December 21, 2021 • 26 mins
Col John Wightman
Professor and Chair, Department of Military & Emergency Medicine, Uniformed Services University
Col Wightman offers very concrete tips on how to tackle common military problems.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
John Wightman (00:00):
Hello, everybody.
Welcome to this session in theleadership track on getting what
you need. Colonel John Whiteman,chair of the department of
military and emergency medicineat the Uniformed Services
University. I've been in uniformalmost 31 years now, I hadn't
been sworn in five weeks beforea wreck invaded Kuwait back in
1990. Prior to that, I was a EMTin a semi rural Colorado area
(00:25):
and then a inner city urbanparamedic for the city of St.
Louis. And pretty much my entirecareer has been in academic
emergency medicine other than acouple of wings staff jobs, one
for the sudden 11th HumanPerformance wing, which is part
of the Air Force ResearchLaboratory at Wright Patterson
Air Force Base in Ohio, and the24 Special Operations Wing at
(00:49):
Hurlburt. Field Florida.
So here's the standarddisclaimer slide. My views are
my own and I have no conflictsof interest. My educational
(01:10):
goals for this session are totalk about the differences
between what you want and what'srequired for you to have like to
suggest kind of a generalizedapproach to two different ways
of achieving that. And then talkabout three examples from my
(01:33):
career and provide some summaryadvice at the end. So,
desirables and requirements,basically, something that you
desire, you may be able toachieve. But if you're running
into some pushback or someroadblocks, you may want to
either tie it to an existingrequirement or make a new
(01:54):
requirement. And really, thebeginning of the definition of
requirements is really the keyphrase establish needs, it has
to be a need to some higherauthority that has the power to
granted or otherwise, make adecision. And it has to be
(02:18):
established by that higherauthority in writing, so that
you have a document from whichyou can work. So what are the
general approaches where you cankind of look at this as either
bringing the decision makers tothe requirement and showing them
that they need to meet thisrequirement, or bringing the
requirement to the decisionmakers. And we'll talk a little
(02:38):
bit more about that. This iskind of like when I teach at
USU. For patients or casualties,you can bring the resources to
the patient by like moving likea roll to like maneuver surgical
unit up to where the patient is,or you can bring the patient to
the resources is evacuate themfrom like row one to a roll two.
(03:03):
So likewise, you can persuadethe decision makers to meet an
existing requirement. You've gotto do your research, you've got
to look for any applicableguidance. You've got to conduct
and document your thoughtprocesses your analysis, what
are the benefits and risks tothe organization not just to you
(03:28):
write a bullet background paperthat helps you frame it, but it
also makes a one pager that youcan provide to all stakeholders
and then develop course ofaction briefing now that may or
may not be before you do aninitial briefing based on the
background that you'vedeveloped. It could be
developing a complete course ofaction briefing prior to
(03:53):
presenting anything to adecision maker. So you can
either just do an informationbriefing or a course of action
briefing or kind of bothcombined, depending on how the
decision maker wants to receivethat. You can also adjust an
existing requirement or create awhole new requirement. You know,
make sure that you're addressingany reasons for objections,
(04:16):
identify your stakeholders, getthem on board, find out who is
for who's against what thepeople who are against what the
reasons are, who's for thatmaybe they've got some
additional reasons to make thisa requirement, whatever it is
that you need, that you may nothave thought about. Find out
who's actually got theresponsibility for making the
(04:37):
change, and then make it easyfor them to change. Just present
your arguments have all the workdone in advance and then
presented to them and hopefullythey can make a decision on the
spot. So here's some examples onso you know, some of you more
(04:58):
junior medical off officers andothers may not realize that 20
years ago, emergency departmentsin many MTF 's were prohibited
from doing moderate or deepsedation. That was a problem for
us. You know, back, when I camein, there weren't as many
(05:24):
board certified emergencyphysicians, there were only 50
Something training programs inthe country. A lot of the
military didn't really know whatto do with us versus somebody
who was a had just a year ofpostgraduate training, and was
just thrust into the emergencydepartment. And so there was a
medical group instruction, whichis what MD gi stands for, for
(05:46):
those of you aren't in the AirForce. And all emergency
physicians that were residencytrained, were privileged for
procedural sedation, but therewas no depth specified. And this
MD Gi, prohibited moderate ordeep sedation outside of the
operating room aside fromperformed by anesthesiologist or
CRNA days. So the problems forthat, you know, we're clearly
(06:11):
that's a problem for emergencymedicine, it was also a problem
for a lot of our consultants.
