GSACEP Lecture Series: The Modern FRST: The Emergency Physician’s Role LTC Shane Summers

Shane Summers, MD, is the Deputy Director, Army Trauma Training Center (ATTC) and is an Associate Professor Military and Emergency Medicine, USUHS.

For access to the slides and to view the whole lecture, visit:
https://pheedloop.com/GSS21/virtual/?page=sessions&section=SES00442M4U09ZQ8B

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Episode Transcript

Shane Summers (00:01):
Good day, everyone. I'm Lieutenant Colonel
Shane summers, and I'm theDeputy Director here at the army
trauma Training Center in Miami,Florida. I'm here to talk to you
today about the forwardresuscitative surgical team. And
more specifically, what Ibelieve the emergency physicians
role should be on those teams.
Little bit of this talk might bearmy centric at times, but I
assure you for the most part,the concepts are broadly

(00:23):
relevant to all of our sisterservices, including our Navy
colleagues that are deployed onfleet surgical teams, and our
Air Force colleagues on groundsurgical teams, and SOS T. The
purpose of this talk is to moreeffectively integrate emergency
physicians into for surgicalteams. And I hope also that
perhaps those of you who aren'tcurrently assigned to frst,

(00:45):
might after this talk, considersigning up to join one. Because
I truly believe that emergencyphysicians provide maximum value
to the frst and could providegreat impact to the quality of
care that we provide for ourwounded warriors downrange. So
without further ado, I'm gonnapull up the slides.

Unknown (01:09):
So in 2018, the US Army decided to convert all of its
fsts Ford surgical teams toforward resuscitative surgical
teams, which essentially meantadding to emergency physicians.
And I would say a good move. Iit's maybe my biased opinion,
but I think it's an upgrade, anemergency physician with their

(01:32):
skill set is tailor made for anfrst. In 2019, I was offered the
opportunity to come down and bea part of the army trauma
training detachment, which ischarged with providing all the
pre deployment training fordeploying FRS T's for the last
20 years. And fsts, before wemade the conversion, and I was

(01:52):
the first emergency physician toactually be part of this unit.
So it's been really cool,working with the ER Doc's that
are coming through here for thelast 18 months on a one to one
basis. And many of them weren'tquite sure what their role was,
you know, on the frst, they'dsay, you know, I'm ashamed that

(02:12):
this is a surgical team, I'm nota surgeon, where do I fit? I'm
not sure. And to be honest withyou, when I first showed up, I
wasn't sure myself. But over thelast 18 months, and working with
them and talking with thesurgeons, I think I've come to
realize a much greaterunderstanding of where the
emergency physician fits onthese teams. And I hope to share
that with you today. So standarddisclaimer, these are my own

(02:36):
personal views and not the viewsof the army. So the army trauma
training center, I believe isthe oldest milset partnership in
the army. We've been aroundsince September 10 2001,
training fsts and FRS t's on amonthly basis. Our detachment is
essentially a fully functioningfrst that's embedded in the

(03:00):
trauma center, in Jacksonhealth, and University of Miami.
So when the teams aren't here, Iwork over in the emergency
department as fully credentialedfaculty, keeping my own skills
up, which has been very good forme. And when I work over that
writer when the teams are here,it's also you know, an eye

(03:22):
opening experience for me andgood for my skill sustainment.
The teams are here two weeks amonth, and the first week they
do didactics in the classroomwith clinical practice guideline
reviews, simulation, skillstations, 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 actualtrauma patients and

(03:46):
resuscitating them as a team,much like they wouldn't when
they're deployed. And many ofthem have never trained together
before they come together at thelast minute. So it's been very
good. But I must admit writer isa little bit old school, in that
it's completely surgeon run.
It's separate from the emergencydepartment. And when I first got
here, they had no idea what todo with emergency physician. And

(04:09):
so I felt a little lost myself,like where do I fit in. And so
that's that really sparked theimpetus for this talk. Because
I'm sure some of my colleaguesout there listening get assigned
to an FST on day one. aren'tsure where they fit, and I hope
to share some lessons learned tohelp you guys better integrate.
So that's my goal. I'm going togive you 10 steps for success if

(04:33):
you say you get assigned to an FRST, what you can do on day one,
to really maximize your time inthat unit. And then I'm going to
lay out the skill set fromemergency position and show how
it really kind of meshes wellwith the frst mission essential
task list and hopefully informothers about what we do because

(04:53):
it still seems like commandersand surgeons, even 2021 don't
really understand what emergencyphysicians do. On a regular
basis and the kind of value webring to the table, and then I
want to talk about some areasfor improvement for us as a
community. Some things that weshould focus on for our pre
deployment training so we can beready to care for soldiers
downrange. And a lot of that alot of these recommendations,

(05:18):
I'm gonna make a come fromexperience here of training
teams on a monthly basis for thelast 18 months. But I also did a
poll on Survey Monkey for all ofour emergency physician and
surgeon rotators to come throughhere since the conversion to the
FRC and have deployed. And Iasked them for, you know, how it
worked when they were deployed.
And having the emergencyphysician on the team was that a

(05:41):
good thing bad thing, what wentwell, what went wrong, and I'll
share that data with you later.
So the frst is by doctrine at 20person element, that simple tune
size element, it split intothree sections. The admin supply
section is the commander and thedebt sergeant. And then the
forward surgical section haseight officers and foreign

(06:04):
listed. So it's to generalsurgeon to orthopedic surgeons
to CRNA is to ICU nurses, andthen our techs and medics. And
then the Ford resuscitativesection is kind of your lane to
start by default by doctrine.
That is a six person element forofficers to enlisted. That's to
er Doc's to ER nurses and tocombat medics. And you're the

(06:26):
leader of that section bydoctrine. Now keep in mind that
these teams are very oftensplitting now to two groups of
10. So as to be moreexpeditionary and to get out
further forward within thegolden hour. And so just keep in
mind, the forward resuscitativesection may become quickly a
team of three, running ACLs. Sowhat is the mission of the frst

(06:51):
is to provide damage controlresuscitation damage control
surgery. What does that mean?
It's about plugging the holes inthe ship, stopping the bleed,
resuscitating them to get themstable so they can get back to
port. Keep the ship a float, notnecessarily repair the ship in
its entirety, but keep it afloatso we can get back to port,

(07:11):
which in the medical world foryou would be the role three,
getting to the higher echelon ofcare. And emergency physicians
are very good at that.
resuscitation and stabilization,and get them to the next level
of care so they can get ongoingtreatment. So what are my 10
steps for success? Step numberone, get to know your trauma

(07:31):
surgeon. This is Colonel MarkBriselli. He is a trauma
surgeon. And one of the bestguys I know. He has deployed
eight times in nine years. Hejoined the army after doing a
civilian residency and civilianfellowship and had zero

(07:51):
obligation to the army anddecided to join anyways and take
a pay cut so as to serve andcare for our soldiers in harm's
way. On day one, I got to knowhim we hang out together. I
trust him he trust me. We knoweach other's families. We like
hanging out. And we talked aboutwe talked shop to you know me.

