Shane Summers, MD, is the Deputy Director, Army Trauma Training Center (ATTC) and is an Associate Professor Military and Emergency Medicine, USUHS.
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Good day, everyone. I'm Lieutenant Colonel Shane summers, and I'm the Deputy Director here at the army trauma Training Center in Miami, Florida. I'm here to talk to you today about the forward resuscitative surgical team. And more specifically, what I believe the emergency physicians role should be on those teams. Little bit of this talk might be army centric at times, but I assure you for the most part, the concepts are broadly relevant to all of our sister services, including our Navy colleagues that are deployed on fleet surgical teams, and our Air Force colleagues on ground surgical teams, and SOS T. The purpose of this talk is to more effectively integrate emergency physicians into for surgical teams. And I hope also that perhaps those of you who aren't currently assigned to frst, might after this talk, consider signing up to join one. Because I truly believe that emergency physicians provide maximum value to the frst and could provide great impact to the quality of care that we provide for our wounded warriors downrange. So without further ado, I'm gonna pull up the slides.Unknown:
So in 2018, the US Army decided to convert all of its fsts Ford surgical teams to forward resuscitative surgical teams, which essentially meant adding to emergency physicians. And I would say a good move. I it's maybe my biased opinion, but I think it's an upgrade, an emergency physician with their skill set is tailor made for an frst. In 2019, I was offered the opportunity to come down and be a part of the army trauma training detachment, which is charged with providing all the pre deployment training for deploying FRS T's for the last 20 years. And fsts, before we made the conversion, and I was the first emergency physician to actually be part of this unit. So it's been really cool, working with the ER Doc's that are coming through here for the last 18 months on a one to one basis. And many of them weren't quite sure what their role was, you know, on the frst, they'd say, you know, I'm ashamed that this is a surgical team, I'm not a surgeon, where do I fit? I'm not sure. And to be honest with you, when I first showed up, I wasn't sure myself. But over the last 18 months, and working with them and talking with the surgeons, I think I've come to realize a much greater understanding of where the emergency physician fits on these teams. And I hope to share that with you today. So standard disclaimer, these are my own personal views and not the views of the army. So the army trauma training center, I believe is the oldest milset partnership in the army. We've been around since September 10 2001, training fsts and FRS t's on a monthly basis. Our detachment is essentially a fully functioning frst that's embedded in the trauma center, in Jackson health, and University of Miami. So when the teams aren't here, I work over in the emergency department as fully credentialed faculty, keeping my own skills up, which has been very good for me. And when I work over that writer when the teams are here, it's also you know, an eye opening experience for me and good for my skill sustainment. The teams are here two weeks a month, and the first week they do didactics in the classroom with clinical practice guideline reviews, simulation, skill stations, and they do to mask out exercises. But in week two, they're working clinically at Ryder and I'm working with them. They're actually seeing actual trauma patients and resuscitating them as a team, much like they wouldn't when they're deployed. And many of them have never trained together before they come together at the last minute. So it's been very good. But I must admit writer is a little bit old school, in that it's completely surgeon run. It's separate from the emergency department. And when I first got here, they had no idea what to do with emergency physician. And so I felt a little lost myself, like where do I fit in. And so that's that really sparked the impetus for this talk. Because I'm sure some of my colleagues out there listening get assigned to an FST on day one. aren't sure where they fit, and I hope to share some lessons learned to help you guys better integrate. So that's my goal. I'm going to give you 10 steps for success if you say you get assigned to an F RST, what you can do on day one, to really maximize your time in that unit. And then I'm going to lay out the skill set from emergency position and show how it really kind of meshes well with the frst mission essential task list and hopefully inform others about what we do because it still seems like commanders and surgeons, even 2021 don't really understand what emergency physicians do. On a regular basis and the kind of value we bring to the table, and then I want to talk about some areas for improvement for us as a community. Some things that we should focus on for our pre deployment training so we can be ready to care for soldiers downrange. And a lot of that a lot of these recommendations, I'm gonna make a come from experience here of training teams on a monthly basis for the last 18 months. But I also did a poll on Survey Monkey for all of our emergency physician and surgeon rotators to come through here since the conversion to the FRC and have deployed. And I asked them for, you know, how it worked when they were deployed. And having the emergency physician on the team was that a good thing bad thing, what went well, what went wrong, and I'll share that data with you later. So the frst is by doctrine at 20 person element, that simple tune size element, it split into three sections. The admin supply section is the commander and the debt sergeant. And then the forward surgical section has eight officers and foreign listed. So it's to general surgeon to orthopedic surgeons to CRNA is to ICU nurses, and then our techs and medics. And then the Ford resuscitative section is kind of your lane to start by default by doctrine. That is a six person element for officers to enlisted. That's to er Doc's to ER nurses and to combat medics. And you're the leader of that section by doctrine. Now keep in mind that these teams are very often splitting now to two groups of 10. So as to be more expeditionary and to get out further forward within the golden hour. And so just keep in mind, the forward resuscitative section may become quickly a team of three, running ACLs. So what is the mission of the frst is to provide damage control resuscitation damage control surgery. What does that mean? It's about plugging the holes in the ship, stopping the bleed, resuscitating them to get them stable so they can get back to port. Keep the ship a float, not necessarily repair the ship in its entirety, but keep it afloat so we can get back to port, which in the medical world for you would be the role three, getting to the higher echelon of care. And emergency physicians are very good at that. resuscitation and stabilization, and get them to the next level of care so they can get ongoing treatment. So what are my 10 steps for success? Step number one, get to know your trauma surgeon. This is Colonel Mark Briselli. He is a trauma surgeon. And one of the best guys I know. He has deployed eight times in nine years. He joined the army after doing a civilian residency and civilian fellowship and had zero obligation to the army and decided to join anyways and take a pay cut so as to serve and care for our soldiers in harm's way. On day one, I got to know him we hang out together. I trust him he