And mostly it was a time delay,you know, it was actually easier
if they came down, because thenyou could have one person
performing the procedure, oneperson watching the sedation,
but sometimes, you know, in themiddle of the day, when
operating rooms were running,you know, delays can be 456
hours. And in the nighttime,there's only one person on for
(06:37):
the whole hospital and kind ofback then it was actually Wright
Patterson, at least where I wasat, at that time was a pretty
busy place. So, you know, therewas a disconnect that even on
call RNA students could performmoderator deep sedation outside
the operating room, but boardcertified emergency physicians
(06:59):
couldn't, you know, this is likea first year internal medicine
resident saying, I don't thinkit's cardiac. So I don't think
they need to be admitted, orfirst year surgery, residents
saying something like, you know,not an acute abdomen, when, you
know, many of us have seen waymore acute abdomens than they
have. So this was a disconnect.
(07:20):
It was kind of a pride thing.
But it was also important forpatient care. So we defined the
problem, we documented everydelay of care for a period of
time, try to make an effort todocument the qualitative effects
on patients. But that was alittle harder to do unless there
was a patient complaint. But wecould definitely get
(07:41):
quantitative data on throughputmetrics. And, you know, which of
these do you think, you know,was, you know, got the
leadership's attention more? Youknow, it was the data that they
had to feed up to higherheadquarters at that time, you
know, now it's, they got to feedup to DHA. So we looked at the
standard of care, we looked atACGME documents for residency
(08:05):
programs, we looked at the setclinical policy at the time, we
pulled key clinical articles.
And we looked at other hospitalsin the area, because really,
it's the standard of care in theregion. That is the important
parameter. Even if it was reallyquantitative metrics that got
(08:29):
people kind of moving on this,the outcome was going to be the
same no matter how we made theargument and a dual arguments
are often better than a singleargument. So we wrote that
background paper, framing theissues, circulated around to the
stakeholders convened a workinggroup. You know, it's
interesting that even now, youknow, 2021, there is no written
(08:54):
requirement to practice at orabove the standard of care in
the community, in any air forceinstruction that I or jag here
could find. There is arequirement to conduct a
standard of care determinationwhen the standard of care has
come into question. And ergo,that means that you really have
to practice to the standard ofcare. And that just makes total
(09:16):
sense. It just was interestingthat there was no actual written
document, mandating that. So wewouldn't looked at the clinical
policies. The key phrases inthis ones, this is back from
2005, is that, you know,emergency physicians are
trained. It's a core competencyof the specialty, and emergency
(09:37):
physicians routinely providethis service throughout the
country, not to mention theregion that we're in. So we
convened this working group. Youknow, the anesthesiology
representative pretty muchargued that only one specialty
was qualified, which wasessentially being exclusionary
emergency medicinerepresentative argued with
(09:59):
evidence Since that emergencyphysicians were qualified and
made it inclusive, and made it alarger part of the team that was
delivering patient care in theacute care and emergency
setting.
It turns out that through someresearch, we also found that
(10:21):
anesthesiology was notcredentialed to provide
procedural sedation outside theoperating room. So that kind of
also boosted our argument alittle bit. So we've talked to
the chief of Clinical Services.
No, that's called the DCCs andother services and csdh in the
(10:42):
Air Force, basically decidedwith us on on a lot of reasons
and rewrote the medical groupinstruction. The problem with
that was it wasn't staff throughus, so we didn't get to see it.
