Col John Wightman
Professor and Chair, Department of Military & Emergency Medicine, Uniformed Services University
Col Wightman offers very concrete tips on how to tackle common military problems.
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Hello, everybody. Welcome to this session in the leadership track on getting what you need. Colonel John Whiteman, chair of the department of military and emergency medicine at the Uniformed Services University. I've been in uniform almost 31 years now, I hadn't been sworn in five weeks before a wreck invaded Kuwait back in 1990. Prior to that, I was a EMT in a semi rural Colorado area and then a inner city urban paramedic for the city of St. Louis. And pretty much my entire career has been in academic emergency medicine other than a couple of wings staff jobs, one for the sudden 11th Human Performance wing, which is part of the Air Force Research Laboratory at Wright Patterson Air Force Base in Ohio, and the 24 Special Operations Wing at Hurlburt. Field Florida. So here's the standard disclaimer slide. My views are my own and I have no conflicts of interest. My educational goals for this session are to talk about the differences between what you want and what's required for you to have like to suggest kind of a generalized approach to two different ways of achieving that. And then talk about three examples from my career and provide some summary advice at the end. So, desirables and requirements, basically, something that you desire, you may be able to achieve. But if you're running into some pushback or some roadblocks, you may want to either tie it to an existing requirement or make a new requirement. And really, the beginning of the definition of requirements is really the key phrase establish needs, it has to be a need to some higher authority that has the power to granted or otherwise, make a decision. And it has to be established by that higher authority in writing, so that you have a document from which you can work. So what are the general approaches where you can kind of look at this as either bringing the decision makers to the requirement and showing them that they need to meet this requirement, or bringing the requirement to the decision makers. And we'll talk a little bit more about that. This is kind of like when I teach at USU. For patients or casualties, you can bring the resources to the patient by like moving like a roll to like maneuver surgical unit up to where the patient is, or you can bring the patient to the resources is evacuate them from like row one to a roll two. So likewise, you can persuade the decision makers to meet an existing requirement. You've got to do your research, you've got to look for any applicable guidance. You've got to conduct and document your thought processes your analysis, what are the benefits and risks to the organization not just to you write a bullet background paper that helps you frame it, but it also makes a one pager that you can provide to all stakeholders and then develop course of action briefing now that may or may not be before you do an initial briefing based on the background that you've developed. It could be developing a complete course of action briefing prior to presenting anything to a decision maker. So you can either just do an information briefing or a course of action briefing or kind of both combined, depending on how the decision maker wants to receive that. You can also adjust an existing requirement or create a whole new requirement. You know, make sure that you're addressing any reasons for objections, identify your stakeholders, get them on board, find out who is for who's against what the people who are against what the reasons are, who's for that maybe they've got some additional reasons to make this a requirement, whatever it is that you need, that you may not have thought about. Find out who's actually got the responsibility for making the change, and then make it easy for them to change. Just present your arguments have all the work done in advance and then presented to them and hopefully they can make a decision on the spot. So here's some examples on so you know, some of you more junior medical off officers and others may not realize that 20 years ago, emergency departments in many MTF 's were prohibited from doing moderate or deep sedation. That was a problem for us. You know, back, when I came in, there weren't as many board certified emergency physicians, there were only 50 Something training programs in the country. A lot of the military didn't really know what to do with us versus somebody who was a had just a year of postgraduate training, and was just thrust into the emergency department. And so there was a medical group instruction, which is what MD gi stands for, for those of you aren't in the Air Force. And all emergency physicians that were residency trained, were privileged for procedural sedation, but there was no depth specified. And this MD Gi, prohibited moderate or deep sedation outside of the operating room aside from performed by anesthesiologist or CRNA days. So the problems for that, you know, we're clearly that's a problem for emergency medicine, it was also a problem for a lot of our consultants. And mostly it was a time delay, you know, it was actually easier if they came down, because then you could have one person performing the procedure, one person watching the sedation, but sometimes, you know, in the middle of the day, when operating rooms were running, you know, delays can be 456 hours. And in the nighttime, there's only one person on for the whole hospital and kind of back then it was actually Wright Patterson, at least where I was at, at that time was a pretty busy place. So, you know, there was a disconnect that even on call RNA students could perform moderator deep sedation outside the operating room, but board certified emergency physicians couldn't, you know, this is like a first year internal medicine resident saying, I don't think it's cardiac. So I don't think they need to be admitted, or first year surgery, residents saying something like, you know, not an acute abdomen, when, you know, many of us have seen way more acute abdomens than they have. So this was a disconnect. It was kind of a pride thing. But it was also important for patient care. So we defined the problem, we documented every delay of care for a period of time, try to make an effort to document the qualitative effects on patients. But that was a little harder to do unless there was a patient complaint. But we could definitely get quantitative data on throughput metrics. And, you know, which of these do you think, you know, was, you know, got the leadership's attention more? You know, it was the data that