator that were was a much larger one, well, even our small Honda 2k generator had some maintenance issues, and there's no one where we are to fix them, I can't just take them to a shop to do it. And sometimes people don't have the right parts for them. And then you don't no longer have a generator. This is actually a picture of where's my mouse, I don't know where my mouse like. This is a picture in the bottom right hand corner of my nurse who is heating up some blood. So if you look at it, I'm sure you remember us doing this. So this is a silver pot that we found and cleaned up. And then a stupid cooker that we put, we put water into the pot, we set the suvey cooker for 105 degrees Fahrenheit, which brought the water to 105 degrees. And then it took the cold blood that we had with us and warmed it up to a the perfect temperature and allowed us to thaw plasma, although it wasn't throwing plasma at a extremely fast rate. So it was a little bit slow took about 20 minutes to thaw frozen plasma. But that was the only way that we had to effectively warm up blood and consistently more about blood like that was that was what we had going for us. And then kind of what you mentioned before, there's no running water. So anything that we did that required water was bottled water that we had. And we had to factor that in when we gave you the estimates for water consumption for missions, we had to factor in how much water that we were going to need for patients and for our blood warming process. So

Brian Thebaud: 27:11

okay, so from my perspective as a ground Force Commander, so there's multiple things that in austere resuscitation and surgical care team can do for you. So when we conduct operations, we abide by what we're calling the golden hour standard, meaning that from the point of injury, our goal is to get a casualty to a surgical facility within one hour. multiple factors can come into play, whether or not we'll be able to abide by the golden hour standard lot of those having to do with the aerial medivac platform that we have assigned to our mission. But again, we've all been on operations before where weather ends up coming in the illumination is poor, and that medivac helicopter is not able to fly thus, thus not allowing us to meet golden our criteria and admission gets canceled. The special thing about the surgical teams is that when you can bring that same level of care forward with you on that operation, you're totally mitigating the need to abide by a golden hour standard, because you're getting the same or better level of care, like Reagan mentioned earlier, right there at the point of injury. You know, the other thing I mentioned also is that the a while this is a our standard that we all strive for certain injuries need to be treated well within an hour from that point of injury. So we're really being Are they really acting as combat multipliers to us by being able to provide that casualty care almost immediately after the injury occurs. So from the from the standpoint of a ground Force Commander, that significantly enhances my ability to provide another level of force protection to my team when conducting operations. And then specific to the last mission that Reagan and I did. When you're also treating casualties from your partner force, knowing that they're going to be able to receive casualty care in minutes versus an hour and a half to two hours, which was around the time it would take the ground, evac any of those casualties back to a similar level of care, the amount of motivation that it provides them to continually push the fight forward and, you know, go back the next night, you know, pick up and continue moving forward again, against a very resilient enemy. Kind of the motivation that that surgical element that medical capability brings to your partnered force. It can't be understated. It's an absolute game changer. You know, in a massive fight like that. So well we ask of, you know, a surgical team that's going out with an otaa. So first of all, like understanding the ground force commander's intent. So that's one thing that we have on each of our missions, a commander is going to give his overall intent, which really is, you know, in end state and the left and right limits They were asking, you know, our force to operate within. So as long as there's a clear understanding of you know, what the actual purpose is for us out on that mission, and that surgical team leader, like understands exactly where they fit into that, it just makes things go much easier. So, you know, if I have to make a tough decision, where we're going to move, and I have to ask them to pack up their trauma bay, you know, there's not that, that argument or really, that discussion points on the grounds that can hamper the operation, because they're operating within the GFC is intense, and they know the reasons why we're doing things, which is a good segue to the next point of maintaining flexibility. There are going to be multiple factors outside of just what is happening in that trauma bay and the medical scenario that the FDA is basing their decisions off of. So while it's probably very easy, I would assume for a medical standpoint, to get very wrapped into exactly what you're doing within medical treatment, you understanding that there is still combat that's going on outside that trauma bay, there's all these other decision points that are ground force commander is going to have to make that effect the medical team that may not be outwardly apparent in that moment, so being able to maintain that degree of flexibility, just goes a long way as far as ease of working with a special operations unit, and then the tactical and technical proficiency. So we really got into it yet, but obviously, like, in a combat environment, you're the best form of medical care you can provide initially, is killing the dude that shooting at you, you know, eliminating the threat that is, you know, causing casualties in the first place. So that you can provide the time and space for you guys to work. So understanding that when you're out with an OT a while your primary job is medical care, understand that you may be asked to perform combat operations, you know, we get ambushed on our way down to wherever we're going. Or even just acting as part of, you know, convoy operations and not being a liability. And being able to seamlessly integrate yourself with a team is, is massively important, because, you know, we look for outside of just the medical care, that's one of those teams can bring. But it's also the ability to, like I said earlier, just seamlessly integrate, and not be a liability in a combat situation.