And when it came out, when therewas a surprise clause that said
that emergency physicians coulddo it could do sedation, but
(11:04):
they couldn't use a nonreversible agent. And so I
pretty much excluded three ofour biggies. tahminae, ketamine
and proof protocol. And we couldstill use them for induction for
intubation. But we couldn't usethem for procedural sedation, at
least at the moderate or deeplevel. So you know, a pride
(11:26):
file, went back to the ChiefClinical Services, and also went
to the med group commander,which essentially, as the MTF
commander, and, you know, said,this needs to be redone, I knew
that there was a new chief ofclinical services coming in
fairly soon. So we kind of slowroll this and just kind of tried
(11:48):
to grease the skids and makesure that we had it all teed up
for that person. And really,once they got there, we made a
quick pitch and gotappropriately staffed. And then
we got the med group instructionadopted, there was a lot of
pushback from the chief ofnursing services, saying that
Emergency Nurses, including somethat were certified, were not
(12:12):
qualified to do moderate or deepsedation with the provider. And
we eventually got that fixed to,we just had to prove that it was
safe to do in the emergencydepartment. And we continued,
the one person does procedure,one person does the sedation
policy. So once we got itadopted, we actually redid our
(12:36):
metrics to show improvement, andthat what we were saying is
going to improve throughputactually did the trick. And it
did. And so people startedlistening to us on other causes
that we had to fix as well. Sothe other thing I want to talk
about is training that wasdisapproved. So back, you know,
(12:58):
at the beginning of the globalwar on terrorism, airports,
flight surgeons who had only hada PG one year, we're having to
fly critical patients from placeto place on rotary wing
platforms, particularly inAfghanistan, but somewhat in
Iraq too, on and you know, withonly one PGY one year, they
(13:20):
didn't have a lot of ICUexperience in their internships,
and they really had noadditional critical care
training. A lot of them feltvery uncomfortable doing this
now, you know, our pair rescuemen that were often with them,
were pretty high speed, but theydon't do you know, critical care
transport, like a CCAP teamdoes. So, you know, you know,
(13:44):
there weren't really was nodoctrine that kind of foresaw
this occurring when 911happened. And, you know, the
first critical care transportteam corps that Seacat course
was in 1998, so predates 2001.
(14:04):
But these other teams that weremore designed for rotary wing
platforms, because a Seacat teamis three people and depending on
the package, five to 800 poundsof gear and not putting on that
on a Blackhawk and then tryingto fly over you know, 14,000
(14:25):
foot ridges. So they came upwith the idea the critical care,
transport team ticket andeventually settled on the
tactical critical careevacuation team attack it. But
those were still in thepipeline. So there really wasn't
anything for these flightsurgeons at the time. So you
know, this was the applicablereg here. And so you know, the
(14:53):
courses that were required, andit well I guess, I should say
recommended at the time, wereThe aeromedical evacuation
course, C four which includeincluded a TLS, advanced trauma,
life support and emergencymedical technician basic course,
that was really it for medicinefor these flight surgeons.
(15:14):
So really couldn't convinceanybody that they needed more
postgraduate training or goingto the Seacat course. But when
we realized that this was reallymostly an F sock issue for these
flight surgeons flying with thePJ's, we narrowed the focus to F
(15:35):
sock rather than trying to getthe entire air force to change.
And we got warfighting linecommanders on board to really
pretty much demand thiscapability. So a new asset
construction was written at thattime, it was 48 101, newer
versions or 4810 10, if you'reinterested in looking at what is
(15:55):
current, but basically, they hadthis statement right up front,
that whoops, sorry, need to goback one. Wrong click here. So
the key statement here really isoperational assets, medical
personnel are required toprovide only the very best error
(16:16):
medical care and critical care.
And who could argue with thatkind of misstatement? You know?
No, they're gonna not providethe best care they possibly can.
Well, how are you going toachieve that? So that same table
had all this stuff written intoit. And, most importantly, for
this mission, the initialcritical care or medical
(16:37):
transport course, which is notexactly the right term, but it's
still the Seacat initialtraining. And so these flight
surgeons that had to do this onrotary platforms, at least got
that two weeks of training, andthere's some hands on with that.
Not a lot with actual patients,but still was better than they
(17:00):
were getting before. The otherthing that you have to do is dig
into regulations and get thoselittle nuggets, they're just
really important. So when I waswith special operations, we had
a purple heart that was deniedpararescuemen he already had
(17:24):
one. He sustained a combatinjury and a undisclosed
location, basically a grenadeexplosion immediately in front
of them. An 18 Delta on thescene, Army Special Forces
Medical Sergeant documented apost concussion syndrome. But as
you'll see, an 18 Delta is not amedical officer, and it takes a
(17:45):
medical officers documentationto document mild TBI. But this
was prior to my arrival at thetwo fours. So this was submitted
once and sent back that therewas insufficient documentation
of the TBI but not really a goodexplanation as why. And it was
(18:06):
submitted again with moredocumentation on the TBI but
again, rejected. So that's whenI ended up picking it up. So if
you go to the instruction, andyou know, the Air Force
instruction comes right from theDepartment of Defense
Instruction, so this could applyto other services as well. If
you, you know, we had to firstensure that the person was
(18:32):
eligible to receive the award.