they had to feed up to higher headquarters at that time, you know, now it's, they got to feed up to DHA. So we looked at the standard of care, we looked at ACGME documents for residency programs, we looked at the set clinical policy at the time, we pulled key clinical articles. And we looked at other hospitals in the area, because really, it's the standard of care in the region. That is the important parameter. Even if it was really quantitative metrics that got people kind of moving on this, the outcome was going to be the same no matter how we made the argument and a dual arguments are often better than a single argument. So we wrote that background paper, framing the issues, circulated around to the stakeholders convened a working group. You know, it's interesting that even now, you know, 2021, there is no written requirement to practice at or above the standard of care in the community, in any air force instruction that I or jag here could find. There is a requirement to conduct a standard of care determination when the standard of care has come into question. And ergo, that means that you really have to practice to the standard of care. And that just makes total sense. It just was interesting that there was no actual written document, mandating that. So we wouldn't looked at the clinical policies. The key phrases in this ones, this is back from 2005, is that, you know, emergency physicians are trained. It's a core competency of the specialty, and emergency physicians routinely provide this service throughout the country, not to mention the region that we're in. So we convened this working group. You know, the anesthesiology representative pretty much argued that only one specialty was qualified, which was essentially being exclusionary emergency medicine representative argued with evidence Since that emergency physicians were qualified and made it inclusive, and made it a larger part of the team that was delivering patient care in the acute care and emergency setting. It turns out that through some research, we also found that anesthesiology was not credentialed to provide procedural sedation outside the operating room. So that kind of also boosted our argument a little bit. So we've talked to the chief of Clinical Services. No, that's called the DCCs and other services and csdh in the Air Force, basically decided with us on on a lot of reasons and rewrote the medical group instruction. The problem with that was it wasn't staff through us, so we didn't get to see it. And when it came out, when there was a surprise clause that said that emergency physicians could do it could do sedation, but they couldn't use a non reversible agent. And so I pretty much excluded three of our biggies. tahminae, ketamine and proof protocol. And we could still use them for induction for intubation. But we couldn't use them for procedural sedation, at least at the moderate or deep level. So you know, a pride file, went back to the Chief Clinical Services, and also went to the med group commander, which essentially, as the MTF commander, and, you know, said, this needs to be redone, I knew that there was a new chief of clinical services coming in fairly soon. So we kind of slow roll this and just kind of tried to grease the skids and make sure that we had it all teed up for that person. And really, once they got there, we made a quick pitch and got appropriately staffed. And then we got the med group instruction adopted, there was a lot of pushback from the chief of nursing services, saying that Emergency Nurses, including some that were certified, were not qualified to do moderate or deep sedation with the provider. And we eventually got that fixed to, we just had to prove that it was safe to do in the emergency department. And we continued, the one person does procedure, one person does the sedation policy. So once we got it adopted, we actually redid our metrics to show improvement, and that what we were saying is going to improve throughput actually did the trick. And it did. And so people started listening to us on other causes that we had to fix as well. So the other thing I want to talk about is training that was disapproved. So back, you know, at the beginning of the global war on terrorism, airports, flight surgeons who had only had a PG one year, we're having to fly critical patients from place to place on rotary wing platforms, particularly in Afghanistan, but somewhat in Iraq too, on and you know, with only one PGY one year, they didn't have a lot of ICU experience in their internships, and they really had no additional critical care training. A lot of them felt very uncomfortable doing this now, you know, our pair rescue men that were often with them, were pretty high speed, but they don't do you know, critical care transport, like a CCAP team does. So, you know, you know, there weren't really was no doctrine that kind of foresaw this occurring when 911 happened. And, you know, the first critical care transport team corps that Seacat course was in 1998, so predates 2001. But these other teams that were more designed for rotary wing platforms, because a Seacat team is three people and depending on the package, five to 800 pounds of gear and not putting on that on a Blackhawk and then trying to fly over you know, 14,000 foot ridges. So they came up with the idea the critical care, transport team ticket and eventually settled on the tactical critical care evacuation team attack it. But those were still in the pipeline. So there really wasn't anything for these flight surgeons at the time. So you know, this was the applicable reg here. And so you know, the courses that were required, and it well I guess, I should say recommended at the time, were The aeromedical evacuation course, C four which include included a TLS, advanced trauma, life support and emergency medical technician basic course, that was really it for medicine for these flight surgeons. So really couldn't convince anybody that they needed more postgraduate training or going to the Seacat course. But when we realized that this was really mostly an F sock issue for these flight surgeons flying with the PJ's, we narrowed the focus to F sock rather than trying to get the entire air force to change. And we got warfighting line commanders on board to really pretty much demand this capability. So a new asset construction was written at that time, it was 48 101, newer versions or 4810 10, if you're interested in looking at what is current, but basically, they had this statement right up front, that whoops, sorry, need to go back one. Wrong click here. So the key statement here really is operational assets, medical personnel are required to provide only the very best error medical care and