(08:15):
We talked about how it's goingto run in the in the in the
trauma resuscitation unit, youknow what our roles are going to
be? You know, we we discuss thelatest and greatest and trauma
care and I learned a ton fromhim. And I think he understands
a lot more about the emergencymedicine mindset now working
with me. And I definitelyunderstand more about the trauma
surgeon perspective. And all ofthat will bleed down into good

(08:37):
team dynamics because when youhave a small team of 20 and the
two at the top are buttingheads. You know, it's a recipe
for disaster for the team andcan destroy morale and maybe
lead to worse patient outcomes.
So get to know your traumasurgeon. You may be pleasantly

(08:59):
surprised. Step number two be anexpert in damage control
resuscitation. So this CPG youshould know inside and out the
clinical practice guideline forthis. You are in effect as the
ER doc the damage controlresuscitation just on the team.
The surgeon may be in theoperating room, knee deep in the

(09:21):
abdomen and don't really knowwhat's going on in ACLs. Your
job is to deliver them to theoperating room your casualty,
warm, well perfused notcoagulopathic appropriately
resuscitated. So the surgeon cando his or her job. And they
might give you a warm hug if youdeliver a casualty that's

(09:41):
appropriately resuscitated tothem. So what does appropriate
resuscitation mean? What aredamage control resuscitation
principles? It's all aboutmitigating this lethal trauma
triad that we all know and talkabout. But the emergency
physician can interrupt thisprocess on all sides and
triangle, which some people evencall the lethal trauma diamond

(10:03):
now where they add hypocalcemiaas the fourth rung. But what
does this mean? It means if youhave a trauma victim that's
showing signs of hemorrhagicshock, you resuscitate with
whole blood transfusion as yourresuscitative fluid of choice.
And if you don't have that, thenyou deliver component therapy in
as close to one to one to oneratio as you can. It means you

(10:27):
do your primary and secondarysurvey and you Dec you identify
all injuries. And then you thenshortly after you cover them up
and keep them warm, and deliverthem that that blood warmed
through the Belmont.
And you deliver TSA if you get atrauma victim with hemorrhagic
shock within three hours of timeof injury, so as to mitigate the

(10:48):
coagulopathy and stabilize thatfibrin plug. And you avoid
crystalloid because that'llcause a delusional coagulopathy
and potentially worse acidosis.
you administer calcium as soonas you reach for those blood
products, so as to avoid thehelp of the hypocalcemia that
occurs with transfusion ofcitrated blood products. So all
these are very, very importantto reduce morbidity and

(11:11):
mortality and trauma and they'regonna fall to you. So be a
damage control, resuscitationlist. Number three, maintain
proficiency in your individualcritical task lists. So I think
of someone I think someone in2018 when they're making
decisions to convert the fstsFRCS, they probably looked at

(11:32):
our ICT ELLs for 62 alpha andsaid, Wow, that looks like that
would fit perfectly on an frstthat fits perfectly with the
mission. And they would beright. These are our procedural
ICT ELLs that are listed, atleast on the army side. And all
of them maybe potentially usefuldownrange in a role to setting

(11:57):
and a lot of these, you aregoing to fall to you because a
surgeon is going to be in theoperating room. And so you
should maintain proficiency withthis. And that I think the best
way to do that is workingregular clinical practice and a
busy Ed either at a medicine ormoonlighting or, you know,

(12:17):
milset partnership, you know,but some of our EM colleagues
are no fault of their own, havebeen assigned to admin jobs and
the army or, you know, brigadebattalion surgeon, job staff
officer, and they may be alittle rusty in some of these
things. So you need to have anhonest self assessment and where
you're at. And part of ATTCmission is to kind of get at

(12:39):
that and get you some refresheron that. But you know, just in
time training is never as goodas regular skill sustainment in
it through regular ed practice.
So, I would advise you to keep alog of these things, I think
it's only a matter of timebefore commanders are coming for
them. I think this is definitelythe direction the military is

(12:59):
going in terms of like measuringand tracking operational
readiness. So maintainproficiency in these keep a law
keep your number, try to stayclinically relevant in emergency
medicine. And you will do yourteam and your patients a great
service downrange. Want to putside by side the emergency
medicine ICT LS with the 61Juliet, which is the general

(13:22):
surgeon ICT LS. And you can seethere's a lot of overlap,
they're synergistic. We playwell off each other. Everything
highlighted in yellow areprocedures of both emergency
physician and the cert and orthe surgeon could perform. And
what's highlighted there aresome minor differences. And

(13:42):
there's some things that arespecific for our skill set and
our specialty and those arehighlighted in green. I don't
think too many surgeons aresuperduper, interested in
performing medicalresuscitations, or treating Edie
patients so that would fall tous. Likewise, I don't think too
many of us are super interestedin performing surgery, or
trained to do so. I know I'mnot. So let the surgeon let the

(14:04):
surgeon do surgery. You canmanage the medical stuff. And
you guys can meet in the middlein the ACLS section for the
trauma resuscitations, and oneof you could be the team lead
and the other could do theprocedures or vice versa. Just
switch back and forth. And beflexible, be adaptive. But it
definitely makes sense to addanother another physician with

(14:25):
this kind of skill set to an FRCand I think that's why the
conversion was made. It's kindof offload the surgeon a little
bit step number four know yourclinical practice guidelines
cold. So the CPGs are on the JTSwebsite, just Google JTS CPG.
They are kind of the go to fordeployed medicine. They talk a

(14:47):
lot about the nuances ofmilitary medicine and how we're
different with our than ourcivilian counterparts. They
break it down by priority. Sothis is just part of the list
from the prioritize reading listfor role to physicians, so and I
picked out the ones that Ithought were most relevant for
emergency medicine. And thecategory one they define as

(15:07):
essential no before you go. Andthese CPGs are very well
written, they're evidence based.
They're written by subjectmatter experts, many of you on
this call, I'm sure haveactually contributed to CPGs.
They're continuously updated. SoI think if I had to pick five,

(15:29):
for you to really know cold, Ithink you should be familiar
with all of them. And a lot ofyou already are just by nature
of being an emergency medicinephysician that practices
regularly. But I would pickthose five that are highlighted
in green, before I deployed tono cold. I also would recommend
that you get the deployedmedicine app and download it to