Regan Lyon: 32:27

Awesome. Alright, so let's get to some cases. So the first thing is I'm going to set the stage a little bit this was at one of our, our locations that we operate at. I'm sure that you remember this very fondly? I do. So this is a picture of a trauma bay that we had, this is everything that's in here is stuff. That's what we brought with us. There's no extra stuff, there's no things that are in the hallway, or anything like this is our limitation. With the exception of a couple of backpacks that we have. It's not an in view. But what you can see is I really wish I had my mouse back that I can whoops. All right. Oh, well. So in the back, there's a pelican case that's on the that's on the table in the very back of the picture. That's our anestesia box that has drugs and everything. Then you have this litter stanchions and litter set up ready to receive a patient with a blanket. That way we kept the patient warm, there's lights that are over by the left hand window that we can turn on if we needed to do surgery or have a little bit more light on it. And then we had the roll bag that's hanging on the right hand side of the picture, just in case we have a mass casualty, it's full of Ace bandages and kerlix, which that's the majority of what we utilized when we had a mass casualty event. And then in the very bottom corner in the foreground, you can see a couple of chest tubes that are sticking out of a backpack, we have a single backpack that we utilize for most of our casualties that came in. And that had a little bit more advanced stuff than just the initial tactical combat casualty care, or T Triple C stuff. And then we acquired a cot to use as another bed in case we had another patient that we needed to evaluate in there. But this o r was set up and the reason that's so there is because it's set up so we can pack it up in 10 minutes. That was our standard that we did. We don't unpack anything if we didn't need to. We kept it as close to packed as possible. So these bags were set up where we can easily just close them and latch them or zip them up and then throw them in to our truck. And the reason that we do that is because at any point in time, operations can change and we may have to get out of there. Very quickly, and we just don't have time to sit and unpack every individual thing out. Because if we, if we do that, we may have to leave things behind. And if we leave things behind, that means that we can't take them with us. And if we sustained casualties, when we leave or in route somewhere that we can't, we have decreased resources in which to treat our patients. So we're already putting ourselves at a disadvantage. The other thing is that even though we pack, or we set this up, so that we can pack up within 10 minutes, we always strive to do it faster. But the reality is, is that sometimes we may have to leave immediately, we don't have 10 minutes to pack up. And if that's the case, you have to have a plan and what you're going to leave behind what's the most important thing that you bring with us with you? What's the least important thing? What can you get by with what can you make do with, like, for example, the litter, if absolutely necessary, we can find some other way to put or something else to put the patient on, we don't actually have to have or litter stands, we can do it on the ground? That's not ideal. But when it comes to the safety of the team, that's something you have to consider. Do you have anything else to add run?

Brian Thebaud: 36:10

Yeah, absolutely. So obviously, we tried to set up the trauma bay. And that means I was going to best facilitate casualties getting in there quickly. And expeditiously. So you guys could go ahead and apply to treatment. The The one thing that really, you know, kept me up at night, that was a concern of the GFC was the amount of people that we would let in during these times, just solely due to the amount of casualties that that we were receiving. So balancing the ease of actually getting casualties to you guys, versus a threat of an enemy getting in there that's disguised as one of our own that's wearing either a suicide vest or getting new vehicle regolith, explosives inside of our compound so that we had other mitigation measures, in effect, that weren't always necessarily ideal for the casualties. And this was really getting into the balance between your medical care, and you know, just your operational considerations. But the extra screening measures when vehicles are coming in our compound to ensure that that vehicle is clean, nobody's getting in that we don't know about that it hasn't been screened. And so that when we're delivering casualties to your team, that we know, we're doing it in a relatively safe manner, because it's been a primary concern at the time, not solely, just the casualties that we're taking in, but also the protection of your team. And you know, the rest of us forces that are out there.

Regan Lyon: 37:33

Right? Is there anything, um, as far as the positioning of the trauma within the building. So obviously, we needed to try to keep it where we were there for a very cold period of time. So our concern was wind flow, because these windows didn't really have glass in them normally. So whether or not the wind was flowing, where it would create a significant drop in temperature in the trauma bay, which was not ideal, but we kind of had to balance that because we had mortars going off and back in the building also. And so that sound made it very difficult to compete. I mean, there was no great place of being in that building, regardless when that was happening. But being closer to that would be would cause more sound pollution in our trauma bay and create a little bit more chaos.