critical care. And who could argue with that kind of misstatement? You know? No, they're gonna not provide the best care they possibly can. Well, how are you going to achieve that? So that same table had all this stuff written into it. And, most importantly, for this mission, the initial critical care or medical transport course, which is not exactly the right term, but it's still the Seacat initial training. And so these flight surgeons that had to do this on rotary platforms, at least got that two weeks of training, and there's some hands on with that. Not a lot with actual patients, but still was better than they were getting before. The other thing that you have to do is dig into regulations and get those little nuggets, they're just really important. So when I was with special operations, we had a purple heart that was denied pararescuemen he already had one. He sustained a combat injury and a undisclosed location, basically a grenade explosion immediately in front of them. An 18 Delta on the scene, Army Special Forces Medical Sergeant documented a post concussion syndrome. But as you'll see, an 18 Delta is not a medical officer, and it takes a medical officers documentation to document mild TBI. But this was prior to my arrival at the two fours. So this was submitted once and sent back that there was insufficient documentation of the TBI but not really a good explanation as why. And it was submitted again with more documentation on the TBI but again, rejected. So that's when I ended up picking it up. So if you go to the instruction, and you know, the Air Force instruction comes right from the Department of Defense Instruction, so this could apply to other services as well. If you, you know, we had to first ensure that the person was eligible to receive the award. So this says that any member of the Armed Forces of the United States who received wounds while serving with friendly forces engaging in armed conflict against an opposing armed force of which the US party is not a belligerent. That was absolutely applicable. But then there's this little see notes four, five and six about the conditions for which, you know, being wounded means Okay, and so TBI is one of those. So I looked all that up. Okay. And if you look at TBI, it says that the medical documentation was contained evidence of residual cognitive deficits, doesn't say for how long and functional impairment requiring medical treatment or support by a medical officer Well, there was no medical officer in this data mass location. And so the 18 Delta's documentation essentially didn't count on, there are some caveats, the medical officer documents that medical officer would have made the same conclusion had a medical officer actually been there, but that wasn't flying. Okay. So we then, you know, looked at other things that were in here, you know, so, so that was this holes, you know, note six talks about that. that medical officers don't have to be there. But then we went looking for other things. And having known the PJ's medical record, I knew that he had had some wounds, one of which included a retained foreign body that had to be removed. But that wasn't in his record either by the retained foreign body was but not the fact that it was removed. So we basically had to track down a physician assistant, a Navy's Special Warfare physician assistant, who had not written that procedure note, that person was deployed, we had to find him in his deployed location, he had to recall the details, add a note to the record, we had to provide sworn testimony that it was actually you know the truth. And so once we got that I contacted the awarding authority to expect a third submission, I informed that person of the additional criterion that I was going to be submitting with and not asking for a TBI determination. I also asked them that, you know, not to have not to let their staff screen out the package before it got to their eyes, I did get kind of a angry email from the deputy SG saying that we screen everything, you know, on their merits, and said, Well, I just want to make sure that I've kind of got the skids greased here, and that nothing holds us up. And that doesn't get denied, before somebody does look at those merits. So we ended up submitting it, and the declaration got approved. Although the awarding authority never got back to me that they actually approved that the only way I found out was from the PJ who, when they actually made the declaration award. So kind of in summary, you know, don't keep challenging the status quo, if it's not working for you figure out a way to make it work for you. And, you know, I heard this phrase from, I think it was at a conference, Jeff Bailey, Colonel Jeff Bailey's trauma surgeon in the Air Force, said be persistently dissatisfied with the status quo and be relentlessly disruptive in getting things fixed. So that's always stuck with me, it's actually on my whiteboard in front of my desk, just to keep reminding me of it. So my summary advice to you is, you know, if you need something, define the problem with the parameters that are important to the decision makers, not to you necessarily, do your homework, look at all the doctrine, regulations, policies, other influences, anything that's in writing that you can bring to bear. And if it's not writing, you know, get something written, that makes it a requirement and establish need, find even the smallest nugget that shifts your request from just desire to require do I can load the purpleheart, the fact that there was retained foreign body and then get that document and match that up to the requirement and get the award made. same would go for any other declaration that you're trying to get through. Do your homework, thorough analysis, because and particularly looking at risk, because that's what commanders understand everything is in risk and risk mitigation. So work on that. Do your information, paper and your information briefing, do your course of action analysis and present your arguments for a decision briefing. You know, look for workable solutions that, you know, get your, you know, figure out the solution, don't just bring up a problem, but bring up a solution. And documents, your successes, you know, do the data even after you get what you want, so that you can prove that you know what you did was actually successful. And don't rub it in when you when, you know, you may need another request. You may need somebody on board for some other problem that you're trying to fix. So, you know, it's great when you do when but don't, you know, put it in other people's faces. So that is all I have for you today. We've got seven and a half minutes for questions and I thank you for your attention out here.