(15:50):
your phone and then download thethe CPGs are listed in the
prioritize reading list for rolltwos. So you have them available
for offline use. While you'redeployed, and during your
downtime, you can pull a CPG andjust review it with your team.
Know your CPG is called Stepfive, showcase your unique skill

(16:13):
set. So emergency physicians arevery flexible, adaptable,
creative, able to do more withless able to task switch and
handle handle multiplecasualties at once. All very
useful skills to have for anfrst. We also have that spidey
sense that we all know aboutwhere you walk in a room and a

(16:35):
patient has a typical complaintsand vague symptoms poorly
described. But something's justnot sitting right with us. We
think something's wrong in ourgut, the hairs on the back of
our neck stand up. And weproceed with further workup. And
lo and behold, find horriblebadness. So that kind of that
kind of spidey sense can bevery, very useful in a setting

(16:58):
where you don't have a lot ofdiagnostic capability. And you
have to pick out sick versus notsick, and make evacuation
decisions based on incompleteinformation and make treatment
decisions based on incompleteinformation. And you're very
good at that. You also have theability to act quickly. And
definitively when you don't haveall the diagnostics back when

(17:19):
you pick out somebody that'ssick, and in need of
resuscitation but aren't quite100% 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 verygood at picking out the medical
reasons for trauma that surgeonmay not always think about, they
may be just thinking about whattraumatic injury someone has,

(17:40):
and whether they do or not. Sowhat are the doctrinal duties
for the 62 Apa as laid out inthe army training publication
for Dash 225. Here they arelisted. And this is just
standard stuff. We know this, wedo this on a regular basis. But
I only list them here just tocontrast them with what's listed

(18:02):
in the same publication for thedoctrinal duties for the
surgeons. And interestingly,they each have only one line.
The general surgeons doctrinalduty is to perform surgery for
patients that require surgery.
And the orthopedic surgeon haspretty much the same perform
surgery for patients withinjuries of the musculoskeletal

(18:24):
system. So just don't be toosurprised if your surgeon is not
totally interested in helpingout take care of patients that
that don't need surgery. Anddon't be totally surprised if
you orthopod is the same way. Weknow as emergency physician,
sometimes we actually have to,you know, have the orthopedist

(18:46):
take a step back a little bit inthe initial phases of a trauma
resuscitation because they're soeager to get in there and look
at the leg. But the patient'sgot non compressible torso
hemorrhage and showing signs ofhemorrhagic shock and we're
trying to resuscitate them. Sodon't be too surprised if your
orthopedic surgeon is notparticularly interested in being
a part of the ACLS piece. Theother part of showcasing your

(19:09):
skill set is for our fellowshiptrained folks out there that are
listening, leverage those skillsand talents and expertise. Many
of these can be useful indeployed environment. EMS, you
guys are the T Triple C expertsand you're the experts in
disaster medicine and mass cowevents. You're like the incident

(19:32):
commanders.
You can do online and offlinemedical control and your you
know, the latest and greatestand pre hospital medicine.
Pre hospital whole bloodtransfusion and hemostatic
compressive devices. So use thatand bring that to the team to
help improve the team andimprove the quality of care we
provide for our patientsdownrange and our toxicologists

(19:55):
out there who my toxicologycolleagues are some of the
smartest people I know use thatskill set, we definitely can see
snake bites downrange, we got awhole CPG dedicated to it. And
we will see overdosesoccasionally. All kinds of
various bites things andanimations PDM I don't think

(20:16):
anyone's better equipped to carefor critically critically
injured or ill child in FRCsetting than a PGM physician.
And then undersea medicine, wemight see to decompression
sickness sports medicine will,you'll probably see a variety of
MSK injuries where that could beuseful. And ultrasound because
FRS Ts, many of them now don'teven have X ray capability,

(20:38):
unless they're attached to aCharlie med role to they don't
have any x ray capability, theydefinitely don't have a scanner.
So ultrasound can be superuseful. And ultrasound is not
just about the fast exam whiledeployed. You know, a lot of
what we see is disease, nonbattle injury and medical
complaints. And so you have awide variety of applications to
choose from, from the asefguidelines that you're trained

(21:00):
in. And I do want to share onestory with you. In Honduras on
my humanitarian mission, and Iwent 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 girllaying there critically ill. And

(21:20):
they told me, they didn't knowwhat was going on with her. And
they asked if I could help. Andshe, they said that she was in
septic shock. And she came inFebruary with multiple flu like
symptoms, and this is pre COVID.
But she's been there for two anda half weeks and requiring
continuous vasopressors. Andthey were unable to like wean
her off vasopressors despiteadequate volume resuscitation,

(21:40):
and they told me that all of herblood cultures have come back
negative and CSF cultures, theytest her for Dengie, which is
common out there. And I wasnegative and urine cultures
negative, and they had no ideawhat was going on. So I busted
out the SonoSite nano that Ibrought with me and I just put a
parasternal long axis view ofher heart. And she had a very
large pericardial effusion thatwas circumferential with

(22:03):
tamponade physiology. So shegets a pair of cardio and
thesis. And this is her threedays later in the ICU, awake,
alert, completely off pressorssmiling and happy. And so this
was a very profound case for me,I'll always remember and always

(22:25):
remember her. But you can make ahuge difference downrange and
the person is probably bestequipped to you know, use the
ultrasound to help makediagnoses like this as you step
number six cross train with yourteam. So everybody on the team
brings unique skills anddifferent backgrounds. So learn

(22:50):
from each other. The picture onthe left is a rotating team from
last year, the green cap is armysurgeon. And the blue cap is the
army emergency physician. And Ilike this, they're working
together to prime the Belmondyou know, cuz sometimes all too
often and busy medicines, wejust call out orders and things
just magically get done. And wekind of take it for granted. You

(23:10):
know, the simple tasks are, youknow, save lives, like running
blood through Belmond fuser. SoI think we need to cross train
on that. And I was I reallyappreciate these two taking the
time to do so. And then in themiddle is me performing or
teaching the medics how to doultrasound guided IV and the
nurses. And I let them you know,I was their guinea pig. And they

(23:32):
were you're practicing on me andgetting skilled with that. And I
think that could help us outoverall as a whole. You know, if
we're unable to attainperipheral IV access in a timely
manner and a trauma victimdownrange that could be force
multipliers for me. And I wouldteach them the fast exam for the
same reasons. And on the right,I really think we should train

(23:52):
with our surgeons, we shouldcross stream with our surgeons,
they can learn from us and wecan learn from them. So when I
got here, I sat in on the assetcourse, which is the advanced
surgical skills and exposure andtrauma course. And it's very,
very surgeon centric. But it wasI think it was a good team
building experience for for meto get to know Briselli and
seeing the kind of awesomethings he does like he's just