So this says that any member ofthe Armed Forces of the United
States who received wounds whileserving with friendly forces
engaging in armed conflictagainst an opposing armed force
of which the US party is not abelligerent. That was absolutely
applicable. But then there'sthis little see notes four, five
(18:55):
and six about the conditions forwhich, you know, being wounded
means Okay, and so TBI is one ofthose. So I looked all that up.
Okay. And if you look at TBI, itsays that the medical
documentation was containedevidence of residual cognitive
deficits, doesn't say for howlong and functional impairment
(19:20):
requiring medical treatment orsupport by a medical officer
Well, there was no medicalofficer in this data mass
location. And so the 18 Delta'sdocumentation essentially didn't
count on, there are somecaveats, the medical officer
documents that medical officerwould have made the same
(19:42):
conclusion had a medical officeractually been there, but that
wasn't flying. Okay. Sowe then, you know, looked at
other things that were in here,you know, so, so that was this
holes, you know, note six talksabout that. that medical
officers don't have to be there.
(20:05):
But then we went looking forother things. And having known
the PJ's medical record, I knewthat he had had some wounds, one
of which included a retainedforeign body that had to be
removed. But that wasn't in hisrecord either by the retained
foreign body was but not thefact that it was removed. So we
(20:28):
basically had to track down aphysician assistant, a Navy's
Special Warfare physicianassistant, who had not written
that procedure note, that personwas deployed, we had to find him
in his deployed location, he hadto recall the details, add a
note to the record, we had toprovide sworn testimony that it
was actually you know the truth.
And so once we got that Icontacted the awarding authority
(20:53):
to expect a third submission, Iinformed that person of the
additional criterion that I wasgoing to be submitting with and
not asking for a TBIdetermination. I also asked them
that, you know, not to have notto let their staff screen out
the package before it got totheir eyes, I did get kind of a
(21:14):
angry email from the deputy SGsaying that we screen
everything, you know, on theirmerits, and said, Well, I just
want to make sure that I've kindof got the skids greased here,
and that nothing holds us up.
And that doesn't get denied,before somebody does look at
those merits. So we ended upsubmitting it, and the
(21:36):
declaration got approved.
Although the awarding authoritynever got back to me that they
actually approved that the onlyway I found out was from the PJ
who, when they actually made thedeclaration award. So kind of in
summary, you know, don't keepchallenging the status quo, if
it's not working for you figureout a way to make it work for
you. And, you know, I heard thisphrase from, I think it was at a
(22:01):
conference, Jeff Bailey, ColonelJeff Bailey's trauma surgeon in
the Air Force, said bepersistently dissatisfied with
the status quo and berelentlessly disruptive in
getting things fixed. So that'salways stuck with me, it's
actually on my whiteboard infront of my desk, just to keep
reminding me of it. So mysummary advice to you is, you
(22:25):
know, if you need something,define the problem with the
parameters that are important tothe decision makers, not to you
necessarily, do your homework,look at all the doctrine,
regulations, policies, otherinfluences, anything that's in
writing that you can bring tobear. And if it's not writing,
you know, get something written,that makes it a requirement and
(22:47):
establish need, find even thesmallest nugget that shifts your
request from just desire torequire do I can load the
purpleheart, the fact that therewas retained foreign body and
then get that document and matchthat up to the requirement and
get the award made. same wouldgo for any other declaration
that you're trying to getthrough. Do your homework,
(23:07):
thorough analysis, because andparticularly looking at risk,
because that's what commandersunderstand everything is in risk
and risk mitigation. So work onthat. Do your information, paper
and your information briefing,do your course of action
(23:27):
analysis and present yourarguments for a decision
briefing. You know, look forworkable solutions that, you
know, get your, you know, figureout the solution, don't just
bring up a problem, but bring upa solution. And documents, your
successes, you know, do the dataeven after you get what you
(23:49):
want, so that you can prove thatyou know what you did was
actually successful. And don'trub it in when you when, you
know, you may need anotherrequest. You may need somebody
on board for some other problemthat you're trying to fix. So,
you know, it's great when you dowhen but don't, you know, put it
(24:09):
in other people's faces. So thatis all I have for you today.