Brian Thebaud: 38:27

Oh, sure. Yeah, I mean, obviously, we look for, like, the best possible location for you guys will establish a trauma bay, or just a couple of things you want to know, some form of concealments, you know, bring in casualties. And, you know, we talked earlier about a hybrid threat and, you know, the enemy having, you know, more conventional weapon systems that allow them to be more accurate, where, where rockets going last, we wanted, you know, a congregation of people, you know, in any one area that's totally visible to potential, I mean, again, the windows, it was frigid out there, I remember trying our best to just plug them up with the cushions and pillows, you know, whatever we could find. They didn't ever really get blown out by a mortar. But um, yeah, those are all considerations. It didn't obviously, always work out. You know, as you know, in a ideal situation, it wasn't always a perfect setup. But I think just understanding what those considerations are, and then having some sort of plan to try to mitigate that, as much as possible is important.

Regan Lyon: 39:29

All right, so let's get into our deployed Scenario number one. So the this first case that we're going to talk about, we were actually at that location of the hour that we just showed you. And we were it was after a five or six day mission, and we were waiting for replacements to come that were due to us in about 15 minutes. So we had packed up everything that was non essential from the trauma bay understanding that at any given point, we could get more patients. Well glad we did, because At that point, we had an ISIS counter attack to the partner forces, which made seven patients show up to our doorstep. And one of which was a gunshot wound to the chest that came directly into the trauma bay. So at this point, just them showing up, I don't necessarily know what the nature of these injuries are, but seven patients to be treated by six providers with the potential of one needing extensive surgery procedures, if not an operation, I had to communicate that immediately to the ground Force Commander. And the reason is, is because I don't I'm not the decision maker whether or not we can stay or not. So the timing of this, we're probably not going to be able to treat and send out the seven patients before 15 minutes. So if we have to be able to leave in 15 minutes, then that's a problem. And I am unaware of what everything Brian is tracking, because I'm just concentrating on the medicine and everything. So I have to keep him informed. And one of the things that are going through my mind is are we going to be able to do the operation? What's my decision making going to be with these with these patients based off of what Brian tells me? And then how am I going to evacuate a patient? Are the evacuation platforms with me? Do I need to bring them with? Do I need to bring the patient with us? Those kinds of things? Do you have anything to add to that? Brian?

Brian Thebaud: 41:32

Yeah, definitely. So it kind of goes into a little bit of what we were talking about earlier, where you're the number one thing that we have to do at that time, despite our replacements coming up, is eliminate whatever threat is causing casualties, the last few one or less, we want to replace them to do is to show up and they're getting right into a fight immediately before they're getting all their stuff, set up their weapon set up. Whatever you want is for them to roll right into that situation. And we continue taking casualties because then we're in a really bad spot. So the decision was made initially, hey, we're going to go ahead and stay in fight. I remember you told me exactly what was going on with the casualty. Now other consideration was the team replacing us didn't have a similar team to yours that was with them. So you're already looking at a decrease in the medical capability on the battlefield, we were just to leave at the time. So I ended up making the decision that we were going to stay finish that engagement allow your team time to treat the casualty. And it goes back to a lot of the clear communication we were talking about because if you told me or like you did tell me exactly like what needed to be done. And I'm going to base my decision off of that. So like what the ground Force Commander then owes that team is a time hack for when they need to be done by. Because while in an ideal situation, you guys would have all day to sit there and work on casualties. There, there are certain things that we needed to do once the new team showed up as far as going back and refitting because of, you know, a potential follow on operation that we could get assigned to. And you know, we had to go back and you know, prepare ourselves for something like that. So I can't remember exactly what the time was I gave you I think it was like an hour, two hours or, you know, ballpark. But

Regan Lyon: 43:20

yeah. So this was our patient, the patient that we discussed in the very beginning, you asked me how to treat in the in the trauma bay, that was actually the patient that came in, he walked into our trauma bay, got up on the bed himself and took off his shirt, which makes me think that Hey, he's completely with a he's not in shock. And then as soon as we got the ultrasound, and he laid down, his vital signs plummeted, and he went into shock. So at this point, now, I'm not in a trauma, or a trauma hospital where I have hours and hours and I call the surgeon and they take him to the O R. Now I have a surgeon and N o r, but I haven't initially before talking with you, I have 15 minutes. And so I'm the this is the way that our team plays into it. So remember, at the beginning, I talked about how we have two leaders on our team, we have a medical decision maker or a medical leader. And then we have a team lead. I was the team lead on our team. And so I was responsible for communicating with you tactically and operationally, mission planning, you know, figuring out these things of how this affects how we treat our patients. My surgeon, partner, Northern was our medical officer. And he was the one who based off the patient presentation made a determination of what medical treatments were appropriate for that patient. And he and I would have to communicate, I would inform him of limitations that we have operationally and he would inform me on limitations that we have medically or things that we needed to do in order to save a life and taking that information. And once once I showed him this ultrasound, he immediately started unpacking his surgical stuff, and I asked him how much time you needed, and he said at least 30 minutes, which knowing, he said that, and it gave the impression that we were going to need more than that. But it was at least going to take us over our time, our initial time hack of 15 minutes when the replacements would be there. So at that point we had to go in, I had to communicate with you. Um, so but the things that were I was presenting to you is this patient's not eligible for a medivac, because they're a partner nation force. And according to our rules of engagement, we can't evacuate them. They even if they there was a matter of fact, if we don't intervene, at some point, this patient's going to die, they're not going to make it, we don't have the time, if we just drive them ourselves. We can't do the surgery in the back of the truck, it's too complicated in order to do that. And the neurosurgeons two hours away, and again, this patient won't make it. And simple control over the bleed will take at least 30 minutes, but it's likely going to be longer. And at that point, you gave us permission to go ahead with the surgery. And you gave us permission to go ahead with the surgery. But I was I had the responsibility then of constantly communicating with the surgeon and with you at any given point being prepared to say that's it, we can't do any more close up. And we have to we have to leave it at this but we save their life, we got them as close as possible and gave them a fighting chance.