(24:16):
it's it's good to know whathappens your patient after the
DD and I gained I gained adifferent appreciation for what
he does in the operating roomand the level of surgical skill
that he has. And then he taughtme a few things and
you know, it was a goodrefresher for anatomy. So you
should do that. And whenever youget with your team get with a

(24:37):
general surgeon and cross train.
Same goes for the orthopedicsurgeon. You know I did a combat
extremity lab with my orthopedicsurgeon, Dr. Boomsma. And I
don't think I'll ever perform anX fix. But it was good to work
with him and see what he does.
And you know, it's interestinghe was telling me that something

(24:58):
I never thought of he's like,you know, it's really, really
challenging in an FRCenvironment to place a pin in a
correct location for an X fix,because we don't have fluoro
capability. And then so Istarted, he was like, Hey, do
you think that maybe ultrasoundcould tell where the pin is. And
I was like, I have no idea. Sowe 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 wereable to see the posterior pin

(25:21):
the pin coming through theposterior cortex and measure the
distance with the ultrasoundmachine, something I never even
thought of before. And he didn'tknow that you could use
ultrasound to kind of look at tosee the adequacy of your
fracture production. So crosstrain with the orthopod, as
well. And there's always likenew fracture reduction
techniques that they can teachyou, they can always help you,

(25:41):
you know, do a better mold withyour plaster. So and then my
orthopod has no idea how to usean ultrasound, so or perform
advanced exam. So I taught himthat. So everyone kind of needs
to know bottom line here. Theyneed to know the overall mission
essential task list for the FRC,but they they need to know each
other's ioctls Kind of. So, youknow, we can you know, help out,

(26:05):
you know, if stuff hits the fan,and we're short on personnel.
Cross training is reallyimportant. So step number seven,
take time to mentor your medics,and everyone in the Ford
resuscitative surgical section Iwould say. So the ICTR checklist
for combat medics in the Army is65 lists or 65 tasks long. So

(26:28):
it's much longer than ours. Butall of them 100% are directly
relevant to em. You know, andsometimes we take these things
for granted. What saves lives inthe first five minutes of a
trauma resuscitation is notultrasound, but it's these
things, it's slapping,tourniquets on and getting to
large bore IVs and startingblood and performing a needle D

(26:49):
for tension pneumothorax. Andthose are things that are listed
in the CTL checklist for medics.
So you have expertise in thattrain them, mentor them, they're
eager for it, take them underyour wing. I did this in Iraq, I
would do like daily littleclasses when my medics and we
would do little workshops, wewith their with their mission
essential tasks. And it workedout well because we actually got

(27:15):
hit with a mask gal. And youknow, when I got I got hit with
three litre patients that weresurgical one with a traumatic
amputation. And before I couldturn my head around the medical
already slapped a tourniquet onand established two large bore
IVs and reported back to me thevital signs. So many of them in
the army, at least have been putin the motor pool or something
like that, and haven't reallypractices as much as they would

(27:37):
like. And we often even embedsense they just they're like the
vital sign collector but theydon't get to do these tasks. So
train with them breakout. Askthem to show them show you your
their ICT checklist and go overwith them and ask them if they
feel comfortable and work withthem. No, you won't be sorry. So
take time to mentor your medics.

(28:00):
Step number eight, maintain openlines of communication with the
command and surgical cell, weoften get stuck on our little
silos where we think you know,we can we don't want to leave
the EDI and the surgeons neverwant to come in the EDI. Now we
need to we need to be able tomove back and forth. You know, I
even asked the surgeons this youknow, because sometimes it can

(28:21):
feel like there's a force fieldaround the Edie around the
operating room rather, that wedon't want to go in there and
ever, like disturb the surgeonwhile they're operating. They're
busy. And I asked the surgeonsthey said no, I would love to
hear from my ER doc put on a capand a mask walking to the ER and
let me know what's going on outthere. So we can come talk about
it and make sure that we all areon the same page. And

(28:42):
communication is not a one waystreet, it works both ways they
should be communicating withyou. So demand that commanders
need to be informed of yourneeds. What you need to provide
optimal care for your traumapatients in ACLs. What if you're
short on supplier, whatresources you need, what
personnel you need the trainingstatus of your people. And the

(29:06):
commander should be informingyou of your mission and and what
the next plans are in the nextsteps and your blood supply and
all that stuff. So it's a twoway street, maintain those open
lines of communication. Stepnumber nine, maximize your
downtime. So right now, most ofthe deployments are slow. And I

(29:32):
guess that's a good thing.
Because you know, that means oursoldiers aren't getting injured
as much. That's a great thing.
But it also means there's goingto be likely a lot of downtime.
Until there isn't. I mean, thereare teams that are still getting
mass a team that rotated throughhere last year took an eight
person mask out which willdefinitely overwhelm an FRC
really, really quick. You know,but when there is downtime,

(29:55):
make, make good use of it. Andif I was to pick one time really
practice during downtime, itwould be the mask out. Because
you can practice all you want.
And, you know, I still thinkthat no one's ever fully
prepared it ever goes perfect.
You know, these teams thatrotate through here and do our
mascot exercise, they routinelyflail on day one. And then day

(30:16):
two, they tend to do better, Iimagine the third or fourth
iteration, they would definitelyiron out a lot of those kinks.
So rehearse. This is us doing across training exercise where
the ACLS section set up the orbeds, the or section and the or
section set up the ACLS goodcross training exercise, I gotta
be honest with you, I didn'tknow how to set up an old bed.
But it's good piece ofinformation to know. And it was

(30:38):
good team building exercise.
Rehearse your ACLs. And thatdoesn't have to be the latest
and greatest and simulationequipment. That can be you know,
mentally rehearsing in your mindand visualizing steps, or
watching a YouTube video. Reviewthe CPU CPGs. As I said before,
I would say one a day is prettyreasonable, you can probably go

(31:00):
through it about 1520 minutes.
And teach your team about theCPG and quiz your team. So you
know, it's really hard in themiddle of a chaotic situation to
go back and pull your CPG forreference. Take time to develop
yourselves and improveyourselves as an officer and a
clinician. Whether that be CME,or reading some leadership books

(31:23):
or doing something like CommandGeneral Staff College, writing
some papers research. Take thattime. You know, because when you
get home and you get back inyour full time job and your
families have been missing yousometimes it's hard to get that
stuff knocked out. And taketimes for yourselves to take
care of yourselves and yourteam. Wellness is super

(31:44):
important. These are stressfultimes being away from your
families. Take time to exercise,eat right sleep well. And look
out for each other, someone'slooking down and take care of
them. Ask them if everything'sokay. If you get stuck with a,
you know, an incident where youunfortunately couldn't save
someone. And like you have a Csoldier on your hands, which is

