• Care under fire – lessons for civilian medics

    by Guest Author. Last modified: 11/07/14



    This is a guest post written by Dr Matthew Harry Thompson. Harry graduated from Imperial College School of Medicine in London in 2008. He spent two years as a Junior Doctor in the UK before undertaking military training with the Royal Navy. He had a busy four years on secondment as a Royal Marine Commando Unit Medical Officer which included operational tours to Afghanistan, North Africa and Somalia where his responsibilities included providing and teaching battlefield medicine. He has a continued interest in out-of-hospital trauma care as he embarks on specialty training within the NHS as an anaesthetist at a Major Trauma Centre in London.

    The names in this article have been changed for confidentiality reasons but the story is tightly based on real events.

    Helmand Province, Afghanistan

    Tom was in the ablutions tent in a small patrol base in Helmand Province, Afghanistan. He was the Combat Medical Technician (CMT) for a Company of soldiers and the only medically trained person on site. He was competent and keen but inexperienced. Fortunately, it had been a quiet tour and most of Tom’s challenges had been administrative. The base was shared with an Afghan National Army (ANA) platoon and Tom had been training them in basic point-of-wounding trauma care.

    He also taught his own Company the basics of <C>ABC and taught them how to assist him in the event of multiple casualties. The lads and he were due to go home in a week and spirits were high in the showers that morning. The others were laughing at some crude joke and asked Tom if their mate, Smithy, had so many sexually transmitted infections that he was beyond saving. Tom was popular with the Company and had got to know each of them well over the six month tour. He declared that not even intravenous bleach would cure Smithy and was rewarded with a friendly punch on the arm. He enjoyed the morning routine now that he was used to the relative discomfort. They left to heat some water for breakfast. The rest of the day was quiet, dominated by menial tasks such as packing up parts of the base and filing inventories. Tom went to bed early as the sun set at 1900 and he had early morning duties.


    An hour into his sleep, Tom was woken by gun fire. A sound he knew well, a single ANA weapon on automatic. He grabbed his body armour, weapon, med bag and helmet and hit the deck to don his kit. He heard shouting. It appeared an ANA soldier was firing onto a nearby accommodation tent; a “green on blue” insider attack. Tom ran into the tent once the firing had stopped and saw the carnage. He had casualties spread out in front of him and three of them were worryingly still. The gunshots started again, although it was impossible to tell the direction of fire. He jumped to the floor and used his body armour to protect himself and a casualty nearby. He heard rounds pass through the tent. Looking down to see Smithy’s face staring back up at him listlessly was the start of a long, difficult and unhappy night for Tom.

    The details of Tom’s subsequent actions are quite remarkable and easily worthy of the military awards bestowed upon him on return to the UK. They deserve more recognition than this article can offer but in summary, after effective triage and treatment, he sent six of the casualties to Camp Bastion on the military medical evacuation helicopters and they all walked out of hospital back in the UK over the next few months. Smithy sadly died that night a few minutes after the first shots were fired.

    Factors at play

    The psychology behind a brave mind-set is beyond the scope of this article and indeed this author. That aside, what factors were at play that allowed Tom to be so effective in such difficult circumstances and with relatively little battle or clinical experience?

    I would argue that as a person, Tom was superb but not uniquely so. I alone can think of tens of examples of fantastic pre-hospital trauma care performed by inexperienced CMTs. Perhaps it is aspects of the military environment that allows this success? If so, what is it about the military in particular that prepared Tom and the other CMTs to deliver a level of care above all expectations in challenging situations? I think there are some obvious and some more subtle factors at play.

    The trauma care in the military at the pre-hospital level is driven by protocol and algorithms. There is very little room for in-depth study of the evidence available or debating, for example, the nuances of two different haemostatic agents. You simply do what it says on the laminated sheet with the issued equipment. This goes very much against our instincts as medical professionals and is difficult to accept, especially if you have had any civilian experience.

    An evidence base is still being utilised albeit on a larger scale but the decisions are taken away from the soldier on the ground. The advantage of course is that you always have a basic structure upon which to base your care. As we say, ‘no plan survives first contact with the enemy’ and in no situation does this hold more true than when you are trying to tourniquet a limb or establish an airway for your friend whilst being shot at.

    The simpler the treatment algorithms can be the better.

    The variability in experience along with a requirement to find and treat the reversible traumatic causes of death systematically, quickly and in difficult circumstances demands this.

    Train as you fight


    In accordance, training is also kept simple with emphasis on the basics being done properly. Procedures are drilled over and over again in outdoor classrooms with blank rounds being fired and smoke grenades cracking all around the student. We train as we fight in the military and it leads to better real life skill acquisition. Tom, although inexperienced, had assessed a person’s chest at night and in body armour before; hundreds of times in fact. He went into automatic mode and didn’t have to think about what he was doing. This was obviously good preparation.

