Lectures

Special Operations Medicine: Introduction into Military Special Operations Surgical Team

Recording

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Military Medicine: How to Practice Good Medicine in Bad Places

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Q&A

Is AFSOC looking to expand SOST and open any more detachments elsewhere or forming more than 8 teams within current detachments?

There is a newly formed guard team, and a new detachment. For fully trained medical teams, probably closer to 6. Expanding might be unrealistic given the current military environment. Guard teams located in Pennsylvania, perhaps other areas.

Did you consider any other branches before choosing the Air Force?

Didn’t feel super strongly, found out specifically about the SOST at an ACEP event, which is what engaged Major Le.

Are the SOST teams divided into area of responsibility?

The teams are trained to pretty much the same level.

Do you know if there are similar opportunities to SOST in the Army National Guard or Air Force Reserves?

Airforce team mostly working in the joint environment, can’t get into specifics on what unit they are supporting, although we do work with Army and Navy. There are teams that are similar in the Army and Navy, although they are slightly newer. Unsure of where they are in their development. There are also a number of conventional teams which can be placed as far forward as SOST,with less focus on tactical proficiency and maneuverability. Some people come to SOST selection from other services. Joining the military during med school can lead to you being placed elsewhere, but conversely, there may not be civilian slots in the future. It is unpredictable so unsure what the process will look like in the future.

In your experience, are medical teams “off limits” from military threats due to the care you can provide to all injured people, or is it the opposite that enemies see you as a major target?

There’s no good answer for it. According to the Air Force, they can be classified either as a combatant or non-combatant. If non-combatant, they should be wearing a red cross, most vehicles don’t have anything to distinguish them from combatants.

Are the teams still deploying overseas on a regular basis?

Less than before at the moment.

Are Physician Assistants utilized in SOST teams?

PAs are not used on the SOST team currently.

What is used for anesthesia?

Almost all TIVA. Most of the time it is ketamine, some paralytic, some opioid

How do you work around the anxiety of the emergency situation? What do you use to keep you focused during surgeries knowing that your scene can become unsafe at any time?

Working in the ER is already super stressful, if you’ve worked in a trauma bay at an ER you should handle the stress okay. Obviously a different situation, but they find ways to make the training very specific to prepare you. Lots of worst case scenarios, and really realistic training. The assessment and selection is done for a reason, basically a week of being really stressed and being challenged mentally and physically.

Do you have any advice for Air Force HPSP students looking to position themselves for SOST?

Just reach out to me or others in the program and we can let you know what worked for us.

Advice for students looking to position themselves for SOST, and how long is the pipeline?

Fastest Dr. Le has seen is 6 months, usually between 6 and 9 months.

If selected for SOST, is there a minimum amount of time you work in SOST?

Unsure, anything under two years just wouldn’t make sense due to the training time. Probably at least 3 years, but not sure if that is written or not.

Is sepsis a big concern during surgery out in the field? If so are the wounded treated immediately with abx’s for preventative measures

Lots of prophylactic antibiotics used, imipenem and ancef most commonly.

Any recommendations to set someone up for SOST when picking 3rd and 4th year rotations?

Unsure about specific rotations, anything getting you exposure to trauma is probably good. EMS work helps. Being physically prepared is very important as well as being medically prepared.

Tactical Medicine: Tactical and Emergency Medical Services

Recording

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Q&A

What kind of tactical medicine opportunities are available for EM physicians to work in the field? Is it through joining a TOMS team?

Absolutely! Dr. Richard Carmona Ret. Surgeon General of the United States, yep he was a SWAT Doc! Dr. Reese – Dallas SWAT-Doc, etc. There are several opportunities as a physician for TEMS/TOMS. The most common is to be involved with your local Law Enforcement and or Fire Department (if they have a SWAT team) and find out how you can be involved. There are many parts of the country depending on where you eventually decide to work that do not have tactical medics. There are several trauma Doc’s that we work with at the national level and they would be happy to share some info. The one caveat to all this, and for any other further involvement in TEMS, is to have some experience in pre-hospital EMS. ED/ER medicine alone will not provide you with the hands on you will be expected to perform as the “SWAT Doc”

What do you do to prevent fire fighters from developing heat related illnesses?

Medical wise, we do vital signs on everyone before and after live fire/burn training sessions. On actual fires while on-duty or extended operations outside in gear such as extrications or a large gas leak where we are in bunker gear for hours sometimes, we set up a medical rehab area (usually a rescue truck or two with AC running) that will take vital signs, and log you in and out for incident command. There is a county-wide firefighter rehab form we use with HR, SaO2, and BP values that will not allow us to go back to operations if we fall outside those numbers. There is a time frame to return to normal values, if not…you get a free ride to see one of you guys at the ER!

