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«FINAL REPORT 30 January 2013 U.S. Central Command Pre-Hospital Trauma Care Assessment Team Russ S. Kotwal, MD MPH COL, MC, USA Director of Trauma ...»

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115. Medics establish trust with combatant unit leaders at the squad and team level where casualties occur. Medics also establish trust with individual Soldiers, who then become combatant unit leaders. (Role I – 75th Ranger Regiment)

116. Medics should have input into medical programs that affect them. Medics believe in and are passionate about their program. However, who is the responsible leader and decisionmaker that provides a “voice” for the medic and for pre-hospital casualty response systems at higher levels? (Role I – 75th Ranger Regiment)

117. Medics and first responders must be empowered and supported. They desire the right tools needed to save lives and successfully complete the mission. Transient pre-hospital medical leaders restrict scope of practice, training, and equipment to the point that medics and first responders cannot fully care for their casualties. (Role I – 75th Ranger Regiment)

118. Global reductions in medic bonuses cause an exodus of combat-seasoned and experienced pre-hospital medics. Medics should be valued for their skills, knowledge, and abilities. Retention efforts should be weighted toward medics with pre-hospital combat experience. (Role I – 75th Ranger Regiment Combatant Leader)

119. Medics desire a pathway for accredited education and certification, college credit, autonomy, advancement, and compensation. Their pathway is suppressed by transient prehospital medical leaders and a system that does not consistently reward or value advanced prehospital technical capability. (Role I – 1st Infantry Division, 3rd Infantry Division, 101st Airborne Division (AASLT), 173rd ABCT, 75th Ranger Regiment)

120. Professionalize the force, and flatten the organization. Monies provide a nominal advantage to special operations units; whereas assessment and selection criteria provide a significant advantage to these units. Review and refine assessment and selection criteria for the services as a whole – especially as deliberate downsizing occurs for the military. Decrease middle management and increase individual autonomy and productivity. (Role I – 75th Ranger Regiment Combatant Leader)

121. It’s good for medical officers to go out on operations with the unit. That’s how the medical officers earn the trust of the Rangers in the unit. We had one medical officer who crawled out into the open to save a wounded Ranger while we were still killing people. (Role I – 75th Ranger Regiment Combatant Commander)

122. SEAL medics desire technical career progression within SOF community to include the creation of a SEAL medic warrant officer. (Tarin Kowt Role I – NSW)

–  –  –

They do not routinely conduct missions with their medics. They are not reliably trained in TCCC at present. (Tarin Kowt Role I – NSW)

124. For Australian forces, primary care physicians (e.g. Family Medicine) are maintained on active duty. They provide medical care, oversight, and medical leadership for Role I. Physician specialists are maintained in the reserves. They have no physician assistants, but they do have nurse practitioners. (Tarin Kowt Role I – Australian Forces Physician)

125. Australian force Role I medical hierarchy: 1) Buddy Aid, 2) Combat First Aider (CFA), 3) medic, 4) physician. All Australian forces are trained on tourniquet application. (Tarin Kowt Role 1 – Australian Forces)

126. The Australian Army School of Health provides medics with a diploma for “Paramedical Science.” (Tarin Kowt Role I – Australian Forces)

127. UK forces have combat medical technicians (CMTs) and team medics. CMTs are medics by occupation and team medics are similar to a US combat lifesaver. The basic CMT course provides a Class II medic. The Class I course provides a Class I medic. The Battlefield Advanced Trauma Life Support (BATLS) Course and the Pre-hospital Emergency Course (PEC) is provided. Paramedic-level advancement was recently initiated for the top performing CMTs.

128. UK physicians go out with Role I to patrol base and conduct combat missions as required.

(Bastion Role I – UK Forces)

129. UK Close Support Squadron medics are imbedded into line units. For pre-hospital documentation, line personnel serve as the scribe. Medics train the line personnel, and all function as a “casualty response team.” Using this practice, UK medics have successfully completed field medical cards on nearly all casualties. (Bastion Role I – UK Forces)

130. A MERT paramedic is a registered independent medical provider who receives a bachelor’s degree in paramedical science and is considered an Emergency Care Practitioner (ECP). All is regulated through the Health Care Professions Counsel and the National Health Service (NHS) who provides Emergency Clinical Guidelines. (Bastion Role I – UK MERT Paramedic)