(32:08):
horribly traumatic for everybodyon the team, take time to
debrief and talk about it. It'llgo a long way with your team.
Step number 10 Get involved withthe joint trauma system. The
mission of the joint traumasystem is to improve trauma
readiness and outcomes throughevidence driven process
improvement. It's a really nobleeffort. And a lot of great

(32:29):
people are in this organization.
Many of you I'm sure are activein 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 theway from the point of injury
down back to CONUS. And whatwent well, and what could be
improved. And then setting someperformance improvement metrics

(32:51):
to see if we can meet those andthen and then collect the data
and see if our interventions areworking. And, you know, we all
kind of know the medicine piece,but a lot of it is the
healthcare delivery piece, arewe actually getting the
interventions we know work tothe patient? So picking a pickup
ei project on your team, itdoesn't have to be something
crazy. It can be like, Does myteam do a good job with

(33:14):
hypothermia prevention? Or whenwe deliver component therapy? Do
we really truly get to thatclose to that one to one to one
ratio? What percentage of thetime does that happen? Do we are
we always given calcium, youknow with after our first unit
of blood, those kind of things.
And you can get involved on thecalls too, I would highly advise
you to do so weekly, the JTFmeets at 08 100 Central Time.

(33:36):
And and there's lessons learnedseminars that are quarterly. And
then you could sit on acommittee for the JTS where you
talk, we actually develop theCPGs and talk about the latest
and greatest equipment thatwe're going to feel out there
and all important stuff. So getinvolved with the GTS you can
make a difference in yourindividual frst. But you can

(33:59):
make even greater difference bybeing involving and being
involved in the departmentdefense trauma registry and
being a part of the Pei processfor the whole system. I'm gonna
talk about operationalreadiness. So for these next few
slides, I'm going to lay out themission essential tasks list for

(34:19):
the frst. And then I'm going togive you a basically my own
personal assessment of where Ithink we are as a community in
that particular task as far asour training status goes.
And where I think we shouldtrain harder, some gaps in
training, some areas forimprovement. Just keep in mind,

(34:39):
these are my own personalrecommendations. These are not
official recommendations for medCOE or ATTC. This is based on my
experience here for the last 18months seeing the ER Doc's and
their level of experience thatcomes you know that come through
here. Not everyone is createdequal. Some have been working at
busy EDS and are you know,highly trained and all of these
tasks and I'm about to mentionwhere Some may have been out of

(35:01):
the loop for a little bit andneed some extra dedicated
training. So we take, we try totailor to their needs. But these
are just basically overall broadbased assessments and may not
necessarily apply to you in acertain task. Alright, so
without further ado, the normalnomenclature I'm going to use
the scoring rubric here is inthe bottom right, these

(35:24):
proficiency ratings are listedin Army Field Manual 7.0. And
it's what the line commandersuse to determine to like, have a
common language for where their,their soldiers are at in their
specific individual criticaltasks, where they think they're
at. And the purpose is reallyjust to train them up to fully
trained before you go. And sofor rapid hemorrhage control,

(35:49):
we're trained in this you know,I would just say at a minimum,
if you're getting ready todeploy, take a look at the T
Triple C guidelines, just so youcan be speaking common language,
your combat medics, but really,I only put this task up here.
Because I want you to train andmentor your combat medics and
ensure that they're up to speedon these things.

(36:14):
This task, chest tube, in myexperience, most if not all, the
merge physicians that comethrough 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 stationrefresher is really all it's
needed for most 62 albums thatcome through here. And that's

(36:35):
what we do, we run them througha trauma sim man, and I watch
and place a chest tube and Isay, 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 andstart teaching their teammates
how to do it, and how to do it,right. Tas perform the fast
exam, we're probably the bestequipped in the unit to do this

(36:58):
and do this, well do this in atimely manner and get great
pictures. You know, the surgeonsaren't always as facile with
this skill as they think theyare. So I you know, when that
when the ER doctor comes here,we do our, we do our ultrasound
lab on the first day thatthey're here. And I watched them

(37:18):
perform a fast exam on a livehuman model. And usually the
imagery is very good. And I justprovide some, you know, a little
bit of feedback, maybe to kindof clean it up a little bit, but
not much there. Usually you'regood to go. So I would say the
emergency physicians should beteaching others in the unit to
make us to make the rest of theunit force multiplier. Alright,

(37:44):
I owe insertion. I would onlywere trained in this but I would
I would give us a t minus onlybecause I've seen some struggle
a little bit with the proximalhumerus IO. A little bit more
challenging, as most people arevery, very familiar with the,
the proximal tibia. You know,but I think that Proximal
Humerus IO is probably preferredfor an adult trauma victim, just

(38:08):
because it delivers superior forflow rates over the tibia IO.
And because it's a line that'sabove the heart, I think we
should be facile and that bareminimum proximal humerus,
proximal tibia, distal tibia.
And so what I do is I runthrough the cadavers over the
Rosenstiel building here inMiami, and they perform one of
each, and I sign them off, andthat's usually probably

(38:32):
sufficient for them to godownrange be ready to central
line, I only put t minus herebecause I think we as a
community overall, most coulduse a little bit more experience
with subclavian. It's, I thinkin residencies the go to Line
has consistently been for last,you know, 15 years ultrasound

(38:54):
guided I ij. And ij is sometimesa challenge and trauma victim
that has a C collar on andgetting up near the head of the
bed. Having the room to be ableto do it is a little bit of a
challenge and getting thesterile sheath out and having
everything logistically nice andprepped is a challenge. So the
surgeons at Ryder use thesubclavian line a lot. It's kind

(39:18):
of their go to Line for whichthey can't if they can't get
peripheral IV access in timelymanner. And so that's what I
train our emergency physicianson when they get here and a lot
of them say they haven't doneone a long time. Blue phantom
model I think is fine. Butideally I'd like to get them all
in the patients need it. Like wewe see a lot of penetrating

(39:40):
trauma here at writer and a fairnumber of patients get Thor
academies. And so if they'regetting resuscitative
thoracotomy, I tell the ER doclike that's they're definitely
getting a right sided chest tubeand that writer they're going to
get a right sided subclavianline as well while the surgeon
is working on the left anteriorlateral thoracotomy. So,
practice on subclavian line, Ithink it's a very good trauma

(40:03):
line. And it's good because youcan do it blind with, you know,
landmark technique relativelysafely, which is good in case
your ultrasound device ever goesout. And also, our surgeons
don't really like the femoralline too much in patients that
have potential for shock fromabdominal hemorrhage. They like
to have a line above thediaphragm and above the heart.