trust me. We know each other's families. We like hanging out. And we talked about we talked shop to you know me. We talked about how it's going to run in the in the in the trauma resuscitation unit, you know what our roles are going to be? You know, we we discuss the latest and greatest and trauma care and I learned a ton from him. And I think he understands a lot more about the emergency medicine mindset now working with me. And I definitely understand more about the trauma surgeon perspective. And all of that will bleed down into good team dynamics because when you have a small team of 20 and the two at the top are butting heads. You know, it's a recipe for disaster for the team and can destroy morale and maybe lead to worse patient outcomes. So get to know your trauma surgeon. You may be pleasantly surprised. Step number two be an expert in damage control resuscitation. So this CPG you should know inside and out the clinical practice guideline for this. You are in effect as the ER doc the damage control resuscitation just on the team. The surgeon may be in the operating room, knee deep in the abdomen and don't really know what's going on in ACLs. Your job is to deliver them to the operating room your casualty, warm, well perfused not coagulopathic appropriately resuscitated. So the surgeon can do his or her job. And they might give you a warm hug if you deliver a casualty that's appropriately resuscitated to them. So what does appropriate resuscitation mean? What are damage control resuscitation principles? It's all about mitigating this lethal trauma triad that we all know and talk about. But the emergency physician can interrupt this process on all sides and triangle, which some people even call the lethal trauma diamond now where they add hypocalcemia as the fourth rung. But what does this mean? It means if you have a trauma victim that's showing signs of hemorrhagic shock, you resuscitate with whole blood transfusion as your resuscitative fluid of choice. And if you don't have that, then you deliver component therapy in as close to one to one to one ratio as you can. It means you do your primary and secondary survey and you Dec you identify all injuries. And then you then shortly after you cover them up and keep them warm, and deliver them that that blood warmed through the Belmont. And you deliver TSA if you get a trauma victim with hemorrhagic shock within three hours of time of injury, so as to mitigate the coagulopathy and stabilize that fibrin plug. And you avoid crystalloid because that'll cause a delusional coagulopathy and potentially worse acidosis. you administer calcium as soon as you reach for those blood products, so as to avoid the help of the hypocalcemia that occurs with transfusion of citrated blood products. So all these are very, very important to reduce morbidity and mortality and trauma and they're gonna fall to you. So be a damage control, resuscitation list. Number three, maintain proficiency in your individual critical task lists. So I think of someone I think someone in 2018 when they're making decisions to convert the fsts FRCS, they probably looked at our ICT ELLs for 62 alpha and said, Wow, that looks like that would fit perfectly on an frst that fits perfectly with the mission. And they would be right. These are our procedural ICT ELLs that are listed, at least on the army side. And all of them maybe potentially useful downrange in a role to setting and a lot of these, you are going to fall to you because a surgeon is going to be in the operating room. And so you should maintain proficiency with this. And that I think the best way to do that is working regular clinical practice and a busy Ed either at a medicine or moonlighting or, you know, milset partnership, you know, but some of our EM colleagues are no fault of their own, have been assigned to admin jobs and the army or, you know, brigade battalion surgeon, job staff officer, and they may be a little rusty in some of these things. So you need to have an honest self assessment and where you're at. And part of ATTC mission is to kind of get at that and get you some refresher on that. But you know, just in time training is never as good as regular skill sustainment in it through regular ed practice. So, I would advise you to keep a log of these things, I think it's only a matter of time before commanders are coming for them. I think this is definitely the direction the military is going in terms of like measuring and tracking operational readiness. So maintain proficiency in these keep a law keep your number, try to stay clinically relevant in emergency medicine. And you will do your team and your patients a great service downrange. Want to put side by side the emergency medicine ICT LS with the 61 Juliet, which is the general surgeon ICT LS. And you can see there's a lot of overlap, they're synergistic. We play well off each other. Everything highlighted in yellow are procedures of both emergency physician and the cert and or the surgeon could perform. And what's highlighted there are some minor differences. And there's some things that are specific for our skill set and our specialty and those are highlighted in green. I don't think too many surgeons are superduper, interested in performing medical resuscitations, or treating Edie patients so that would fall to us. Likewise, I don't think too many of us are super interested in performing surgery, or trained to do so. I know I'm not. So let the surgeon let the surgeon do surgery. You can manage the medical stuff. And you guys can meet in the middle in the ACLS section for the trauma resuscitations, and one of you could be the team lead and the other could do the procedures or vice versa. Just switch back and forth. And be flexible, be adaptive. But it definitely makes sense to add another another physician with this kind of skill set to an FRC and I think that's why the conversion was made. It's kind of offload the surgeon a little bit step number four know your clinical practice guidelines cold. So the CPGs are on the JTS website, just Google JTS CPG. They are kind of the go to for deployed medicine. They talk a lot about the nuances of military medicine and how we're different with our than our civilian counterparts. They break it down by priority. So this is just part of the list from the prioritize reading list for role to physicians, so and I picked out the ones that I thought were most relevant for emergency medicine. And the category one they define as essential no before you go. And these CPGs are very well written, they're evidence based. They're written by subject matter experts, many of you on this call, I'm sure have actually contributed to CPGs. They're continuously updated. So I think if I had to pick five, for you to really know cold, I think you should be familiar with all of them. And a lot of you already are just by nature of being an emergency medicine physician that practices regularly. But I would pick those five that are highlighted in green, before I deployed to no cold. I also would recommend that you get the deployed medicine app and download it to your phone and then download the the CPGs are listed in the prioritize reading list for roll twos. So you have them available for offline use. While you're deployed, and during your downtime, you can pull a CPG and just review it with your team. Know your CPG is called Step five, showcase your unique skill set. So emergency physicians are very flexible, adaptable, creative, able to do more with less able to task switch and handle handle multiple casualties at once. All very useful skills to have for an frst. We also have that spidey sense