131. The Joint Royal Colleges Ambulance Liaison Committee Guideline Development Group (JRCALC-GDG) develops and reviews national clinical practice guidelines for NHS paramedics although the principles are applicable to all pre-hospital clinicians. Guidelines can be found at the following URL: http://www.jrcalc.org.uk/guidelines.html. Although paramedics must adhere to these guidelines, an emergency medicine physician has the ability to authorize and expand scope of practice as required. (Bastion Role I – UK MERT)

132. Medical directors for PJs are sometimes initial entry general medical officer (GMO) flight surgeons with minimal clinical and practical experience. The PJ Medical Oversight and Advisory Board (MOAB) and PJ Handbook assist by providing clinical guidelines. However, sometimes the unit flight surgeon may impose restrictions on scope of practice. Sometimes this is overridden as was the case with flight surgeons being directed to conduct training for blood product administration program. (Bastion Role I – USAF Senior PJ)

–  –  –

133. Should we recreate and redevelop a medical warrant officer program? The Interservice Physician Assistant Program selection should elevate the importance of combat experience as a selection factor for the program. (Bastion Role I – USMC/USN)

134. Significant prior combat medic experience should be a major selection factor for physician assistant school. (BAF Role I – CJSOTF, 1st Cavalry Division, 1st Infantry Division, 173rd ABCT;

Role I – 75th Ranger Regiment) 135. “As a SEAL platoon chief - I have incredible operational autonomy. With respect to medical issues, I have essentially no autonomy when it comes to which meds I give and can order.” (Tarin Kowt Role I – NSW Platoon Chief)

136. SEALs no longer have SEAL operators who are designated as corpsmen; all trident wearers are designated as “SEAL Operator.” SEALs who have attended the Special Operations Combat Medic (SOCM) Course are denoted informally as “SEAL SOCM Medics.” (Tarin Kowt Role I – NSW) The impact on medical readiness to perform combat casualty care resulting from this fundamental change in enlisted personnel designation has not been evaluated.

137. Every deploying SEAL squadron should have a physician or a physician assistant with them. That person should have had an NSW medical provider orientation and should attend TCMC or TCCC orientation - not walk in the situation cold. (Tarin Kowt Role I – NSW)

138. There are currently no medical officers or physician assistants assigned to individual SEAL teams or squadrons. They are assigned to NSW Logistic Groups. There are non-SEAL Independent Duty Corpsman assigned to the SEAL teams who may have no background in NSW and who may disempower SEAL SOCM Medics from the skills that they are taught and required to have by USSOCOM directive. (Tarin Kowt Role I – NSW)

139. NSW is the only SOF organization that deploys team-sized units without a PA or physician. MARSOC deploys company-sized elements with SOIDCs. (Tarin Kowt Role I – NSW)

140. Some NSW units have begun using USMC Special Operations IDCs (HM 8403s) or USAF PJs for battlefield trauma care because of the difficulty of maintaining both SEAL combatant and medical skills. (Tarin Kowt Role I – NSW)

141. I have been through the Special Forces 18-D school, but NSW took away all of my medical capabilities because now I am now designated as a SEAL Operator. On a recent deployment to Africa, we had an evacuation time of 4 hours, but no physician, no PA, and no medications for the SEAL medics. There should be a clearly outlined pathway for medical skills progression in NSW from SEAL SOCM Medic to 18D to PA and this medical progression should be valued and encouraged by the SEAL community. We MUST have better deployed medical support for SEAL units when they are deployed in isolated settings – either an 18D trained provider, a PA, or an Emergency Medicine or Family Practice physician. These individuals must be familiar with SEAL and CJSOTF operations. (Tarin Kowt Role I – NSW Combatant Leader)

142. NSW and BUMED should consider creating a SOF corpsman who can function as a medic in both NSW and MARSOC. They could then stop sending SEALs to SOCM if they will not be allowed to function as medics when they graduate. (Tarin Kowt NSW Role 1 – Senior Medic)

–  –  –

143. I’m pretty sure that if a SEAL platoon chief was a sniper before he became a platoon chief, he would be allowed to function as a sniper if he chose to do so. (Tarin Kowt Role 1 – Senior Medic)