Brian Thebaud: 46:26

Yeah, I imagine it's probably something that's extremely different than a US drama Center has been told, like how much time you have to work on a casualty.

Regan Lyon: 46:34

Yeah, I don't know of anyone who would dare tell a surgeon how much time they have to work on a trauma patient. That's trauma surgeons, trauma, surgeons are prepared to be in surgery for hours upon hours upon hours on end, in order to to accomplish the objective of stopping the bleeding and getting the patient back to as close as possible as normal and stable. So that's just not necessarily reality, given our situation.

Brian Thebaud: 47:02

Sure. That Yeah, I jumped ahead of myself a little bit, but just to rehash some of the considerations. So like, the unbound team didn't quite have the same medical capability that we have, because I believe they were only working with one physician at the time. So I mean, obviously, you guys being a six person team, it's very different. So I mean, that's, that's a massive consideration when we're looking at a mass scale scenario that they're rolling straight into. The other thing being that when you get out there to the flood, you're your first thing is you're getting your mortar tube set up, you're getting your weapon set up, you're getting essentially prepared to buy, you don't want to roll into a combat scenario before you're ready to fully engage with that. So what we wanted to do was finish that first. So it gave them the time to actually get set up or prepared for their next week or so. out there. And again, with you know, giving you the time hack, not knowing that, you know, we can potentially get assigned to a follow on operation, running low on resources, you know, the time act was necessary, because, you know, operationally, there's still things that you know, you and I could have been assigned to after this and we needed to be prepared to accomplish that mission as well.

Regan Lyon: 48:16

Yep, totally agree. So, the outcome you approved are delay of movement. The surgery commenced, our surgeon actually had to open the chest and do a repair on the left ventricle. He received the patient received 12 units of blood thoracotomy, he got bilateral chest tubes. These are actual pictures from the operation in which Mark was repairing that hole in the left ventricle, which had he not done it at the time that he did, the patient would easily bled out or bled so much into the pair cardium that it would have caused his heart not to be able to pump any blood to the rest of the body, it would have been a very quick death is dispo vitals so when we sent him out, it was 100 and lemon over 5697 heart rate 95%. And he was breathing 13 times the amount of time so when he showed up to her doorstep to the time that we got him into the ambulance and out the door was 75 minutes, which is actually pretty good considering all the procedures and everything that he had done. And one of the things that I want to highlight here is while the surgery was going on, and as we were starting to wrap up the surgery, I was informing you that we are getting ready and we're we're starting to soak the patient and get them ready for evacuation but my team that was not actively engaged in the surgery started packing up everything that we didn't need. So they were working on that and moving things to the truck. And then as the patient was taken off of the or bed and onto the ambulance bed and the medics were getting the transfer information from the surgeon and the anesthesiologist The team packed up the rest of the stuff that litters the litter stanchions and the equipment that we had used for surgery and threw it into the back of the truck. We were able to get our, our body armor on our comms did a comms check, got into the convoy did a quick truck check and make sure we were ready for the convoy, you guys were waiting for us. And we actually left with the convoy before the ambulance actually left the site because they were still getting the patient set up in the back of the ambulance. And it we had to pull over I don't know if you remember this, but the analyst is trying to get by our convoy. And because the the roads were in such bad condition they had, we had to pull over for them to be able to pass us and actually made it. Yeah, so we did pretty good time getting back though. And the patient had arrived and was in the their next surgery to try to do a little bit more definitive care by the time we got back. So Mark was actually able to go to that surgical team and scrub in with the case and do a second surgery on the same patient. But it just goes to show like being prepared to pack up and ready to go and that we we didn't hinder you guys any more. for it. No, I have a question for you. Did this give us any kudos with the partner force? Like did this help us out with the partner force and being able to do this surgery?

