The aim of the Military Emergency Medical Services and Disaster Medicine Fellowship Program is to train physicians for the challenges of pre-hospital care on the battlefield, in defense of the homeland or wherever else troops may be, said Army Lt. Col. (Dr.) Robert Mabry, the fellowship’s program director, at San Antonio Military Medical Center in Texas.
“Pre-hospital care” is that critical time between a traumatic event and when care is received at a military treatment facility.
Mabry and his colleagues conducted a study of service members injured on the battlefield in Iraq and Afghanistan from 2001 to 2011. The study found that of the 4,596 battlefield fatalities analyzed, 87.3 percent died of their injuries before ever reaching a medical facility.
Of those deaths, 75.7 percent were classified as nonsurvivable, meaning they would have died even had they reached the facility earlier, and 24.3 percent were deemed potentially survivable.
That study, the first of its kind, was published in the Journal of Trauma and Acute Care Surgery in 2012.
Although battlefield medicine has vastly improved during every war since World War II, Mabry said, that 24.3 percent statistic cited in his study – those who died who might have lived – kept nagging him. “That’s where we can make the biggest difference in improving patient outcomes,” he said.
Mabry found that no one “owns” responsibility for battlefield care delivery. “No single senior military medical leader, directorate, division or command is uniquely focused on battlefield care,” he said.
“The diffusion of responsibility is a result of multiple agencies, leaders and units of the service medical departments each claiming bits and pieces with no single entity responsible for patient outcomes forward of the combat hospitals,” he added.
Commanders on the ground do own the assets of battlefield care – medics, battalion physicians, physician assistants, flight medics and all the equipment – but they are “neither experts in, nor do they have the resources to train their medical providers for forward medical care,” he said. Commanders rely on the medical departments to provide the right personnel, training, equipment and doctrine, he continued, but the medical departments “defer responsibility to line commanders,” he added.
“While this division of responsibility may at first glance seem reasonable,” Mabry said, “the net negative effect of line commanders lacking expertise and medical leaders lacking operational control is analogous to the axiom, ‘When everyone is responsible, no one is responsible.’”
One of the main difficulties in addressing pre-hospital care, he said, is that “we know very little about what care is provided before casualties reach the combat hospital.”
Only one military unit – the Army’s 75th Ranger Regiment – tracks what happens to every casualty during all phases of care, Mabry said.
“Ranger commanders routinely use this data to improve their casualty response systems,” he said, adding that the Rangers “are the only U.S. military unit that can demonstrate no potentially preventable deaths in the pre-hospital setting after more than a decade of combat.”
While only the 75th Rangers did pre-hospital tracking, once the wounded arrived at a combat support hospital, they were met with “robust surgical support and had less than a 2 percent chance of dying,” he said.
Those who did die at the combat support hospital generally had a severe head injury or were in profound shock due to the loss of blood when they arrived, but some had conditions that were “potentially salvageable had they had some aggressive resuscitation in the field,” he added.
But the culture of military medicine is “hospital-based,” the doctor reiterated, and “no one owns battlefield medicine.”
The hospital-based mentality has its roots in the Cold War. During the Vietnam War and later, the idea was to “put as many patients as possible in a helicopter and fly them as fast as you can to get them off the battlefield to the field hospital,” Mabry said. After Vietnam, those doctors, nurses and medics returned to the United States, took off their uniforms and “built our civilian trauma systems,” he said. Before Vietnam, he added, emergency medical services, trauma surgery and emergency medicine didn’t exist as we know them today.
As a result of the war experience, sick or injured civilians in the United States today are transported to a trauma center by helicopter, accompanied by a critical-care flight paramedic and a critical-care flight nurse – both highly trained and very experienced.
“Civilians took the ball, ran with it, and significantly evolved their processes to an advanced standard of care,” Mabry said. “But we stayed with our Vietnam model, focusing on speed, so the two models are incredibly different.”
In Afghanistan, speed became a problem, he said. “When I was deployed in 2005,” he explained, “I would have to wait three hours for medevacs sometimes, and if it were a host-nation casualty, sometimes even longer.”
And the level of care in-flight was less than premium, the doctor added.
“The medics, through no fault of their own, were still trained at the basic medic level,” he said. “At that time, flight medics had no requirement to provide any hands-on care to an actual patient during their training. For many, their first encounter with a seriously injured casualty was during the first flight of their first deployment.”
Mabry concluded from his studies and field experience that the solution to the care gap cannot be addressed with a single-bandage approach. A solution, he said, would require “evidence-based improvements in tactical combat casualty care guidelines, data-driven research, remediation of gaps in care and updated training and equipment.”
And to supervise those medics, their training and the medevac equipment and procedures, there would need to be a specially trained and qualified physician in charge of that pre-hospital phase, he said.
Mabry’s own experience includes 11 years as an enlisted soldier, starting out in the infantry and then becoming a Special Forces medic with a tour in Mogadishu, Somalia, in 1993 during the battle made famous in the movie “Black Hawk Down.” He said those experiences had a profound impact on him and shaped his desire to become an Army doctor – which he did.