144. The PJ community is hovering at approximately 50% manning. (BAF Role I – USAF Senior PJ)

145. A reserve physician who works for the Air Combat Command (ACC) has recently assumed the leadership role for PJ medical issues. He has been designated by the USAF SG as the PJ consultant. He is dedicated, very involved, and has been a key element in achieving a very high level of PJ medical readiness. (Bastion Role I – USAF Senior PJ)

146. USMC battalions need approximately 65 HMs to deploy. There are usually 30-40 permanently assigned. Approximately 25 are pulled from Naval hospitals to deploy with the battalion. (Bastion Role I – USMC/USN physician)

147. The large majority of Marine Recon and MARSOC HMs are Special Operations IDCs rather than SOCMs or 8404s (basic USMC support corpsman). (Bastion Role I – USMC corpsmen) Training

148. Medical training and readiness should be measured before deployments and considered a go or no go item with Commander attention. (Theater Trauma Conference)

149. Army physicians and 68W medics, SFC and above, assigned to line units attend the Tactical Combat Medical Care (TCMC) course, where they are taught TCCC prior to deployment per Forces Command directive. (BAF Role I – 1st Infantry Division)

150. Army medics E-6 and below attend the Brigade Combat Trauma Team Training (BCT3) course per Forces Command Directive. TCCC is part of BCT3. (BAF Role I – 1st Infantry Division)

151. Military physicians, physician assistants, and nurses deployed to MTFs in CJOA-A do NOT always get trained in TCCC. (BAF Role III; Salerno Role II; Kandahar Role III; Tarin Kowt Role II; Bastion Role III) These providers would therefore not necessarily understand the approach and the rationale for the pre-hospital care provided by combat medical personnel.

152. Navy physicians assigned to Marine line units have no requirement to be trained in TCCC.

(Bastion Role I – 1 Marine Expeditionary Force; Bastion Role I – Combat Logistics Regiment

15) These providers would therefore not necessarily understand the approach and the rationale for the pre-hospital care provided by their corpsmen.

153. It does no good to train medics, corpsmen, and PJs in TCCC if their Division, Brigade, and Battalion physicians and physician assistants do not allow them to perform the interventions recommended in TCCC. This underscores the importance of training the physicians and physician assistants in TCCC. (Role I – Physician Assistant)

–  –  –

154. The 75th Ranger Regiment Regimental Command Inspection (RCI) program tracks and evaluates 100% Ranger First Responder achievement. This effort is not “pencil whipped.” (Role I – 75th Ranger Regiment Combatant Leader)

155. The biggest difference in combat casualty care in the 75th Ranger Regiment has been the Ranger First Responder course. Conventional forces do not do anything like that. All of my platoon members are assistant medics. (Role I – 75th Ranger Regiment medic)

156. When we have a day off – we do medical training. (Role I – 75th Ranger Regiment Combatant Leader)

157. Casualty response training for first responders and combatant leaders is often not incorporated into unit battle drills. (BAF Role I – 1st Infantry Division) This is an essential component of battlefield trauma care. (Role I – 75th Ranger Regiment)

158. Provide a structure and foundation for casualty response systems and trauma care training. Culture and strategy follow structure. Prioritize resources and training based on structure. Master the basics. Reinforce the basics. Achieve confidence through competence on the basics. Do not just train the basics, condition the basics through repetition. Akin to marksmanship, physical training, and small unit tactics, first responders must become the masters of the basics of pre-hospital casualty response. Combatant NCOs provide first responder continuity for casualty response systems. (Role I – 75th Ranger Regiment)

159. Casualty response systems must be tailored to the unit and the mission. One size does not fit all; however, the framework for a casualty response system is not being evenly applied.

Initial medical training programs must be accompanied by sustainment medical training programs in order to achieve enduring effects. Initial medical training programs are centralized and easier to standardize and implement. Sustainment medical training programs are decentralized and more difficult to standardize and implement evenly across the military. (Role I – 75th Ranger Regiment)

160. Some units may only be training first responders in TCCC to a level of “familiarization” versus conditioning first responders to a level of “proficiency” or a level of “mastery”. Casualty response training should be repetitious hands-on training commensurate to marksmanship, physical training, and small unit tactics. Unit casualty response rehearsals should be conducted routinely. A medical equipment pre-combat check (PCC) and pre-combat inspection (PCI) should be conducted prior to every mission. (Role I – 75th Ranger Regiment)

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