that we all know about where you walk in a room and a patient has a typical complaints and vague symptoms poorly described. But something's just not sitting right with us. We think something's wrong in our gut, the hairs on the back of our neck stand up. And we proceed with further workup. And lo and behold, find horrible badness. So that kind of that kind of spidey sense can be very, very useful in a setting where you don't have a lot of diagnostic capability. And you have to pick out sick versus not sick, and make evacuation decisions based on incomplete information and make treatment decisions based on incomplete information. And you're very good at that. You also have the ability to act quickly. And definitively when you don't have all the diagnostics back when you pick out somebody that's sick, and in need of resuscitation but aren't quite 100% sure what's going on. And you're diagnostics aren't back, you act because you can't wait. And you're very good at that. You're also you're also very good at picking out the medical reasons for trauma that surgeon may not always think about, they may be just thinking about what traumatic injury someone has, and whether they do or not. So what are the doctrinal duties for the 62 Apa as laid out in the army training publication for Dash 225. Here they are listed. And this is just standard stuff. We know this, we do this on a regular basis. But I only list them here just to contrast them with what's listed in the same publication for the doctrinal duties for the surgeons. And interestingly, they each have only one line. The general surgeons doctrinal duty is to perform surgery for patients that require surgery. And the orthopedic surgeon has pretty much the same perform surgery for patients with injuries of the musculoskeletal system. So just don't be too surprised if your surgeon is not totally interested in helping out take care of patients that that don't need surgery. And don't be totally surprised if you orthopod is the same way. We know as emergency physician, sometimes we actually have to, you know, have the orthopedist take a step back a little bit in the initial phases of a trauma resuscitation because they're so eager to get in there and look at the leg. But the patient's got non compressible torso hemorrhage and showing signs of hemorrhagic shock and we're trying to resuscitate them. So don't be too surprised if your orthopedic surgeon is not particularly interested in being a part of the ACLS piece. The other part of showcasing your skill set is for our fellowship trained folks out there that are listening, leverage those skills and talents and expertise. Many of these can be useful in deployed environment. EMS, you guys are the T Triple C experts and you're the experts in disaster medicine and mass cow events. You're like the incident commanders. You can do online and offline medical control and your you know, the latest and greatest and pre hospital medicine. Pre hospital whole blood transfusion and hemostatic compressive devices. So use that and bring that to the team to help improve the team and improve the quality of care we provide for our patients downrange and our toxicologists out there who my toxicology colleagues are some of the smartest people I know use that skill set, we definitely can see snake bites downrange, we got a whole CPG dedicated to it. And we will see overdoses occasionally. All kinds of various bites things and animations PDM I don't think anyone's better equipped to care for critically critically injured or ill child in FRC setting than a PGM physician. And then undersea medicine, we might see to decompression sickness sports medicine will, you'll probably see a variety of MSK injuries where that could be useful. And ultrasound because FRS Ts, many of them now don't even have X ray capability, unless they're attached to a Charlie med role to they don't have any x ray capability, they definitely don't have a scanner. So ultrasound can be super useful. And ultrasound is not just about the fast exam while deployed. You know, a lot of what we see is disease, non battle injury and medical complaints. And so you have a wide variety of applications to choose from, from the asef guidelines that you're trained in. And I do want to share one story with you. In Honduras on my humanitarian mission, and I went on, on day one, I walked through the ICU and the ICU, Doc's took me to this bed, where there was this 18 year old girl laying there critically ill. And they told me, they didn't know what was going on with her. And they asked if I could help. And she, they said that she was in septic shock. And she came in February with multiple flu like symptoms, and this is pre COVID. But she's been there for two and a half weeks and requiring continuous vasopressors. And they were unable to like wean her off vasopressors despite adequate volume resuscitation, and they told me that all of her blood cultures have come back negative and CSF cultures, they test her for Dengie, which is common out there. And I was negative and urine cultures negative, and they had no idea what was going on. So I busted out the SonoSite nano that I brought with me and I just put a parasternal long axis view of her heart. And she had a very large pericardial effusion that was circumferential with tamponade physiology. So she gets a pair of cardio and thesis. And this is her three days later in the ICU, awake, alert, completely off pressors smiling and happy. And so this was a very profound case for me, I'll always remember and always remember her. But you can make a huge difference downrange and the person is probably best equipped to you know, use the ultrasound to help make diagnoses like this as you step number six cross train with your team. So everybody on the team brings unique skills and different backgrounds. So learn from each other. The picture on the left is a rotating team from last year, the green cap is army surgeon. And the blue cap is the army emergency physician. And I like this, they're working together to prime the Belmond you know, cuz sometimes all too often and busy medicines, we just call out orders and things just magically get done. And we kind of take it for granted. You know, the simple tasks are, you know, save lives, like running blood through Belmond fuser. So I think we need to cross train on that. And I was I really appreciate these two taking the time to do so. And then in the middle is me performing or teaching the medics how to do ultrasound guided IV and the nurses. And I let them you know, I was their guinea pig. And they were you're practicing on me and getting skilled with that. And I think that could help us out overall as a whole. You know, if we're unable to attain peripheral IV access in a timely manner and a trauma victim downrange that could be force multipliers for me. And I would teach them the fast exam for the same reasons. And on the right, I really think we should train with our surgeons, we should cross stream with our surgeons, they can learn from us and we can learn from them. So when I got here, I sat in on the asset course, which is the advanced surgical skills and exposure and trauma course. And it's very, very surgeon centric. But it was I think it was a good team building experience for for me to get to know Briselli and seeing the kind of awesome things he does like he's just it's it's good to know what happens your patient after the DD and I gained I gained a different appreciation for what he does in the operating room and the level of surgical skill that he has. And then he taught me a few things and you know, it was a good refresher for