(40:25):
So they go with subclavian. Sopractice, perform intubation.
We're trained in this you haveto do 35 Just to graduate
residency, although there havebeen some folks that have not
intubated patients in a coupleyears that come through. You
know, even myself, when I wasthe residency director, Bamse,
like the residents did all theinnovations. So, I would always
try to get to the,like, the cadaver lab at Spring

(40:50):
branch and balbirnie to try to,you know, practice intubation on
a cadaver. And I think that washelpful. But those models, those
little mannequins, I don't thinkare ideal for refresher
training, just because they'resuper easy to intubate. And
nothing can really simulate thethe grossly bloody trauma
airway, for which you may haveto intubate downrange. So I

(41:14):
would recommend that if you'vebeen out of practice, and
haven't intubate in a while, youcan practice on some mannequins,
but don't make it 100% of yourinnovations on mannequins, try
to rotate with us at ATTC. Ormaybe even rotate in the
operating room, sometimes wesend rotators up to the
operating room to do someelective cases, if they haven't

(41:36):
intubated in a while, weencourage them to use both DL
and VL because I have found alot of our graduating residents,
they all they ever used was VL.
And, again, that, that yourbattery could go out on your
video laryngoscope down range ormay not be available. So you
have to be facile with both.
Performer Craig, I say we'repracticed on this. And that's

(42:01):
only because most everyone Italked to that's come through
here has never done one in theirlives. They've done it on a you
know, you have to have three tograduate, but the 100% of those
can be simulated, so they've alldone it on, you know, you know,
either a mannequin or cadaver,but it's just not the same
because you know, you want touse you want to use live tissue

(42:21):
because like tissue bleeds andand you know, so that's the
closest you're gonna get toprobably simulating it is a poor
sign models actually a prettygood model for this, we use this
during our mascot exercise. Andso I would recommend you train
on live tissue, if possible. Andif you haven't done one in a

(42:42):
while, maybe review some videos.
And then I like the Bougieguided Creek is a technique you
only need three pieces ofequipment. And I like to keep it
simple and chaotic, crazysituations of a can't intubate
can't ventilate situation, Idon't like to, I like to pull
the trigger and just grab theequipment and have it ready to
go without busting out thiscomplicated kit. So I think I

(43:05):
can intubate anybody prettyquickly with those three pieces
of equipment. So Escar Artemi pminus, if we're going to be
honest with ourselves, mostpeople are marginally practiced
in this task. And that's fine.
We have surgeons on our team andI think that that's in their
wheelhouse and they should doit. But that being said, we send
the emergency to physicians tothe asset course and they do

(43:28):
these kinds of things with thewith the surgeons present cross
training just in case emergency.
Same goes for fasciotomy frst isin the Army has general surgeons
and orthopedic surgeons. So theyshould be the default go to to
do this kind of thing. There isa lower threshold to perform

(43:48):
fasciotomy in a role to settingbecause these patients are high
risk for compartment syndrome.
And the logistical issues of youknow, flying them back, you
would hate for them to get tothe rule three and they've
gotten across muscle because youfailed to act. Definitely if
they get avascular shunt,they're going to get
prophylactic fasciotomy if theyhave high risk mechanism, or
they're very difficult toevaluate because they're the bad
mechanism. They're intubated andsedated, and you know, they got

(44:11):
a TIB fib fracture or somethinglike that. They're probably
going to get a prophylacticfasciotomy I think the I think
the surgeon should do this, butyou should be trained in it and
asset course if possible. Incase you need to do it in an
emergency. Particularly I wouldthink maybe it won't want you
might have to do it. Okay,Rebola. So I had to give a shout

(44:35):
out to Regan Lyon, who'sprobably on this call. She
published her experience inSyria in the journal trauma,
acute care surgery. They tookcare of a ton of traumas during
the offensive against ISIS,probably more traumas and I took
care of in my life. This is herpart of her special operations

(44:55):
surgical team. I think they didgreat things out there and I was
really just really impressedafter reading this report of
some of the amazing things thatthey did. They're kind of the
proof of concept, I think forwhy Rebola could be potentially
useful. For traumaticallyinjured casualties downrange
when we, when they present to aroll to facility. They placed
20, rubella catheters, many ofthem I know were placed by the

(45:20):
emergency physician. And allpatients survived to the next
session, a lot of care. And youknow, we don't have long term
follow up data on them, becausea lot of them were, you know,
serum defense forces, it's myunderstanding. But this is at
least a good proof of concept.
The reason why it's importantfor the emergency physician to
learn this skill is because Dr.
Northern, the gentleman in themiddle, who's the surgeon can

(45:41):
only take one person on thetable at a time. And it's my
understanding that ACLs hadmultiple critically injured
casualties that were withhemorrhagic shock.
Bleeding below the diaphragm,that could be temporize. But
until they could get to thetable until Dr. Northern can get
them on the table. And ACLssection was responsible for

(46:01):
doing that. And I think thatthat's why I think this reboa
TAs will fall to the emergencyposition. Because if the surgeon
is present, and you only haveone casualty then and they're in
hemorrhagic shock, they'll justgo to the O R. But what happens
when you get multiplecasualties. So I think it's
important to have this tool inour arm in our armamentarium.

(46:25):
Our TAS proficiency I put us,generally speaking as marginally
practice from what I've seen. SoI think we should undergo formal
training virtually in allinstances, before we go down
range. And that could be thebest course which is the, the
put on by the American Collegeof Surgeons, or we do reboa
training here, or star c, whichis bam, CS predeployment frst

(46:48):
training platform, all fine. Ithink this is not something that
really should be taught withdidactics it should be a hands
on experience with a highfidelity sim simulator like the
primetime simulator or somethinglike that. Or maybe a live or
I'm sorry, I perfused cadaver orsomething like that might be the
next best option. But it'sdefinitely something we should

(47:09):
practice and could bepotentially useful. Perform
lateral canthal Atomy I wouldput us a practice in this task.
Just because most peopleactually haven't done one on a
human patient. You know, we'vewe've, we've read about it.
We've watched videos, we trainedin residency, we may have done

(47:31):
it on live tissue, but very fewpatients. It's not it's not all
that common for a patient tohave an orbital compartment
syndrome. What I see that beingsaid you do need to diagnose
this condition had a role to inand perform this procedure
otherwise they could lose theireyesight before they get to the
role three. So i i During theasset course the emergency

(47:52):
physicians here perform lateralcamped on a cadaver and we also
tried to get them to do itduring the mask exercise with
live tissue on porcelain modelby injecting some saline behind
the eye simulating a retrobulbarhematoma. Sustained thoracotomy.
You've got a general surgeonthere. I think this is best