We've got seven and a halfminutes for questions and I
thank you for your attention outhere.
Hello, everybody.
Welcome to this session in theleadership track on getting what
you need. Colonel John Whiteman,chair of the department of
military and emergency medicineat the Uniformed Services
University. I've been in uniformalmost 31 years now, I hadn't
been sworn in five weeks beforea wreck invaded Kuwait back in
1990. Prior to that, I was a EMTin a semi rural Colorado area
(00:25):
and then a inner city urbanparamedic for the city of St.
Louis. And pretty much my entirecareer has been in academic
emergency medicine other than acouple of wings staff jobs, one
for the sudden 11th HumanPerformance wing, which is part
of the Air Force ResearchLaboratory at Wright Patterson
Air Force Base in Ohio, and the24 Special Operations Wing at
(00:49):
Hurlburt. Field Florida.
So here's the standarddisclaimer slide. My views are
my own and I have no conflictsof interest. My educational
(01:10):
goals for this session are totalk about the differences
between what you want and what'srequired for you to have like to
suggest kind of a generalizedapproach to two different ways
of achieving that. And then talkabout three examples from my
(01:33):
career and provide some summaryadvice at the end. So,
desirables and requirements,basically, something that you
desire, you may be able toachieve. But if you're running
into some pushback or someroadblocks, you may want to
either tie it to an existingrequirement or make a new
(01:54):
requirement. And really, thebeginning of the definition of
requirements is really the keyphrase establish needs, it has
to be a need to some higherauthority that has the power to
granted or otherwise, make adecision. And it has to be
(02:18):
established by that higherauthority in writing, so that
you have a document from whichyou can work. So what are the
general approaches where you cankind of look at this as either
bringing the decision makers tothe requirement and showing them
that they need to meet thisrequirement, or bringing the
requirement to the decisionmakers. And we'll talk a little
(02:38):
bit more about that. This iskind of like when I teach at
USU. For patients or casualties,you can bring the resources to
the patient by like moving likea roll to like maneuver surgical
unit up to where the patient is,or you can bring the patient to
the resources is evacuate themfrom like row one to a roll two.
(03:03):
So likewise, you can persuadethe decision makers to meet an
existing requirement. You've gotto do your research, you've got
to look for any applicableguidance. You've got to conduct
and document your thoughtprocesses your analysis, what
are the benefits and risks tothe organization not just to you
(03:28):
write a bullet background paperthat helps you frame it, but it
also makes a one pager that youcan provide to all stakeholders
and then develop course ofaction briefing now that may or
may not be before you do aninitial briefing based on the
background that you'vedeveloped. It could be
developing a complete course ofaction briefing prior to
(03:53):
presenting anything to adecision maker. So you can
either just do an informationbriefing or a course of action
briefing or kind of bothcombined, depending on how the
decision maker wants to receivethat. You can also adjust an
existing requirement or create awhole new requirement. You know,
make sure that you're addressingany reasons for objections,
(04:16):
identify your stakeholders, getthem on board, find out who is
for who's against what thepeople who are against what the
reasons are, who's for thatmaybe they've got some
additional reasons to make thisa requirement, whatever it is
that you need, that you may nothave thought about. Find out
who's actually got theresponsibility for making the
(04:37):
change, and then make it easyfor them to change. Just present
your arguments have all the workdone in advance and then
presented to them and hopefullythey can make a decision on the
spot. So here's some examples onso you know, some of you more
(04:58):
junior medical off officers andothers may not realize that 20
years ago, emergency departmentsin many MTF 's were prohibited
from doing moderate or deepsedation. That was a problem for
us. You know, back, when I camein, there weren't as many
(05:24):
board certified emergencyphysicians, there were only 50
Something training programs inthe country. A lot of the
military didn't really know whatto do with us versus somebody
who was a had just a year ofpostgraduate training, and was
just thrust into the emergencydepartment. And so there was a
medical group instruction, whichis what MD gi stands for, for
(05:46):
those of you aren't in the AirForce. And all emergency
physicians that were residencytrained, were privileged for
procedural sedation, but therewas no depth specified. And this
MD Gi, prohibited moderate ordeep sedation outside of the
operating room aside fromperformed by anesthesiologist or
CRNA days. So the problems forthat, you know, we're clearly
(06:11):
that's a problem for emergencymedicine, it was also a problem
for a lot of our consultants.