anatomy. So you should do that. And whenever you get with your team get with a general surgeon and cross train. Same goes for the orthopedic surgeon. You know I did a combat extremity lab with my orthopedic surgeon, Dr. Boomsma. And I don't think I'll ever perform an X fix. But it was good to work with him and see what he does. And you know, it's interesting he was telling me that something I never thought of he's like, you know, it's really, really challenging in an FRC environment to place a pin in a correct location for an X fix, because we don't have fluoro capability. And then so I started, he was like, Hey, do you think that maybe ultrasound could tell where the pin is. And I was like, I have no idea. So we just kind of played, we were bouncing ideas off each other, and we just kind of played with it. And we it turns out, we were able to see the posterior pin the pin coming through the posterior cortex and measure the distance with the ultrasound machine, something I never even thought of before. And he didn't know that you could use ultrasound to kind of look at to see the adequacy of your fracture production. So cross train with the orthopod, as well. And there's always like new fracture reduction techniques that they can teach you, they can always help you, you know, do a better mold with your plaster. So and then my orthopod has no idea how to use an ultrasound, so or perform advanced exam. So I taught him that. So everyone kind of needs to know bottom line here. They need to know the overall mission essential task list for the FRC, but they they need to know each other's ioctls Kind of. So, you know, we can you know, help out, you know, if stuff hits the fan, and we're short on personnel. Cross training is really important. So step number seven, take time to mentor your medics, and everyone in the Ford resuscitative surgical section I would say. So the ICTR checklist for combat medics in the Army is 65 lists or 65 tasks long. So it's much longer than ours. But all of them 100% are directly relevant to em. You know, and sometimes we take these things for granted. What saves lives in the first five minutes of a trauma resuscitation is not ultrasound, but it's these things, it's slapping, tourniquets on and getting to large bore IVs and starting blood and performing a needle D for tension pneumothorax. And those are things that are listed in the CTL checklist for medics. So you have expertise in that train them, mentor them, they're eager for it, take them under your wing. I did this in Iraq, I would do like daily little classes when my medics and we would do little workshops, we with their with their mission essential tasks. And it worked out well because we actually got hit with a mask gal. And you know, when I got I got hit with three litre patients that were surgical one with a traumatic amputation. And before I could turn my head around the medical already slapped a tourniquet on and established two large bore IVs and reported back to me the vital signs. So many of them in the army, at least have been put in the motor pool or something like that, and haven't really practices as much as they would like. And we often even embed sense they just they're like the vital sign collector but they don't get to do these tasks. So train with them breakout. Ask them to show them show you your their ICT checklist and go over with them and ask them if they feel comfortable and work with them. No, you won't be sorry. So take time to mentor your medics. Step number eight, maintain open lines of communication with the command and surgical cell, we often get stuck on our little silos where we think you know, we can we don't want to leave the EDI and the surgeons never want to come in the EDI. Now we need to we need to be able to move back and forth. You know, I even asked the surgeons this you know, because sometimes it can feel like there's a force field around the Edie around the operating room rather, that we don't want to go in there and ever, like disturb the surgeon while they're operating. They're busy. And I asked the surgeons they said no, I would love to hear from my ER doc put on a cap and a mask walking to the ER and let me know what's going on out there. So we can come talk about it and make sure that we all are on the same page. And communication is not a one way street, it works both ways they should be communicating with you. So demand that commanders need to be informed of your needs. What you need to provide optimal care for your trauma patients in ACLs. What if you're short on supplier, what resources you need, what personnel you need the training status of your people. And the commander should be informing you of your mission and and what the next plans are in the next steps and your blood supply and all that stuff. So it's a two way street, maintain those open lines of communication. Step number nine, maximize your downtime. So right now, most of the deployments are slow. And I guess that's a good thing. Because you know, that means our soldiers aren't getting injured as much. That's a great thing. But it also means there's going to be likely a lot of downtime. Until there isn't. I mean, there are teams that are still getting mass a team that rotated through here last year took an eight person mask out which will definitely overwhelm an FRC really, really quick. You know, but when there is downtime, make, make good use of it. And if I was to pick one time really practice during downtime, it would be the mask out. Because you can practice all you want. And, you know, I still think that no one's ever fully prepared it ever goes perfect. You know, these teams that rotate through here and do our mascot exercise, they routinely flail on day one. And then day two, they tend to do better, I imagine the third or fourth iteration, they would definitely iron out a lot of those kinks. So rehearse. This is us doing a cross training exercise where the ACLS section set up the or beds, the or section and the or section set up the ACLS good cross training exercise, I gotta be honest with you, I didn't know how to set up an old bed. But it's good piece of information to know. And it was good team building exercise. Rehearse your ACLs. And that doesn't have to be the latest and greatest and simulation equipment. That can be you know, mentally rehearsing in your mind and visualizing steps, or watching a YouTube video. Review the CPU CPGs. As I said before, I would say one a day is pretty reasonable, you can probably go through it about 1520 minutes. And teach your team about the CPG and quiz your team. So you know, it's really hard in the middle of a chaotic situation to go back and pull your CPG for reference. Take time to develop yourselves and improve yourselves as an officer and a clinician. Whether that be CME, or reading some leadership books or doing something like Command General Staff College, writing some papers research. Take that time. You know, because when you get home and you get back in your full time job and your families have been missing you sometimes it's hard to get that stuff knocked out. And take times for yourselves to take care of yourselves and your team. Wellness is super important. These are stressful times being away from your families. Take time to exercise, eat right sleep well. And look out for each other, someone's looking down and take care of them. Ask them if everything's okay. If you get stuck with a, you know, an incident where you unfortunately couldn't save someone. And like you have a C soldier on your hands, which is horribly traumatic for everybody on the team, take time to debrief and talk about it. It'll go