Brian Thebaud: 51:25

Yeah, I mean, absolutely. I can't count how many times and not even just with this surgery, but with you know, I don't can't remember how many surgeries you guys did throughout the deployment. I know it was a lot. But my partner Force Commander, you know, consistently coming to me talking about the work that your team was doing as far as you're saving the lives of his soldiers. Luckily, we never had the instance where we had to go out there without you guys. But I, I would fully expect that if we ever showed up without your team there, there would be some heartache amongst the partner for us, because they were very much big fans of the work that you guys were doing.

Regan Lyon: 52:07

Awesome. All right. So we have one more scenario to go through. So this is a picture from the next location that Well, one of the other locations that we were at. And again, you can see that we kind of make do with what we can. So along the left hand side of the wall, you see a couple of the backpacks that we had that had some of our advanced medical equipment. And then in the very, very back is our table that has the anesthesia box on it. And then we have the litter stand and light. And that again is the same that we had this whole time. And we just, you know, different location different a little bit different setup, but same equipment. But we were having so many issues trying to find places to put patients because of the limited situation. And only having one letter and one letter stanchion made it a little bit difficult to treat patients on the ground. So we actually took some of the mortar containers that were discarded and built patient beds. And so these were beds that we built out of these mortar cans to be able to put patients on top of it have a little bit elevated platform to do procedures on. So we made the best for what we have. Yeah. Alright, so this is deployed Scenario number two, I'm gonna let you take it away and describe a little bit about what is going on here.

Brian Thebaud: 53:30

Yeah, sure. So what I mentioned at the beginning of the presentation, that's where we're at 1212 man team, reason that we arrive at that number is because it provides us the ability to split, essentially going six and six, we're still maintaining the same capability as far as you know your weapon sergeant, engineer, medic and communication sergeant, what's your leadership, we're in a situation where needed to split the team for a another mission that we had going on around the same area. So our split team would depart early morning. So you can see here and you know this scenario number two, that your 440 split team departs the base that we were at. around two hours later, I'm woken up because we have an attack going on, which is nothing unheard of. But in this instance, is ended up being probably the largest, you know, attack that we faced, or definitely the largest attack that we faced, all deployment will restarted receiving casualties almost immediately. So you know, while we're still more than capable in a split team environment, you're still losing, you know, six people that could be helping hands, you're doing something so at 630 you see here we had four patients in the CCP and by 12 3051 patients had presented. So just other things that we're doing during this time. We have the mortar Fire missions going on that are trying to break apart the counter attack. We have multiple airstrikes that we're doing at the time, we have half the team there. And SOS now has a 51, patient, mass mass casualty situation that is really an all hands on deck situation with trying to get these guys taken care of Yo, all in the meantime trying to repress the new ISIS counter attack that's occurring, maintain communications with my split element that's way closer than we are and repel the attack. So that was in a gist of it there was there was a fair amount going on that day.

Regan Lyon: 55:37

Yes, there was. So when you were woken up at six o'clock, so these are actual pictures of my team, not on that day, necessarily, but how we were all sleeping in the same room, and you were woken up, and I heard the words counter attack. And previously, when something like that had happened, where there was a significant concern about it, we got a significant amount of patients. So I immediately woke up my respiratory therapist who was sleeping right next to me. And he was also my team Sergeant and I said, Hey, get up, there's a counter attack. And without even saying anything, we knew what that meant. So at 620, we began hearing sirens, and we were already ready to go and waiting for the patients, the four patients that came into the CCE at the CCP, we knew were just the beginning. And then as you can see, it gradually increase. But we kind of had a knowledge based off of if someone's coming to wake you up regarding this. So even though it's common knowledge that there's probably a significant reason why and therefore casualties are going to come. So I had to get my team ready. Even though the there was no mention initially of casualties. We didn't know of any, it's just I knew to automatically assume and have my team ready to go.