(48:15):
performed by the the generalsurgeon. If you if if you didn't
have a surgeon present, youprobably should never perform a
resistive thoracotomy, there'sno point. And if you have a
surgeon present, why not letthem do it or and you can be
assist, you can assist. So Iguess maybe if they're in the
operating room, and you got todo it, it'd be important to

(48:37):
maybe you can like relieve thatpericardial tamponade. And then
they can get them they can getto the operating room right
after that. And your surgeons,you know, right down the hall.
It's a good skill to have we dotrain in this, you know, in the
residencies, I'm sure on livetissue is a good model like poor
sign model. When the rotatorscome through here, I have them.
I have their their generalsurgeon walk the ER doc through

(48:59):
the procedure on live tissue.
And that tends to work outpretty well as far as a good
refresher training. Performedborehole craniotomy. So, per the
CPGs, there have been 36 cranialprocedures performed by non
neurosurgeons that are role tofacility since Oh, if an oaf
began. So it's a rare event butnot a never event. And this is

(49:23):
again something where thepatient may decompensate and and
have irreversible brain injuryand death, seizure, coma death
before they even make it to therule three. So you may have yet
to be prepared to do this forcerebral herniation syndromes
when you can't get them to therule three in a timely manner
and you have no neurosurgeonsupport. This is a procedure I
think is best left for the thegeneral surgeon. They have often

(49:45):
done craniotomies and residencywith neurosurgeons. They train
on it in the asset course. But Ido recommend cross training with
them during asset proceduralsedation and analgesia we're
trained in this we have to do 15procedural sedation is just to

(50:06):
graduate and then we many of uscontinuously continue to use
this in our regular practice,we're very good at treating
pain, and very well worth verywell versed in, you know, taking
care of adverse events that mayor may not occur with, uh, with
procedural sedation as far asairway maneuvers and techniques.
So you and the CRNA are going toshare this task. And I would

(50:31):
say, you know, you probably justneed to take a peek of the CPG,
these two CPGs that I havelisted here,
and call it a day. Perform nerveblocks. This is something where
I think a training gap exists.
And it's variable some, somepeople come through here have
completed ultrasound fellowship,and they're pretty high speed

(50:52):
with this. And some I've neverdone it in their life, which is
why I have the variable ratinghere. But I think that this is
something that we should reallystart to think about training.
During our pre deploymentplatforms like ATTC or star See,
just because it has thepotential to reduce the opioid
analgesia requirements for oursoldiers, particularly if we're

(51:14):
in a prolonged field caresituation, we've got a fracture,
or mangled extremity. And we'realready very skilled with
ultrasound itself. So it'sreally just about kind of
learning the anatomy. And, youknow, so if I was to start
somewhere with how we should getat training meeting this
training requirement, I wouldprobably look at the New York
School of regional anesthesia,they have some very good online

(51:38):
modules that you can do, butideally, in a perfect world.
This is best get best achievedby rotating on a regional
anesthesia service and actuallyperforming nerve blocks on
patients. I did get theopportunity to do this in
Honduras. And my answer is aresident who was rotating with

(52:00):
who actually flew out there withme was helping me in the or
perform these nerve blocks andit was it was awesome. I learned
a lot and I definitely think itcould be beneficial for our
soldiers downrange. Reducingfractures and dislocations. I
only give us a t minus because,you know, my experience at Bamse

(52:21):
like oftentimes we would justcall the orthopedist to reduce
the fractures rather thanreducing it ourselves. So
sometimes these resi programsand busy medicines, we have
every specialty no demand, so wejust call them I think some of
the community Doc's are betterat this than others. You know,
but again, you have anorthopedic surgeon there, so why
not use them. And then you couldperform the procedural sedation

(52:44):
piece. Run a code. This is us.
This is our wheelhouse. We'retrained in this if you've been
in regular clinical practice,still remember the Kuwaiti bus
driver that I took care of inIraq that came in with a STEMI
and a B fib arrest these thingshappen downrange. He got shocked

(53:06):
and got to neck to place and allthe other things and did quite
well. So it's a really coolcase. For me, I still remember
to this day. We will take careof these codes. I don't think we
need extra ACLs training just bynature of being board certified
and being in practice. We shouldbe good to go here. But just be
prepared to take care of thembecause you know, sometimes,

(53:28):
downrange we see these DODcivilians and contractors and
local nationals that havesignificant comorbid conditions.
Management of acute illnesses. Iwant to read a quote from my
survey that I sent out. This isfrom an emergency physician
currently deployed, quotecurrently deployed to CENTCOM
with an frst no surgeries donein the last four months have

(53:51):
been required to manage COVIDoutbreak, abdominal pain, chest
pain, syncope, renal colic, andnumerous infectious disease
complaints. So it sounds likethey're frst became an emergency
department. So just be preparedfor that. And you are trained to
do that. All right. Speaking ofacute illnesses, who runs a sick

(54:13):
call? Well, our view of Utopiawould be that there is no sick
call. But the reality of thesituation is soldiers on the
farm are going to present youwith minor complaints seeking
your help. I think, in a perfectworld, empower your medics to
run the sick call. Becauseyou're really there were
murdered physicians and yourdamage control resuscitation is

(54:34):
right, you're there to take careof, and be prepared for the next
mass Caliban that comes in andperform far forward surgery. But
so empower your medics to runsick all there's this manual
call at TMC algorithm directedtroop medical care where they
can run through a flow sheet andbased on chief complaint and
they can pick out the red flagsand call you if they need you
and corpsman to they'reexcellent at this. You know, but

(54:58):
if your commander really wantsto to kind of take lead on that,
you know, maybe, just maybe youcan get the orthopod to see the
musculoskeletal complaints, andthe surgeon sees the
undifferentiated abdominalcomplaint complaints, abdominal
pain complaints, but I don'tknow good luck with that. You
guys are gonna have to work thatout as a team at a time. So now

(55:21):
finally, I'll close with mysurvey. So, here's the results.
So I pulled all the emergencyphysicians and surgeons who
attended ATTC in the last 18months, and I got 27 respondents
back, which is about a 50%response rate five oh 17 numbers
physicians, 10 surgeons, thevast majority of whom had
deployed and were activecomponent.

(55:45):
Whether results Question numberone, rate your level agreement
with a statement, emergencyphysicians are a valuable
addition to the frst andencouragingly. 90% of surgeons
said strongly either stronglyagreed or agreed with the
majority saying they stronglyagree. And an emergency
physicians also felt valued onthe team. So this is encouraging

(56:07):
data. You know, we did get onedisagreement one naysayer, one
hater. I guess I never reallythought that we would get 100%
You know, Goldstar happinessfrom our surgeons. But I think
90 percents pretty good,something we should be, you
know, excited about movingforward if we ever deployed on

(56:29):
one of these teams. Alright, Iasked him about the working
relationship between I asked thethe surgeon how you feel about
working with your numbersposition and vice versa. And
again, same same results,essentially 90% either agreed or
strongly agreed that they workedwell. With the surgeons, I'm

(56:51):
sorry, 90% of surgeons eitherstrongly agreed or agree that
they worked very well and had agood working relationship with
their ER doc. So That'sexcellent news. And the ER Doc's
like surgeons to hear somecomments from the surgeon. From
that same question, I'll let youread those.