a long way with your team. Step number 10 Get involved with the joint trauma system. The mission of the joint trauma system is to improve trauma readiness and outcomes through evidence driven process improvement. It's a really noble effort. And a lot of great people are in this organization. Many of you I'm sure are active in this organization. It's all about seeing what we did well, kind of on a you know, when we get a we follow patients all the way from the point of injury down back to CONUS. And what went well, and what could be improved. And then setting some performance improvement metrics to see if we can meet those and then and then collect the data and see if our interventions are working. And, you know, we all kind of know the medicine piece, but a lot of it is the healthcare delivery piece, are we actually getting the interventions we know work to the patient? So picking a pickup ei project on your team, it doesn't have to be something crazy. It can be like, Does my team do a good job with hypothermia prevention? Or when we deliver component therapy? Do we really truly get to that close to that one to one to one ratio? What percentage of the time does that happen? Do we are we always given calcium, you know with after our first unit of blood, those kind of things. And you can get involved on the calls too, I would highly advise you to do so weekly, the JTF meets at 08 100 Central Time. And and there's lessons learned seminars that are quarterly. And then you could sit on a committee for the JTS where you talk, we actually develop the CPGs and talk about the latest and greatest equipment that we're going to feel out there and all important stuff. So get involved with the GTS you can make a difference in your individual frst. But you can make even greater difference by being involving and being involved in the department defense trauma registry and being a part of the Pei process for the whole system. I'm gonna talk about operational readiness. So for these next few slides, I'm going to lay out the mission essential tasks list for the frst. And then I'm going to give you a basically my own personal assessment of where I think we are as a community in that particular task as far as our training status goes. And where I think we should train harder, some gaps in training, some areas for improvement. Just keep in mind, these are my own personal recommendations. These are not official recommendations for med COE or ATTC. This is based on my experience here for the last 18 months seeing the ER Doc's and their level of experience that comes you know that come through here. Not everyone is created equal. Some have been working at busy EDS and are you know, highly trained and all of these tasks and I'm about to mention where Some may have been out of the loop for a little bit and need some extra dedicated training. So we take, we try to tailor to their needs. But these are just basically overall broad based assessments and may not necessarily apply to you in a certain task. Alright, so without further ado, the normal nomenclature I'm going to use the scoring rubric here is in the bottom right, these proficiency ratings are listed in Army Field Manual 7.0. And it's what the line commanders use to determine to like, have a common language for where their, their soldiers are at in their specific individual critical tasks, where they think they're at. And the purpose is really just to train them up to fully trained before you go. And so for rapid hemorrhage control, we're trained in this you know, I would just say at a minimum, if you're getting ready to deploy, take a look at the T Triple C guidelines, just so you can be speaking common language, your combat medics, but really, I only put this task up here. Because I want you to train and mentor your combat medics and ensure that they're up to speed on these things. This task, chest tube, in my experience, most if not all, the merge physicians that come through here have been trained in this task fully. You know, you have to do 10 chest tubes just to graduate from residency, and then you know, so I think, you know, skill station refresher is really all it's needed for most 62 albums that come through here. And that's what we do, we run them through a trauma sim man, and I watch and place a chest tube and I say, that looks good. And I sign them off. And then they move on, I actually asked them to go to the next skill station over and start teaching their teammates how to do it, and how to do it, right. Tas perform the fast exam, we're probably the best equipped in the unit to do this and do this, well do this in a timely manner and get great pictures. You know, the surgeons aren't always as facile with this skill as they think they are. So I you know, when that when the ER doctor comes here, we do our, we do our ultrasound lab on the first day that they're here. And I watched them perform a fast exam on a live human model. And usually the imagery is very good. And I just provide some, you know, a little bit of feedback, maybe to kind of clean it up a little bit, but not much there. Usually you're good to go. So I would say the emergency physicians should be teaching others in the unit to make us to make the rest of the unit force multiplier. Alright, I owe insertion. I would only were trained in this but I would I would give us a t minus only because I've seen some struggle a little bit with the proximal humerus IO. A little bit more challenging, as most people are very, very familiar with the, the proximal tibia. You know, but I think that Proximal Humerus IO is probably preferred for an adult trauma victim, just because it delivers superior for flow rates over the tibia IO. And because it's a line that's above the heart, I think we should be facile and that bare minimum proximal humerus, proximal tibia, distal tibia. And so what I do is I run through the cadavers over the Rosenstiel building here in Miami, and they perform one of each, and I sign them off, and that's usually probably sufficient for them to go downrange be ready to central line, I only put t minus here because I think we as a community overall, most could use a little bit more experience with subclavian. It's, I think in residencies the go to Line has consistently been for last, you know, 15 years ultrasound guided I ij. And ij is sometimes a challenge and trauma victim that has a C collar on and getting up near the head of the bed. Having the room to be able to do it is a little bit of a challenge and getting the sterile sheath out and having everything logistically nice and prepped is a challenge. So the surgeons at Ryder use the subclavian line a lot. It's kind of their go to Line for which they can't if they can't get peripheral IV access in timely manner. And so that's what I train our emergency physicians on when they get here and a lot of them say they haven't done one a long time. Blue phantom model I think is fine. But ideally I'd like to get them all in the patients need it. Like we we see a lot of penetrating trauma here at writer and a fair number of patients get Thor academies. And so if they're getting resuscitative thoracotomy, I tell the ER doc like that's they're definitely getting a right sided chest tube and that writer they're going to get a right sided subclavian line as well while the surgeon is working on the left anterior lateral thoracotomy. So, practice on subclavian line, I think it's a very good trauma line. And it's good because you can do it blind with, you know, landmark technique relatively safely, which is good in case your ultrasound device ever goes out. And also, our surgeons don't really like