Brian Thebaud: 56:55

Yeah. Yeah. And so you can see here in the picture, it's a little spread out. But those are two mortar tubes out there. And you can see all the empty ammo canisters laying next to them, just to give you an idea of the amount of mortars we're firing back during this attack. And you'll keep in mind, it's also directly outside the trauma base to your regular market and the rest of the team trying to perform your surgeries otherwise, life saving procedures while we're shaking the whole house with with mortars, so not a not an easy situation to be in. So my thought process at the time, the top priority is again to defeat the counter attack and provide the sauce, all the resources, the resources, they need. To save the most amount of lives possible. So again, team split, I managing and controlling the airstrikes and the mortars supporting the sauce, and also securing the base near because depending on the size of the counter attack in this one, you're the number of enemy enemy fighters were in the hundreds. So also securing our base because it's could be a very high likelihood that if our partner force does have to retreat from their, you know, first line defenses, then you know, we can become the most forward element out there, which is not the ideal situation for us at the time. But what I needed from the surgical team then so the status of medical supplies, obviously, with a 51, patient mass casualty situation, they are running through medical supplies extremely quickly. And that was also the last day that we were supposed to be out there. So we'd already been out there for five days and running through supplies. Before that. Some things that they were very good at providing me that helps me you know, paint an overall picture of the battlefield and and again, why it made them in the combat multiplier was through as we have casualties coming in, and I'm able to see the types of wounds that are occurring. So whether it's predominantly IED, then we know there's probably a lot of stay behind devices that ISIS is left, or whether it's a lot of you know, sniper injuries that are coming from a particular part of the battlefield, we understand that we may have an enemy sniper and can relatively place him in in general areas. So kind of like the medical information that was fed to me helps me make operational decisions, as well. And then the other thing, just being the brief updates to maintain situational awareness. And again, I highlight brief. And that's because there's so much other stuff going on. And I'm not a medical professional, I just need to know basically the five W's of exactly what's occurring so I can make the proper operational decisions and I can resource her team as best as possible.

Regan Lyon: 59:38

Yeah, so I'm gonna give example of that brief communication in just a second. So let's talk about the outcome really quick. So first of all, this is what I call a gradual mass cow. I don't know if this is actual official terminology, but the way I categories categorize this is there's two different kinds of Mass cows, an instantaneous mass cow. So basically a truckload of patients come to a hospital or whatever and drop off a whole bunch of patients or you arrive on scene somewhere. And there is a whole bunch of people either affected by a bomb that went off or a lightning strike or some other kind of event that takes out a lot of casualties at the same time. And then there's a gradual mass callin which an event continues on and more casualties are sustained over time, there's not a definitive end to it. And also, when you're at a hospital or treatment, location, you have vehicles or some kind of transport vehicles that are bringing patients to you and in waves, so it's not a truckload of patients just show up. And that's what you get, you would get four at a time or seven at a time, or five, and then two, and then all of a sudden, you have 51 patients at your doorstep. And that's typically, that's most of the mass cows that we see, for example, Las Vegas shooting was the same way people were just being scooped up and thrown into vehicles. And the key with that is the first group of patients that you get may not be the most serious patients, they may not be the ones that you need to use your resources on. But you also don't know how many patients are coming behind them. So it becomes a very tricky situation. What's required is a quick disposition. In order to prevent yourself from getting into the situation of gradual Moscow, if you can help it, I mean, 51 patients that are coming at our doorstep, we're going to have a mask out period and the statement, there's no way around it. But if there's, you know, say a group of three patients that are coming to us, and then another group of four patients coming to us, if we have a quick disposition of the patients, the first three, then we don't have to worry about the four others coming and piling on. And now we have seven patients that we're dealing with, instead of, instead of just the next wave of four, you have to still evaluate everyone, you have to do triage and make sure that you're not missing a life threatening event. Perfect example is the gunshot wound to the chest that we just talked about. He was walking and talking. And had he not shown us that the single gunshot wound that was under his arm, than we would never would have known, you know, like if we just went off of the fact that he was walking and talking and just fine. And then offload the minerals. The minerals do not require damage control, surgery, resuscitation and damage control surgery and resuscitation is what we are about, we do not do definitive care, we just stopped the bleeding to prevent any further damage or death. And then at the next location, they do a little bit more definitive control. And like I mentioned, you don't know the endpoint. So that's important communicating with you and getting the information of any any information you have whether or not that attack is still going on or not. And even if it's not knowing that we may have people who trip booby traps or IEDs, that will bring us another wave of patients. So just because the shooting has stopped doesn't necessarily mean that the patients have stopped, but it may give us a little bit better of an idea. When the first patients came in the first four came into the trauma bay, there was one patient in particular that he was the sickest of the group. But he was talking kind of he had a gunshot wound through the back of his neck that came out his mouth. And he was bleeding and through his mouth, but he was able to point to it. He was making sense to his talking his vital signs and everything were great. He was just obviously was concerned because he continued bleeding through the mouth, and not at a high rate just enough to make him concerned. There we did an evaluation on him and determined that he needed surgery. He just didn't need surgery now, and knowing what was coming our way. And knowing that the transport time was only an hour and that his vital signs were okay and there wasn't any signs that there was arterial damage, then he could go to the next location and didn't need our care. In any other situation, we may have considered doing something. Although we were very limited on what we can do for someone like that. But we needed to offload him he wasn't necessarily a minimal, but there was nothing else that we could offer except, you know, antibiotics and pain control and then sent on his way. So for the next six hours, we dealt with 51 blasting gunshot wound patients, six of which came to us and they were already deceased by the time they arrived. Three were urgent surgical and required going to getting some kind of operation from us. Five were urgent, which was defined as needing blood resuscitation, there are 26 delayed patients and 11 minerals. And when you came to you came to me several times asking what the status was or whether or not we need in bed supplies and the simple example of a quick and brief scenario or a quick brief update for you Hey, we have one in surgery right now we have to waiting forum, we have five that we're giving blood to and seeing how they do, we may have to do surgery on one. And then we have 26 that are waiting for transport. And I don't have to get into what they're having surgery for, or, you know, anything like that just giving you some kind of idea of how many surgeries are going to have to take place. And when I'm waiting on so I have 26 people that need evacuation, that clues you in that maybe if you have any resources that can help us with that, to send them on their way, or to you know, send them to us so we can get them out.