(57:21):
even acknowledged that theemergency medicine physician had
far more knowledge andexperience with dealing with
undifferentiated complaints. Andthey acknowledge the synergy
that could potentially exist.
And that how the we're allworking together here to
maximize patient care. I askedboth groups of physicians who

(57:43):
they thought should be thetrauma team leader. So this has
kind of been a little bit ofpoint of contention, you know,
trying to figure out, you know,because a Bamse, like emergency
physicians often will run thetrauma and a certain kind of
kind of stands back just stepsin to the patient needs surgery.
So you have two physicians thatare perfectly capable of being

(58:05):
the trauma team lead on the sameteam, how's that dynamic going
to work, and I pulled the teams,this is what I got. So you can
see there's overwhelmingconsensus that when the surgeon
is not around, like say they'rein the O R, that the emergency
physician should be the teamleader for you know, these ACLs
trauma, resuscitations. Thatmakes sense. Now, there was a

(58:29):
little bit of contention when itcame to when the surgeon is
present. So, but still themajority of folks, both
emergency physicians andsurgeons think when the surgeon
is present, that they should bethe team lead, the surgeon
should be the team lead and theemergency physician should do
the primary secondary survey,the fast exam and the critical

(58:50):
procedures. And, you know, somesome of the surgeons actually
thought that, you know, the ERcan be the team lead for all of
them. And I'll just take them ifthey need to go to the or. But,
you know, so this is, this issomething you need to hammer out
ahead of time and have open andhonest discussion with your
surgeon about. But you know, Ithink this is this is kind of
cool, how like, they feel verycomfortable with us, you know,

(59:14):
performing being a team leadwhen they're not around and even
being a team lead when they arearound and they feel very
comfortable with us performingthe very important trauma survey
and the ultrasound exam and theprocedures. So sometimes that
can be even more fun. That couldbe the team leader, we get to
play a little bit. So thesummary of these is Trauma Team

(59:35):
Lead question from the comments.
Essentially, what I'm seeinghere from these teams that
deployed the last 18 months isthat when the surgeon is not
around the 60 to alpha should bethe team lead and perform the
survey. When the surgeon isaround, it depends on the
situation. So if there's a massCal event, it's really going to
be like a divide and conquertype thing. Certain is going to
run one bad er is going to runanother but if there's only one

(59:56):
casualty, the default probablyis going to be the surgeon
service. Team Lead and six toAlpha performs the primary and
secondary, the ultrasound andthe procedures. Now, they may
need to swap for procedures, youknow. So whenever someone zooms
in to do a procedure, they losefocus of the entire room and
visibility on the overall 50,000foot view of the trauma
resuscitation. So maybe thatemergency physician would need

(01:00:18):
to zoom out and takeovers teamlead in that instance. And vice
versa. So you got to be flexibleand adaptable. You got to
communicate, because buttingheads in the middle of a trauma
resuscitation, as I said before,is just didn't go very, very
wrong when that happens. So Iasked about procedures. And you

(01:00:42):
can see here the surgeon, Iasked the surgeon, what
procedures they're comfortablewith emergency physician
performing. And I asked theemergency physician what
procedures they're comfortableperforming just to see if there
was a disconnect. And it lookslike the surgeon is very
comfortable, at least on theseteams polled with their
emergency physician performingall of their resuscitated
procedures that you would thinkairway management chest tubes,

(01:01:05):
cry eggs, fast exam, centrallines or lines, all that stuff
and being the team lead and evenRebola 70% of the time, which I
thought might be a little loweractually. So but you know, there
was a little disconnect incertain things and when I when I
defined disconnect as being thatthe ER doc says they can do it

(01:01:27):
and the surgeon says no, youcan't. Those procedures were few
and far between but really theycame down to you know, like a
burr hole. Actually burr holethe yard most er Doc's won't
even comfortable doing that. Itcame down to like fasciotomy and
Escar automate some of the ERDoc's thought they could do it
but the surgeons were like notso fast. There's a little bit of

(01:01:47):
disconnect on lateral can't 95%of er Doc's think they can do
it. Only 70% of surgeons thinksthe ER Doc's can do it. So
bottom line here, hash this out,talk about it. Let them know
what procedures you've done andwhat you're comfortable in
performing. And who's going todo what procedure and what
situation. And my final questionon the survey was who's going to
be are you interested incommanding and shock at the

(01:02:12):
center here? We have zero yesesfrom the surgeons, no surgeon
poll was interested incommanding an frst.
And so I view that as a greatleadership opportunity for you
guys. I think the teams thatrotate through here where they
have physician leader, and we'vehad a couple that have had
emergency physician leader, andthey tend to be more seasoned,

(01:02:35):
they work better as a team, theytend to be more clinically up to
date. And they make smarterdecisions because they know the
clinical aspect of it. So takethat leadership opportunity that
void in leadership and step upis our teams needed our soldiers
needed. So in summary, the CCOAlpha brings a lot of value to

(01:02:56):
the frst you're by doctrine, theleader of the Ford resuscitative
section but you you have a broadskill set that can bring so much
more to the team. cross trainwith each other and get to know
each other. Start with a 61Juliet, your trauma surgeon,
that strong working relationshipis absolutely vital. maintain

(01:03:18):
proficiency in your ICT ELS knowyour CPGs cold and rehearse
during your downtime, rehearse,rehearse, rehearse, in
particular the mask cow. Andbefore you go make sure you
address any potential traininggaps that may exist. Again, the
best way to get at your ioctlsis skill sustainment at a busy
ed. So talk to commanders ifyou're not stationed at one of

(01:03:41):
those places, talk to commandersabout Moonlighting. And don't go
moonlights in some like lowvolume area where you see a
couple patients try to work insomeplace that's busy so you
keep those skills up. It reallymatters when you get downrange.
So for those of you out therethat are deployed or getting
ready to deployed, thank you foryour service. Just remember
what's waiting for you when youget home. I will share my

(01:04:03):
experience when I got home frommy third deployment, waking my
little girl up at seven in themorning. Good morning all right,

(01:04:41):
this concludes my talk. And Ihope all is well with you stay
safe. Hope to see you soon.
Thanks for listening