the femoral line too much in patients that have potential for shock from abdominal hemorrhage. They like to have a line above the diaphragm and above the heart. So they go with subclavian. So practice, perform intubation. We're trained in this you have to do 35 Just to graduate residency, although there have been some folks that have not intubated patients in a couple years that come through. You know, even myself, when I was the residency director, Bamse, like the residents did all the innovations. So, I would always try to get to the, like, the cadaver lab at Spring branch and balbirnie to try to, you know, practice intubation on a cadaver. And I think that was helpful. But those models, those little mannequins, I don't think are ideal for refresher training, just because they're super easy to intubate. And nothing can really simulate the the grossly bloody trauma airway, for which you may have to intubate downrange. So I would recommend that if you've been out of practice, and haven't intubate in a while, you can practice on some mannequins, but don't make it 100% of your innovations on mannequins, try to rotate with us at ATTC. Or maybe even rotate in the operating room, sometimes we send rotators up to the operating room to do some elective cases, if they haven't intubated in a while, we encourage them to use both DL and VL because I have found a lot of our graduating residents, they all they ever used was VL. And, again, that, that your battery could go out on your video laryngoscope down range or may not be available. So you have to be facile with both. Performer Craig, I say we're practiced on this. And that's only because most everyone I talked to that's come through here has never done one in their lives. They've done it on a you know, you have to have three to graduate, but the 100% of those can be simulated, so they've all done it on, you know, you know, either a mannequin or cadaver, but it's just not the same because you know, you want to use you want to use live tissue because like tissue bleeds and and you know, so that's the closest you're gonna get to probably simulating it is a poor sign models actually a pretty good model for this, we use this during our mascot exercise. And so I would recommend you train on live tissue, if possible. And if you haven't done one in a while, maybe review some videos. And then I like the Bougie guided Creek is a technique you only need three pieces of equipment. And I like to keep it simple and chaotic, crazy situations of a can't intubate can't ventilate situation, I don't like to, I like to pull the trigger and just grab the equipment and have it ready to go without busting out this complicated kit. So I think I can intubate anybody pretty quickly with those three pieces of equipment. So Escar Artemi p minus, if we're going to be honest with ourselves, most people are marginally practiced in this task. And that's fine. We have surgeons on our team and I think that that's in their wheelhouse and they should do it. But that being said, we send the emergency to physicians to the asset course and they do these kinds of things with the with the surgeons present cross training just in case emergency. Same goes for fasciotomy frst is in the Army has general surgeons and orthopedic surgeons. So they should be the default go to to do this kind of thing. There is a lower threshold to perform fasciotomy in a role to setting because these patients are high risk for compartment syndrome. And the logistical issues of you know, flying them back, you would hate for them to get to the rule three and they've gotten across muscle because you failed to act. Definitely if they get avascular shunt, they're going to get prophylactic fasciotomy if they have high risk mechanism, or they're very difficult to evaluate because they're the bad mechanism. They're intubated and sedated, and you know, they got a TIB fib fracture or something like that. They're probably going to get a prophylactic fasciotomy I think the I think the surgeon should do this, but you should be trained in it and asset course if possible. In case you need to do it in an emergency. Particularly I would think maybe it won't want you might have to do it. Okay, Rebola. So I had to give a shout out to Regan Lyon, who's probably on this call. She published her experience in Syria in the journal trauma, acute care surgery. They took care of a ton of traumas during the offensive against ISIS, probably more traumas and I took care of in my life. This is her part of her special operations surgical team. I think they did great things out there and I was really just really impressed after reading this report of some of the amazing things that they did. They're kind of the proof of concept, I think for why Rebola could be potentially useful. For traumatically injured casualties downrange when we, when they present to a roll to facility. They placed 20, rubella catheters, many of them I know were placed by the emergency physician. And all patients survived to the next session, a lot of care. And you know, we don't have long term follow up data on them, because a lot of them were, you know, serum defense forces, it's my understanding. But this is at least a good proof of concept. The reason why it's important for the emergency physician to learn this skill is because Dr. Northern, the gentleman in the middle, who's the surgeon can only take one person on the table at a time. And it's my understanding that ACLs had multiple critically injured casualties that were with hemorrhagic shock. Bleeding below the diaphragm, that could be temporize. But until they could get to the table until Dr. Northern can get them on the table. And ACLs section was responsible for doing that. And I think that that's why I think this reboa TAs will fall to the emergency position. Because if the surgeon is present, and you only have one casualty then and they're in hemorrhagic shock, they'll just go to the O R. But what happens when you get multiple casualties. So I think it's important to have this tool in our arm in our armamentarium. Our TAS proficiency I put us, generally speaking as marginally practice from what I've seen. So I think we should undergo formal training virtually in all instances, before we go down range. And that could be the best course which is the, the put on by the American College of Surgeons, or we do reboa training here, or star c, which is bam, CS predeployment frst training platform, all fine. I think this is not something that really should be taught with didactics it should be a hands on experience with a high fidelity sim simulator like the primetime simulator or something like that. Or maybe a live or I'm sorry, I perfused cadaver or something like that might be the next best option. But it's definitely something we should practice and could be potentially useful. Perform lateral canthal Atomy I would put us a practice in this task. Just because most people actually haven't done one on a human patient. You know, we've we've, we've read about it. We've watched videos, we trained in residency, we may have done it on live tissue, but very few patients. It's not it's not all that common for a patient to have an orbital compartment syndrome. What I see that being said you do need to diagnose this condition had a role to in and perform this procedure otherwise they could lose their eyesight before they get to the role three. So i i During the asset course the emergency physicians here perform lateral camped on a cadaver and we also tried to get them to do it during the mask exercise with live tissue on porcelain model by injecting some saline behind the eye