Brian Thebaud: 1:05:37

So, yeah, I think, you know, as teams like ours, like continue to work together, you start to you, the brevity becomes more seamless, you know, if this situation had happened, the first mission that we had been out together, there probably would have been a little more, a few more friction points that we encountered here. But I think because of how comfortable our teams were with each other at that point, it was almost just like, Hey, what do you need? And, you know, were you able to do describe that, to me briefly told me exactly what I needed to know, to make those types of decisions, but also knew enough, at the time that you had enough going on that I'm going to just get you guys what you need to sustain yourself, give you any extra hands we can to help out and otherwise, I'm going to go outside and fight the fight and stay out of your way.

Regan Lyon: 1:06:23

Yeah, yeah. So the other thing that you have to consider in the maska, which obviously, if a patient needs surgery, they need surgery. And but when as soon as we make a decision to take a patient to surgery, that takes at least three people out of my team to treat patients. So that leaves me with three, three people to manage the rest of them. So I'm the 50, well, 51 patients that we had, one is in surgery, 50. Others are requiring treatment and triage. And we only have three people to do so and arguably probably only two because the critical care nurse is helping with the actual blood resuscitation for the five others that are in critical condition and needing blood support. So those are decisions that I had to make with Mark and trusting our surgeon that he's decided to do surgery on truly people who are not going to make it based off of everything else that we talked about earlier, and the Medical Decision makings that he is he is letting us know and understand that by doing surgery, we're taking our team now down to to hack. So not only is your team at half, now our team is at half. And we're having to work this which means that we may rely a little bit more on your team. But I also have to remember that there's a fight going on, and I can't take your team, the medical mission is not the priority. In this, as you mentioned, the best medicine and in such a situation is to to neutralize the threat. And you guys were working on that we were just trying to decrease the casualties from that. So keeping that in mind, everyone is busy. And we had to figure out how to best force multiply and get the job done. Yeah, absolutely. So that kind of comes into this last or this next slide. So in order to do that, we have to be a team player. And for the medical team, we have to know each other's roles. I have to know that, for example, my surgeon is the one who makes the medical decisions, which I've mentioned a couple of times, and he has to keep in mind that I'm the direct line of communication with you to know operational and tactical decisions. And sometimes our medical decision making is not going to line up with that of the decisions that we would make if we were in a trauma center. establishing those lanes clearly up front and understanding when one person's direction trumps the other one is important in order to get along. It's part of the team dynamic and it has nothing to do with one person knows best or not. It's just a checks and balances that we have within our team to make sure that we're doing the right thing for the patients ultimately, and then realizing that even though we have a medical recommendation, that decision lies with you. As a ground Force Commander, you're the one who's going to make the decision based off of the information that I bring to you. I just have to communicate the risk and benefits of doing something or not doing something. And that comes kind of with trust, you know, the other thing is feeling comfortable stepping in. So when we're in the trauma bay in the United States, there's a ton of people in there and they're doing a whole bunch of other things. And as an emergency physician, if I'm in charge of the airway, for example, and the nurses setting up the rapid infusion or infusion for blood. I may not understand all the intricacies that come with setting that equipment up and Being able to put the patient into getting blood rapidly, I know that it's happening. But I don't necessarily know how the important part here is to know how to like figure that out, because at some point, you may be the one that has to do that. And in this case, we don't have a rapid transducer with blood. But some people have never actually prepped a blood line to, you know, for transfusion, and prepared it to actually transfuse blood. And that's kind of important to know. So you don't infuse a whole bunch of air into the patient or clots into the patient and knowing how best to do that. So figuring out what you don't know asking someone do to do it and trying to figure out how best to do the job. The Perfect example is the patient or the picture in the upper right hand corner. That's me on the left hand side, and I'm putting in the IV. And if you talk to me talk to er nurses in the United States, and the number of times they've seen an ER physician actually putting in an IV in a trauma situation, it's very few, because we just don't do it that often. That's not our expertise. That's not what we do. But in these situations, I had to become very proficient at it, because this patient came in at 10 o'clock at night, and I was the first person to get woken up. And I was waiting on the rest of my team to get dressed and come into the trauma base. So I had partner medics working with me, and I had to I put on the tourniquets, and then we were trying to establish some kind of line to be able to start a resuscitation. And in the just working in the US, that's not necessarily what I would do. The other thing, so trust is I mentioned it before, but that's one of the most important things to have an effective team. In fact, effective teams in this environment have to trust each other and trust each other's judgment. So when I told when I did some triage for mass cows, and I told my surgeon, hey, this guy is sick, and needs to go to the or he didn't question me, he trusted me And believe me, and but I would only reserve telling him that when I when I needed it, if there was any hesitation on my part, I would say hey, can you come take a look at this patient like I didn't, I didn't over, I didn't abuse that relationship that we had, I let him know. And that kept it. So he knew I was only being very demanding of this patient needs to go to the surgery. Now, when I was very serious, and this patient needed it. But anything like that of being able to effectively communicate and have faith and trust in your team of knowing what they're talking about. And then sorting, you know, if it ends up not being the case, if I was wrong, and something sorting that out later and doing a hot wash, or after action and figuring out what went wrong. So