    There are less patent things however that contributed to Tom’s success. His medical bag, for example, was also simple, laid out in the order of his algorithm, and he was proud of his level of organisation. He was familiar with all of the kit, able to identify things instantly by feel and sight and could operate them blindly. In fact, he was always playing with something from his bag (much to the amusement of the lads). This allowed him to constantly be sure it was all in date, functioning properly and fully stocked. He had lived with that bag next to him for half a year and felt lost without it.

    Tom had also been in the pub regularly with his CMT friends. Prior to deployment, all the CMTs lived and trained together. They shared stories informally, listened to their seniors, attended debriefs and watched videos on their laptops. Tom knew (either consciously or subconsciously) what feelings to expect before, during and after the event so as they happened, he was neither surprised nor inhibited by them. He was even reassured by their presence at times during that night.

    The immediate response of the rest of the base to the event also helped Tom to achieve his tasks. The communications and logistical aspects of a military operation smoothly transfer into major medical incident management. There were willing stretcher bearers and runners. A radio operator was assigned to Tom and one sergeant managed the scene itself whilst another supervised the helicopter landing site. The importance of this framework of support within which he performed his clinical interventions was paramount.

    Indeed, he had trained with these supporting personnel as a team before. There had been mass casualty scenarios in the pre-deployment training where the cooks, the guards, the officers and the engineers had all been shown their roles and then had a chance to rehearse them. The team had done this before together. They knew that Bob from the cookhouse knew how to put a Guedel in and that Bill from the guardroom had a box of extra flashlights and batteries. It meant that some of the usual delays encountered by new teams were largely avoided. The team was not doing this for the first time when it counted.

    Feedback as a learning tool

    Moreover, each member of the team, including Tom, had been criticised during debriefs. I don’t mean that a senior or a peer had gently suggested that someone might want to put the tourniquet on tighter next time. I mean really criticised and made to repeat it again and again until it was perfect. This criticism was not delivered with a bullying or aggressive attitude, but a “lives will depend on this being perfect and if you can’t do it now, you won’t do it when it counts” attitude.

    It is unique to the military from what I have encountered and possible purely because of the type of characters you find who can give and take feedback without allowing personal feelings to be injured. The elevated levels of individual confidence probably make this form of criticism/feedback sustainable. Additionally, we find that the people who enter the medical field of any branch of the military tend to do so for the right reasons and actually want to be criticised. They want to be really good medics because their friends’ lives may depend on it. Their own lives may depend on it.

    Lessons for civilian medics


    So we are led to the inevitable question: Can any of the factors that influence the military CMTs be employed by their civilian counterparts, who arguably have a more sophisticated and certainly have a more varied workload, to help them be better at their job? Can civilian patients benefit from any of these ramblings?

    Having worked in both environments, as a teacher and a pupil, feeling experienced and inexperienced, in multi-disciplinary teams and practicing independently, I think there are some things to learn from the way the military prepares its medics. None of them are particularly complicated concepts and many of them are general attitudes or common approaches but all of them create an environment where the level of care provided by both individuals and by teams is allowed to improve unimpeded by a particular person’s inadequacies, attitudes or a lack of drive to do things the right way.

    So I leave you with this, my personal opinion on the topic (and I don’t pretend it is anything more substantial):

    1. Welcome feedback, in any form that it may take, and learn something from it – even if you are only learning how to deal with bad feedback and even if it is delivered aggressively or upsettingly. Try, although it is hard, to deal with any personal issue you have with your colleague separately. The way feedback is conveyed should not take away from the point being made if the ultimate goal is communal improvement.
    2. Give feedback at every opportunity if you think it can help someone improve and don’t necessarily feel you have to sugar coat it with five positive things. Military personnel work in an environment where negative feedback is considered a normal part of the working day. This means that when it is supplied, that individual doesn’t take it personally. People may not agree with your feedback and that is fine. At least the topic has been broached and if they hear the same analysis again from someone different, perhaps they will take it more seriously. Alternatively, your incorrect feedback may lead to you learning something.
    3. Be an equipment geek and love your pre-hospital bag/ambulance/helicopter. The level of familiarity that Tom had saved him time and stress which may have saved a life or a limb.
    4. Train with the people you will ‘fight’ with if you can. Major Trauma Centres in the UK are using this team based approach to scenario training with everyone from the haematology technician to the receptionist to the vascular team rehearsing their roles together. Their results are speaking for themselves.
    5. If you have two options presented to you in a pre-hospital environment and neither is more proved or more likely to benefit the patient than the other, think about making the simpler route your default setting. It can eradicate more unmanageable variables and give you more time to deal with the unforeseen.

    And finally, if you disagree with anything or everything I have written then please tell me. I won’t get upset.

    Dr. Harry (@prehospmed)

    London, UK

    With thanks to Mitchell Thomas (@jrparamed) for his experienced input and the many blogs in the #FOAMed community that help us all to question how we do things.

    Editor’s notes:

    Mitchell is an Australian Paramedic and he runs the Downstairs Care out There blog over at http://www.dscotblog.com…you should check it out!

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    Guest Author

    Guest posts are written by various organisations and authors with an interest in EMS, prehospital care, research and other relevant topics.

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