simulating a retrobulbar hematoma. Sustained thoracotomy. You've got a general surgeon there. I think this is best performed by the the general surgeon. If you if if you didn't have a surgeon present, you probably should never perform a resistive thoracotomy, there's no point. And if you have a surgeon present, why not let them do it or and you can be assist, you can assist. So I guess maybe if they're in the operating room, and you got to do it, it'd be important to maybe you can like relieve that pericardial tamponade. And then they can get them they can get to the operating room right after that. And your surgeons, you know, right down the hall. It's a good skill to have we do train in this, you know, in the residencies, I'm sure on live tissue is a good model like poor sign model. When the rotators come through here, I have them. I have their their general surgeon walk the ER doc through the procedure on live tissue. And that tends to work out pretty well as far as a good refresher training. Performed borehole craniotomy. So, per the CPGs, there have been 36 cranial procedures performed by non neurosurgeons that are role to facility since Oh, if an oaf began. So it's a rare event but not a never event. And this is again something where the patient may decompensate and and have irreversible brain injury and death, seizure, coma death before they even make it to the rule three. So you may have yet to be prepared to do this for cerebral herniation syndromes when you can't get them to the rule three in a timely manner and you have no neurosurgeon support. This is a procedure I think is best left for the the general surgeon. They have often done craniotomies and residency with neurosurgeons. They train on it in the asset course. But I do recommend cross training with them during asset procedural sedation and analgesia we're trained in this we have to do 15 procedural sedation is just to graduate and then we many of us continuously continue to use this in our regular practice, we're very good at treating pain, and very well worth very well versed in, you know, taking care of adverse events that may or may not occur with, uh, with procedural sedation as far as airway maneuvers and techniques. So you and the CRNA are going to share this task. And I would say, you know, you probably just need to take a peek of the CPG, these two CPGs that I have listed here, and call it a day. Perform nerve blocks. This is something where I think a training gap exists. And it's variable some, some people come through here have completed ultrasound fellowship, and they're pretty high speed with this. And some I've never done it in their life, which is why I have the variable rating here. But I think that this is something that we should really start to think about training. During our pre deployment platforms like ATTC or star See, just because it has the potential to reduce the opioid analgesia requirements for our soldiers, particularly if we're in a prolonged field care situation, we've got a fracture, or mangled extremity. And we're already very skilled with ultrasound itself. So it's really just about kind of learning the anatomy. And, you know, so if I was to start somewhere with how we should get at training meeting this training requirement, I would probably look at the New York School of regional anesthesia, they have some very good online modules that you can do, but ideally, in a perfect world. This is best get best achieved by rotating on a regional anesthesia service and actually performing nerve blocks on patients. I did get the opportunity to do this in Honduras. And my answer is a resident who was rotating with who actually flew out there with me was helping me in the or perform these nerve blocks and it was it was awesome. I learned a lot and I definitely think it could be beneficial for our soldiers downrange. Reducing fractures and dislocations. I only give us a t minus because, you know, my experience at Bamse like oftentimes we would just call the orthopedist to reduce the fractures rather than reducing it ourselves. So sometimes these resi programs and busy medicines, we have every specialty no demand, so we just call them I think some of the community Doc's are better at this than others. You know, but again, you have an orthopedic surgeon there, so why not use them. And then you could perform the procedural sedation piece. Run a code. This is us. This is our wheelhouse. We're trained in this if you've been in regular clinical practice, still remember the Kuwaiti bus driver that I took care of in Iraq that came in with a STEMI and a B fib arrest these things happen downrange. He got shocked and got to neck to place and all the other things and did quite well. So it's a really cool case. For me, I still remember to this day. We will take care of these codes. I don't think we need extra ACLs training just by nature of being board certified and being in practice. We should be good to go here. But just be prepared to take care of them because you know, sometimes, downrange we see these DOD civilians and contractors and local nationals that have significant comorbid conditions. Management of acute illnesses. I want to read a quote from my survey that I sent out. This is from an emergency physician currently deployed, quote currently deployed to CENTCOM with an frst no surgeries done in the last four months have been required to manage COVID outbreak, abdominal pain, chest pain, syncope, renal colic, and numerous infectious disease complaints. So it sounds like they're frst became an emergency department. So just be prepared for that. And you are trained to do that. All right. Speaking of acute illnesses, who runs a sick call? Well, our view of Utopia would be that there is no sick call. But the reality of the situation is soldiers on the farm are going to present you with minor complaints seeking your help. I think, in a perfect world, empower your medics to run the sick call. Because you're really there were murdered physicians and your damage control resuscitation is right, you're there to take care of, and be prepared for the next mass Caliban that comes in and perform far forward surgery. But so empower your medics to run sick all there's this manual call at TMC algorithm directed troop medical care where they can run through a flow sheet and based on chief complaint and they can pick out the red flags and call you if they need you and corpsman to they're excellent at this. You know, but if your commander really wants to to kind of take lead on that, you know, maybe, just maybe you can get the orthopod to see the musculoskeletal complaints, and the surgeon sees the undifferentiated abdominal complaint complaints, abdominal pain complaints, but I don't know good luck with that. You guys are gonna have to work that out as a team at a time. So now finally, I'll close with my survey. So, here's the results. So I pulled all the emergency physicians and surgeons who attended ATTC in the last 18 months, and I got 27 respondents back, which is about a 50% response rate five oh 17 numbers physicians, 10 surgeons, the vast majority of whom had deployed and were active component. Whether results Question number one, rate your level agreement with a statement, emergency physicians are a valuable addition to the frst and encouragingly. 