Brian Thebaud: 1:12:48

you mentioned building the trust, I think a key part of that also is you know, when your two teams are going to be working together as closely as ours did, like granted, you have your team and I have my both very different capabilities. But at the end of the day you're going out as as one team on combat patrols. So integration with all the operational planning and contingency planning shouldn't just be yo da that's to be the ADA, and every asset or enabler, that's, that's traveling on that combat patrol with them. So our ability to train as a team and integrated amongst each other and whether that's you know, our guys giving your team more training on weapons or communications to to bring you up to a higher level that when you showed up in country, or that's you guys training your myself for, you know, a camo guy on how to get the chest to wear, you know, our medics do more advanced procedures with an ultrasound or whatever else, I think builds a lot of trust, just understanding like how proficient you guys are what we do, and you guys understand our proficiency level, you know, in our combat tasks. But at the end of the day, it's building cohesiveness. And it's building strong teams. I think that has a lot to do with developing trust early on.

Regan Lyon: 1:14:05

Yeah, absolutely. And the more things that we can do and and making sure that we're on the same page, the better. So

Brian Thebaud: 1:14:15

yeah, absolutely.

Regan Lyon: 1:14:17

All right. So time for this conclusion. So what's the way forward? So as we mentioned, it's pretty inevitable that based off of the way that conflict is going now that we're going to be putting ourselves in more austere locations and medical teams are going to be postured in ways that with operational units and outside of the normal hospital environment. So we have to start getting away from the fixed facility mindset. We have to start getting into this ability to move ability to be flexible, but provide the same medicine just with less stuff, less help. The other thing is that there's an austere and tactical mindset that has to happen. You Have to get, you have to start realizing there are other external factors that are going to determine how you treat patients, you're doing damage control, only, you're not doing definitive care. So it's stop the bleed, stop the contamination and, and get the patient to where they can be transported, and tried to decrease the amount of resources that you utilize because you have limited resources at your disposal. And then consider all the operational considerations that you have. If you have if you function as a, as a mobile team, you have to start getting used to doing this learning to troubleshoot. And if you do, so, you're going to be able to handle any deployment. So if you end up getting put in a fixed facility, then that's okay. You're capable of doing it if you have to be mobile, but but, you know, it makes life at a fixed facility even easier, because then you have a lot more resources at your at your disposal.

Brian Thebaud: 1:15:59

Sure. And then, as far as, you know, my perspective goes from the special operations teams. Yeah, I'll be the first to admit that I didn't know a whole lot about SOS, or just, you know, austere resuscitation surgical teams before I showed up. I think where we could really make our money is integration prior to deployment. You know, I think looking at a training events, you guys could be included in where your your capability starts to become more widely known around, whether that's the Special Forces community or really just the soft community in general. So people know what's out there. goes back into building that trust and cohesiveness we talked about earlier because if we can start building that prior to actually going forward on a deployment, then I think we have a much better understanding of, you know, our capability as a team when we arrive in whatever country you're going to. But we're also able to train that you know, specifically at home station and build lasting relationships that that just, you know, pay dividends in the long run.

Regan Lyon: 1:17:03

Totally agree. And that way we can do presentations like this and help help push our our medical capabilities even for further forward. So

Brian Thebaud: 1:17:15

absolutely.