And mostly it was a time delay,you know, it was actually easier
if they came down, because thenyou could have one person
performing the procedure, oneperson watching the sedation,
but sometimes, you know, in themiddle of the day, when
operating rooms were running,you know, delays can be 456
hours. And in the nighttime,there's only one person on for
(06:37):
the whole hospital and kind ofback then it was actually Wright
Patterson, at least where I wasat, at that time was a pretty
busy place. So, you know, therewas a disconnect that even on
call RNA students could performmoderator deep sedation outside
the operating room, but boardcertified emergency physicians
(06:59):
couldn't, you know, this is likea first year internal medicine
resident saying, I don't thinkit's cardiac. So I don't think
they need to be admitted, orfirst year surgery, residents
saying something like, you know,not an acute abdomen, when, you
know, many of us have seen waymore acute abdomens than they
have. So this was a disconnect.
(07:20):
It was kind of a pride thing.
But it was also important forpatient care. So we defined the
problem, we documented everydelay of care for a period of
time, try to make an effort todocument the qualitative effects
on patients. But that was alittle harder to do unless there
was a patient complaint. But wecould definitely get
(07:41):
quantitative data on throughputmetrics. And, you know, which of
these do you think, you know,was, you know, got the
leadership's attention more? Youknow, it was the data that they
had to feed up to higherheadquarters at that time, you
know, now it's, they got to feedup to DHA. So we looked at the
standard of care, we looked atACGME documents for residency
(08:05):
programs, we looked at the setclinical policy at the time, we
pulled key clinical articles.
And we looked at other hospitalsin the area, because really,
it's the standard of care in theregion. That is the important
parameter. Even if it was reallyquantitative metrics that got
(08:29):
people kind of moving on this,the outcome was going to be the
same no matter how we made theargument and a dual arguments
are often better than a singleargument. So we wrote that
background paper, framing theissues, circulated around to the
stakeholders convened a workinggroup. You know, it's
interesting that even now, youknow, 2021, there is no written
(08:54):
requirement to practice at orabove the standard of care in
the community, in any air forceinstruction that I or jag here
could find. There is arequirement to conduct a
standard of care determinationwhen the standard of care has
come into question. And ergo,that means that you really have
to practice to the standard ofcare. And that just makes total
(09:16):
sense. It just was interestingthat there was no actual written
document, mandating that. So wewouldn't looked at the clinical
policies. The key phrases inthis ones, this is back from
2005, is that, you know,emergency physicians are
trained. It's a core competencyof the specialty, and emergency
(09:37):
physicians routinely providethis service throughout the
country, not to mention theregion that we're in. So we
convened this working group. Youknow, the anesthesiology
representative pretty muchargued that only one specialty
was qualified, which wasessentially being exclusionary
emergency medicinerepresentative argued with
(09:59):
evidence Since that emergencyphysicians were qualified and
made it inclusive, and made it alarger part of the team that was
delivering patient care in theacute care and emergency
setting.
It turns out that through someresearch, we also found that
(10:21):
anesthesiology was notcredentialed to provide
procedural sedation outside theoperating room. So that kind of
also boosted our argument alittle bit. So we've talked to
the chief of Clinical Services.
No, that's called the DCCs andother services and csdh in the
(10:42):
Air Force, basically decidedwith us on on a lot of reasons
and rewrote the medical groupinstruction. The problem with
that was it wasn't staff throughus, so we didn't get to see it.