90% of surgeons said strongly either strongly agreed or agreed with the majority saying they strongly agree. And an emergency physicians also felt valued on the team. So this is encouraging data. You know, we did get one disagreement one naysayer, one hater. I guess I never really thought that we would get 100% You know, Goldstar happiness from our surgeons. But I think 90 percents pretty good, something we should be, you know, excited about moving forward if we ever deployed on one of these teams. Alright, I asked him about the working relationship between I asked the the surgeon how you feel about working with your numbers position and vice versa. And again, same same results, essentially 90% either agreed or strongly agreed that they worked well. With the surgeons, I'm sorry, 90% of surgeons either strongly agreed or agree that they worked very well and had a good working relationship with their ER doc. So That's excellent news. And the ER Doc's like surgeons to hear some comments from the surgeon. From that same question, I'll let you read those. even acknowledged that the emergency medicine physician had far more knowledge and experience with dealing with undifferentiated complaints. And they acknowledge the synergy that could potentially exist. And that how the we're all working together here to maximize patient care. I asked both groups of physicians who they thought should be the trauma team leader. So this has kind of been a little bit of point of contention, you know, trying to figure out, you know, because a Bamse, like emergency physicians often will run the trauma and a certain kind of kind of stands back just steps in to the patient needs surgery. So you have two physicians that are perfectly capable of being the trauma team lead on the same team, how's that dynamic going to work, and I pulled the teams, this is what I got. So you can see there's overwhelming consensus that when the surgeon is not around, like say they're in the O R, that the emergency physician should be the team leader for you know, these ACLs trauma, resuscitations. That makes sense. Now, there was a little bit of contention when it came to when the surgeon is present. So, but still the majority of folks, both emergency physicians and surgeons think when the surgeon is present, that they should be the team lead, the surgeon should be the team lead and the emergency physician should do the primary secondary survey, the fast exam and the critical procedures. And, you know, some some of the surgeons actually thought that, you know, the ER can be the team lead for all of them. And I'll just take them if they need to go to the or. But, you know, so this is, this is something you need to hammer out ahead of time and have open and honest discussion with your surgeon about. But you know, I think this is this is kind of cool, how like, they feel very comfortable with us, you know, performing being a team lead when they're not around and even being a team lead when they are around and they feel very comfortable with us performing the very important trauma survey and the ultrasound exam and the procedures. So sometimes that can be even more fun. That could be the team leader, we get to play a little bit. So the summary of these is Trauma Team Lead question from the comments. Essentially, what I'm seeing here from these teams that deployed the last 18 months is that when the surgeon is not around the 60 to alpha should be the team lead and perform the survey. When the surgeon is around, it depends on the situation. So if there's a mass Cal event, it's really going to be like a divide and conquer type thing. Certain is going to run one bad er is going to run another but if there's only one casualty, the default probably is going to be the surgeon service. Team Lead and six to Alpha performs the primary and secondary, the ultrasound and the procedures. Now, they may need to swap for procedures, you know. So whenever someone zooms in to do a procedure, they lose focus of the entire room and visibility on the overall 50,000 foot view of the trauma resuscitation. So maybe that emergency physician would need to zoom out and takeovers team lead in that instance. And vice versa. So you got to be flexible and adaptable. You got to communicate, because butting heads in the middle of a trauma resuscitation, as I said before, is just didn't go very, very wrong when that happens. So I asked about procedures. And you can see here the surgeon, I asked the surgeon, what procedures they're comfortable with emergency physician performing. And I asked the emergency physician what procedures they're comfortable performing just to see if there was a disconnect. And it looks like the surgeon is very comfortable, at least on these teams polled with their emergency physician performing all of their resuscitated procedures that you would think airway management chest tubes, cry eggs, fast exam, central lines or lines, all that stuff and being the team lead and even Rebola 70% of the time, which I thought might be a little lower actually. So but you know, there was a little disconnect in certain things and when I when I defined disconnect as being that the ER doc says they can do it and the surgeon says no, you can't. Those procedures were few and far between but really they came down to you know, like a burr hole. Actually burr hole the yard most er Doc's won't even comfortable doing that. It came down to like fasciotomy and Escar automate some of the ER Doc's thought they could do it but the surgeons were like not so fast. There's a little bit of disconnect on lateral can't 95% of er Doc's think they can do it. Only 70% of surgeons thinks the ER Doc's can do it. So bottom line here, hash this out, talk about it. Let them know what procedures you've done and what you're comfortable in performing. And who's going to do what procedure and what situation. And my final question on the survey was who's going to be are you interested in commanding and shock at the center here? We have zero yeses from the surgeons, no surgeon poll was interested in commanding an frst. And so I view that as a great leadership opportunity for you guys. I think the teams that rotate through here where they have physician leader, and we've had a couple that have had emergency physician leader, and they tend to be more seasoned, they work better as a team, they tend to be more clinically up to date. And they make smarter decisions because they know the clinical aspect of it. So take that leadership opportunity that void in leadership and step up is our teams needed our soldiers needed. So in summary, the CCO Alpha brings a lot of value to the frst you're by doctrine, the leader of the Ford resuscitative section but you you have a broad skill set that can bring so much more to the team. cross train with each other and get to know each other. Start with a 61 Juliet, your trauma surgeon, that strong working relationship is absolutely vital. maintain proficiency in your ICT ELS know your CPGs cold and rehearse during your downtime, rehearse, rehearse, rehearse, in particular the mask cow. And before you go make sure you address any potential training gaps that may exist. Again, the best way to get at your ioctls is skill sustainment at a busy ed. So talk to commanders if you're not stationed at one of those places, talk to commanders about Moonlighting. And don't go moonlights in some like low volume area where you see a couple patients try to work in someplace that's busy so you keep those skills up. It really matters when you get downrange. So for those of you out there that are deployed or getting ready to deployed, thank you for your service. Just remember what's waiting for you when you get home. I will share my experience when I got home from my third deployment, waking my little girl up at seven in the morning. Good morning all right, this concludes my talk. And I hope all is well with you stay safe. Hope to see you soon. Thanks for listening