He later returned to Special Forces as a battalion surgeon and served tours in Afghanistan in 2005 and 2010.
Mabry illustrated the power of patient outcome data and how it can drive changes in military medicine – something he hopes to do with his fellowship program. His team tracked down a National Guard medevac unit from California whose members were mostly all critical-care-trained paramedics in their civilian jobs – working for the California Highway Patrol and other stateside EMS agencies. They deployed to Afghanistan about four years ago, taking their civilian EMS model with them, he said.
“I compared their patient outcomes to the standard medevac outcomes and found a 66 percent reduction in mortality using the civilian medic system,” he said. As a result of that outcome, the Army revamped its training of flight medics.
Airway treatment is another example of how patient outcome data can drive procedural changes, Mabry said.
“If you get an airway injury in the field, you’re usually shot in the neck or in the face and have a traumatic disruption of the airway,” he explained. A study revealed that when medics perform a cricothyrotomy — cutting an incision in the neck so patients can breathe –they failed at that procedure about 30 percent of the time, Mabry said, noting that it’s a very high-risk, high-stress, yet ultimately life-saving procedure. “So armed with that data,” he said, “we went back and figured out a way to make the procedure smoother and simpler.”
The result is that medics now have a tool that will make them more proficient at cricothyrotomies.
“So that’s what I’m trying to get at — training physician leaders who can look at problems or opportunities for improvements in the field, who have the ability to articulate how to improve systems, give medics better training, better tools, and so to improve patient outcomes,” Mabry said. “We want doctors who can look at the data and training and protocols, and use research to solve those battlefield pre-hospital problems.”
Examples of what those physicians might do include understanding the injury patterns for a particular unit and locality, analyzing the trauma transfer system, and seeing where the medics might need more training, Mabry said. The physician also could look across the medical research environment and determine which new therapies to incorporate for patient outcome improvements.
The sort of system Mabry said he’s describing is similar to what civilian EMS directors do stateside.
This summer, the first fellow will graduate from the program’s two-year curriculum. “We’re one of the first EMS programs in the U.S. to be accredited, so we’re excited about that,” Mabry said. The program was accredited in October 2012.
The first year is the civilian EMS fellowship, accredited by the American Council on Graduate Medical Education and the American Board of Emergency Medicine. During that first year, the doctors work at a big-city EMS agency, learning the “system of systems” of EMS, Mabry said, using a term that refers to the overall EMS system, which is composed of other systems such as ambulances, helicopters, personnel, training, protocols, trauma destinations, communications, medical equipment and so on.
This enables them to be able to direct a military EMS system, he explained.
The second year is the military portion, which is non-accredited. Each service has its own unique requirements, Mabry said. In the Army, for example, the doctor would work with the battalion medical officers at the Tactical Combat Medical Care course, participate in medic training at the combat medic schoolhouse, and see how this all works at the strategic level at the Institute of Surgical Research and Joint Trauma System in San Antonio.
Additionally, the fellows will learn about homeland security medical procedures and integrate with local, regional and national disaster planners, Mabry said. They also learn about international disaster support — things such as earthquakes and tsunamis — that the services might be called upon to support.
During the entire two-year period, the fellows are studying in the evenings for a master’s degree in public health. The degree “gives them the ability to use epidemiology, statistics and a public health model to go in and say, ‘Hey, look, here’s the challenge we have in this particular area.’” Mabry explained. “They can then articulate from a policy level how this affects the population or health problem, conduct an analysis and then [know] how to make a case for resources, policy changes and things like that.”
Mabry described the curriculum of the program’s first fellow, who will graduate in the summer. His first year was with the San Antonio Fire Department EMS. For his second year, he attended the National Park Service Search and Rescue Course and did his public health practicum with the Joint Trauma System.
He also has worked with the Army Medical Department’s Center and School and participated in a number of policy and research projects.
He’s now at Johns Hopkins University attending the Health Emergencies in Large Populations Course, designed primarily for international disaster relief work. He’s working with some of the world’s leading experts in the field, Mabry added.
Then he goes to the flight surgeon course. Upon completion of his fellowship June 30, he’s projected to go to Afghanistan for six months to work in the Joint Trauma System as the pre-hospital director. His follow-on assignment will be in the Army’s Critical Care Flight Paramedic Training Program in San Antonio.
Three other fellows are going through their first year: one Air Force and two Army doctors. For next year, Mabry said, he hopes to get a Navy doctor in the fellowship, though the Navy currently is not providing the funding. The idea is to get three fellows a year, representing each of the services, he said.
Once the physicians complete their fellowships, Mabry said, the goal is to get them in positions where their training will make a difference: division surgeons, brigade surgeons, Special Forces group surgeons, directors of trauma systems, training programs and so on.
While military doctors already are highly trained and motivated, Mabry said, he’s looking for those who think outside the box, see problems from unique perspectives and perform at all levels: leadership, research, training, problem solving.
Eventually, Mabry said, he hopes to build a cadre who collaborate across the services to “shed light on that battlefield blind spot” of pre-hospital care and change the mindset from hospital-centric care to one that provides state-of-the-art care across the entire chain of survival, starting in the pre-hospital setting at the point of injury.