And when it came out, when therewas a surprise clause that said
that emergency physicians coulddo it could do sedation, but
(11:04):
they couldn't use a nonreversible agent. And so I
pretty much excluded three ofour biggies. tahminae, ketamine
and proof protocol. And we couldstill use them for induction for
intubation. But we couldn't usethem for procedural sedation, at
least at the moderate or deeplevel. So you know, a pride
(11:26):
file, went back to the ChiefClinical Services, and also went
to the med group commander,which essentially, as the MTF
commander, and, you know, said,this needs to be redone, I knew
that there was a new chief ofclinical services coming in
fairly soon. So we kind of slowroll this and just kind of tried
(11:48):
to grease the skids and makesure that we had it all teed up
for that person. And really,once they got there, we made a
quick pitch and gotappropriately staffed. And then
we got the med group instructionadopted, there was a lot of
pushback from the chief ofnursing services, saying that
Emergency Nurses, including somethat were certified, were not
(12:12):
qualified to do moderate or deepsedation with the provider. And
we eventually got that fixed to,we just had to prove that it was
safe to do in the emergencydepartment. And we continued,
the one person does procedure,one person does the sedation
policy. So once we got itadopted, we actually redid our
(12:36):
metrics to show improvement, andthat what we were saying is
going to improve throughputactually did the trick. And it
did. And so people startedlistening to us on other causes
that we had to fix as well. Sothe other thing I want to talk
about is training that wasdisapproved. So back, you know,
(12:58):
at the beginning of the globalwar on terrorism, airports,
flight surgeons who had only hada PG one year, we're having to
fly critical patients from placeto place on rotary wing
platforms, particularly inAfghanistan, but somewhat in
Iraq too, on and you know, withonly one PGY one year, they
(13:20):
didn't have a lot of ICUexperience in their internships,
and they really had noadditional critical care
training. A lot of them feltvery uncomfortable doing this
now, you know, our pair rescuemen that were often with them,
were pretty high speed, but theydon't do you know, critical care
transport, like a CCAP teamdoes. So, you know, you know,
(13:44):
there weren't really was nodoctrine that kind of foresaw
this occurring when 911happened. And, you know, the
first critical care transportteam corps that Seacat course
was in 1998, so predates 2001.
(14:04):
But these other teams that weremore designed for rotary wing
platforms, because a Seacat teamis three people and depending on
the package, five to 800 poundsof gear and not putting on that
on a Blackhawk and then tryingto fly over you know, 14,000
(14:25):
foot ridges. So they came upwith the idea the critical care,
transport team ticket andeventually settled on the
tactical critical careevacuation team attack it. But
those were still in thepipeline. So there really wasn't
anything for these flightsurgeons at the time. So you
know, this was the applicablereg here. And so you know, the
(14:53):
courses that were required, andit well I guess, I should say
recommended at the time, wereThe aeromedical evacuation
course, C four which includeincluded a TLS, advanced trauma,
life support and emergencymedical technician basic course,
that was really it for medicinefor these flight surgeons.
(15:14):
So really couldn't convinceanybody that they needed more
postgraduate training or goingto the Seacat course. But when
we realized that this was reallymostly an F sock issue for these
flight surgeons flying with thePJ's, we narrowed the focus to F
(15:35):
sock rather than trying to getthe entire air force to change.
And we got warfighting linecommanders on board to really
pretty much demand thiscapability. So a new asset
construction was written at thattime, it was 48 101, newer
versions or 4810 10, if you'reinterested in looking at what is
(15:55):
current, but basically, they hadthis statement right up front,
that whoops, sorry, need to goback one. Wrong click here. So
the key statement here really isoperational assets, medical
personnel are required toprovide only the very best error
(16:16):
medical care and critical care.
And who could argue with thatkind of misstatement? You know?
No, they're gonna not providethe best care they possibly can.
Well, how are you going toachieve that? So that same table
had all this stuff written intoit. And, most importantly, for
this mission, the initialcritical care or medical
(16:37):
transport course, which is notexactly the right term, but it's
still the Seacat initialtraining. And so these flight
surgeons that had to do this onrotary platforms, at least got
that two weeks of training, andthere's some hands on with that.
Not a lot with actual patients,but still was better than they
(17:00):
were getting before. The otherthing that you have to do is dig
into regulations and get thoselittle nuggets, they're just
really important. So when I waswith special operations, we had
a purple heart that was deniedpararescuemen he already had
(17:24):
one. He sustained a combatinjury and a undisclosed
location, basically a grenadeexplosion immediately in front
of them. An 18 Delta on thescene, Army Special Forces
Medical Sergeant documented apost concussion syndrome. But as
you'll see, an 18 Delta is not amedical officer, and it takes a
(17:45):
medical officers documentationto document mild TBI. But this
was prior to my arrival at thetwo fours. So this was submitted
once and sent back that therewas insufficient documentation
of the TBI but not really a goodexplanation as why. And it was
(18:06):
submitted again with moredocumentation on the TBI but
again, rejected. So that's whenI ended up picking it up. So if
you go to the instruction, andyou know, the Air Force
instruction comes right from theDepartment of Defense
Instruction, so this could applyto other services as well. If
you, you know, we had to firstensure that the person was
(18:32):
eligible to receive the award.