Training wise, we do our best to acclimatize (lots of it) to working in bunker gear. As an example; we start off our recruit classes (new hires, not academy students) wearing just bunker pants with escalating PT sessions to eventually include coat, hood, mask, gloves and air-pack. The goal is to work in full bunker and do the actual skills (hose lines, ladders, search and rescue) without feeling uncomfortable in gear. We do this for 8 weeks, everyday (for our new recruit program) even after they have completed the 18 week fire academy. Personal fitness level is always on the radar and we do our best to keep in “gear shape.” More importantly is monitoring work-rest cycles, hydration, urine output, and work-output based on heat index. Rhabdomyolysis and true heat illnesses are actually less common than you’d think, as instructor cadre and company officers are pretty much always on top of this as we all work and live in S. Florida. We do see this more often when we have out of state or foreign training visitors / students during our exchange training programs. We have had some European, South American (Chili), and Canadian FF’s go down in training with some heat related illnesses, but were all OK and recovered fine. We take it serious and will pull people out of the mix if we start to see any early signs of heat related illness.

Do you see EM physicians being able to participate in TEMS as more of a teaching role or is there field opportunity?

Yes and Yes. When our scope of practice ends, the MD/DO picks up for instruction in such a way that often changes or protocols. I would like to say I could teach a “Mass Transfusion Protocol” class or “complications with ortho injuries” but it would only be from the pre-hospital side, my level of medical education, and or theory. We really like when physicians instruct based on what happens after we deliver casualties to the ED, and then to the OR. Often times knowing that we can be preventative in pre-hospital aspects like broad spectrum antibiotics, or actually not doing something like long-spine boards for minor back injuries comes from physicians looking at the data and getting that back to us. If a new ALS procedures such as thoracostomy or in some EMS systems even escharotomy protocols get rolled out for critical care paramedics, often times it is the physicians who are teaching us. There really is not much in-between such as RN, NP, or PA, in the world of TEMS. Although, PA’s (that work the trauma bay) are starting to get more and more involved in TEMS as a bridge between street medics and trauma doc’s. for the aforementioned procedures. A proactive physician with some field experience is a tremendous instructional asset for TEMS. Protocol changes such as TXA, PRBC’s, Plasma, Whole Blood, sutures, antibiotics in the field, etc. These items are discussed and researched in format designed for your level of understanding, not ours. So after all the cohort studies are in, we need someone to comb through the PhD level “stuff” and help explain why we are, or are not going to use/do something in the field.

How can we as medical students start to get involved with TOMS and TEMS? Are there ride along opportunities?

We always advocate for anyone getting involved in Emergency Medicine to ride along with your local Fire Department. If anything, it will give you a better understanding of what we don’t (or can’t) do, as opposed to what we are able to do in the field. There are no ride along programs for TEMS. TEMS medics (SWAT Medics) are generally firefighters who have been assigned to the SWAT team in-conjunction with their respective law enforcement counterpart. This is often through a rigorous physical selection process and oral interviews. They are then put through SWAT school, weapons school, any specialty school based on the team, sometimes the police academy, and a formal TEMS program. We do have TECC and TCCC classes that would give you a great insight to the world of TEMS. The Medical Directors for the Fire Departments are still the medical directors for TEMS teams. We still fall under the general medical protocols for our department or region. Federal TEMS teams do operate under different protocols, as they are often attached to State Department or DOD units and will assume the responsibilities of a more expansive set of protocols. TEMS Medics on Federal teams such as CBP/BORSTAR, DEA/FAST, and FBI/HRT will often deal with remote medical issues of casualties as well as teammates (childbirth in austere environments, wound care/sutures, dental issues, infections, illnesses and injuries from human trafficking victims, local anesthesia / nerve blocks are often in their scope ) and are able to perform much like a PA/NP would.

Do you have any other resources for those who want to dive deeper?

Yes. Spending a few bucks (like you guys don’t have enough books to worry about) on Tactical Medical Essentials 2^nd edition, and PHTLS 9^th Edition would be good reading to get into the evolution of TEMS and how it is now implemented into modern day EMS.

What do you feel is the most rewarding part of working in the field?

Great question. The “field” as you refer to, is where you work as well (hospital), let me explain. This is my theory, but I challenge anyone to prove me wrong! Burger and a beer to the winner…

I have been an EMT/ Paramedic for almost 25 years, filled up a lot of passports, and took some mental notes in social patterns along my journey. There are only three buildings on the planet (literally not figuratively) that a person will inherently turn and run towards in their most desperate time of need without hesitation… Hospital, fire station, and a police station. The very first person they see in any of these three buildings will be entrusted with their life, and automatically assumed non-threating, and an ally. If you think about that for a minute, of all the buildings in the world…all the other buildings and houses in a city, there are only three that someone will drive or run towards by mental default while in grave danger, or dying. If you are fortunate enough in life to have worked in any of these three places, or considering working in these (three) places, you have to make sure you fully understand that concept and the responsibility that comes along with it. If you don’t, you should consider a career in the fourth building.

That is my reward my friend. I get to work in one of the three buildings…