So this says that any member ofthe Armed Forces of the United
States who received wounds whileserving with friendly forces
engaging in armed conflictagainst an opposing armed force
of which the US party is not abelligerent. That was absolutely
applicable. But then there'sthis little see notes four, five
(18:55):
and six about the conditions forwhich, you know, being wounded
means Okay, and so TBI is one ofthose. So I looked all that up.
Okay. And if you look at TBI, itsays that the medical
documentation was containedevidence of residual cognitive
deficits, doesn't say for howlong and functional impairment
(19:20):
requiring medical treatment orsupport by a medical officer
Well, there was no medicalofficer in this data mass
location. And so the 18 Delta'sdocumentation essentially didn't
count on, there are somecaveats, the medical officer
documents that medical officerwould have made the same
(19:42):
conclusion had a medical officeractually been there, but that
wasn't flying. Okay. Sowe then, you know, looked at
other things that were in here,you know, so, so that was this
holes, you know, note six talksabout that. that medical
officers don't have to be there.
(20:05):
But then we went looking forother things. And having known
the PJ's medical record, I knewthat he had had some wounds, one
of which included a retainedforeign body that had to be
removed. But that wasn't in hisrecord either by the retained
foreign body was but not thefact that it was removed. So we
(20:28):
basically had to track down aphysician assistant, a Navy's
Special Warfare physicianassistant, who had not written
that procedure note, that personwas deployed, we had to find him
in his deployed location, he hadto recall the details, add a
note to the record, we had toprovide sworn testimony that it
was actually you know the truth.
And so once we got that Icontacted the awarding authority
(20:53):
to expect a third submission, Iinformed that person of the
additional criterion that I wasgoing to be submitting with and
not asking for a TBIdetermination. I also asked them
that, you know, not to have notto let their staff screen out
the package before it got totheir eyes, I did get kind of a
(21:14):
angry email from the deputy SGsaying that we screen
everything, you know, on theirmerits, and said, Well, I just
want to make sure that I've kindof got the skids greased here,
and that nothing holds us up.
And that doesn't get denied,before somebody does look at
those merits. So we ended upsubmitting it, and the
(21:36):
declaration got approved.
Although the awarding authoritynever got back to me that they
actually approved that the onlyway I found out was from the PJ
who, when they actually made thedeclaration award. So kind of in
summary, you know, don't keepchallenging the status quo, if
it's not working for you figureout a way to make it work for
you. And, you know, I heard thisphrase from, I think it was at a
(22:01):
conference, Jeff Bailey, ColonelJeff Bailey's trauma surgeon in
the Air Force, said bepersistently dissatisfied with
the status quo and berelentlessly disruptive in
getting things fixed. So that'salways stuck with me, it's
actually on my whiteboard infront of my desk, just to keep
reminding me of it. So mysummary advice to you is, you
(22:25):
know, if you need something,define the problem with the
parameters that are important tothe decision makers, not to you
necessarily, do your homework,look at all the doctrine,
regulations, policies, otherinfluences, anything that's in
writing that you can bring tobear. And if it's not writing,
you know, get something written,that makes it a requirement and
(22:47):
establish need, find even thesmallest nugget that shifts your
request from just desire torequire do I can load the
purpleheart, the fact that therewas retained foreign body and
then get that document and matchthat up to the requirement and
get the award made. same wouldgo for any other declaration
that you're trying to getthrough. Do your homework,
(23:07):
thorough analysis, because andparticularly looking at risk,
because that's what commandersunderstand everything is in risk
and risk mitigation. So work onthat. Do your information, paper
and your information briefing,do your course of action
(23:27):
analysis and present yourarguments for a decision
briefing. You know, look forworkable solutions that, you
know, get your, you know, figureout the solution, don't just
bring up a problem, but bring upa solution. And documents, your
successes, you know, do the dataeven after you get what you
(23:49):
want, so that you can prove thatyou know what you did was
actually successful. And don'trub it in when you when, you
know, you may need anotherrequest. You may need somebody
on board for some other problemthat you're trying to fix. So,
you know, it's great when you dowhen but don't, you know, put it
(24:09):
in other people's faces. So thatis all I have for you today.
We've got seven and a halfminutes for questions and I
thank you for your attention outhere.
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