Articles
Mechanisms for Training Military Surgeons
For various reasons, training military surgeons will become a serious point of attention.
By analyzing the different factors contributing to the requirement for such training, an internationally recognized curriculum should be organized. Such an analysis can also be important with respect to cost containment for such a course.
Introduction
An increasing demand for the training of military surgeons and their teams is to be expected.
This is mainly because of far reaching super/sub specialization in the surgical profession, whereas the military surgeon has to be a “generalist”. On the other hand the quality of the skills of the military surgeon affects the quality of the whole surgical team as well.
The aim of this article is to analyze the various components of the skills of the military surgeon in order to be able to develop a satisfactory training program for the military surgeon and the military surgical team.
Based on this analysis also cost effectiveness of such a training could be taken into account.
Methods
Starting point for the training program is what has to be expected of the military surgeon: what should a military surgeon possess with respect to knowledge and skills, in order to be able to perform his work safely under circumstances of war.
The military surgeon should be well acquainted with the Military Health System Echelons of Care, the principles of Aeromedical Evacuation (MEDEVAC, TACEVAC, STRATEVAC) and Combat Trauma System Implementation (Joint Theater Trauma Registry [JTTR]). Also acute resuscitation and critical care according to the principles of (Battlefield) Advanced Trauma Life Support ([B]ATLS) and Intensive Care (IC) treatment. These principles do not necessarily need to be instructed then.
Fig 1: Mechanisms for training military surgeons.
Theoretical knowledge can be instructed in classes while for the instruction of practical skills a combination has to be found between theoretical instruction and technical training.
Instruction has to be provided for the following specific subjects:
• Face, Neck and Eye Trauma
• Head and Spine Trauma
• Thoracic Trauma
• Abdominopelvic Trauma
• Soft-Tissue Trauma and Burns
• Orthopedic Trauma
• Vascular Trauma
All this should be completed with “Special Scenario’s” like the Management of Pediatric Trauma, Removal of Unexploded Ordnance, Ectopic Pregnancy, Penetrating Abdominal Trauma in the Pregnant Patient, Continuous Peripheral Nerve Block and Tetanus.(2)
An enumeration like this seems to be rather extensive en clearly indicates the dilemma between the “generalist” and the “super/subspecialist”. However the limitation for the military surgeon as a generalist is that in the first place the care is confined to “Damage Control Surgery”: the limitation of damage by the application of the most direct acute surgery (Life and Limb saving). The meaning of this being to make the wounded ready for safe transport in order to be treated in a next echelon by other specialists. Total and durable reconstructions have to be carried out elsewhere.
Fig 2: Damage Control Surgery
The purpose of this article is to analyze the subjects that play a role in the training of military surgeons in order to be able to compose a sufficient teaching program for the surgeon and his team.
The four pillars for such a training are:
1. Basic knowledge (theoretical/practical)(what is supposed to be known?).
2. Instruction (theoretical)(what has to be taught?).
3. Skill (practical)(what has to be practiced?).
4. Training (practical)(what has to exercised with the whole team?)
Ad 1) from every surgeon a specific package of knowledge and skills is to be expected (“a surgeon is a surgeon”). May be it is advisable to write these items down but they do not have to be taught separately.
These items include: opening and closing of the abdomen and extremities, wound care, (B)ATLS, preparing a wounded patient for an operation, care after the operation including Intensive Care Treatment (ICT), positioning of the wounded on the operation table, transfusion- and antibiotic management, indirect effects of wounds, burns and the Glasgow Coma Scale (GCS).
Also the rough anatomy of the whole body ought to be memorized: the knowledge of the course of important vessels, nerves and tracts. This being important for the “do no harm” principle (for example: unintended damage to the mammary artery during thoracotomy can lead to unnecessary but extensive blood loss).
Ad 2) to be instructed are: opening and closing of the thorax, wound ballistics (high energy trauma), NATO language vocabulary, NATO Time Lines, the use of tissue adhesives, Behind Armour Blunt Trauma (BABT) and blunt trauma, blast injuries (mines, Improvised Explosive Devices [IED]), “Consensus statement on length preserving amputations (Department of the Army [USA])”, registry of burns and evacuation (also in children)(2). All of this could be taught in classes.
Ad 3) for training in skills a program could be made to include all kinds of surgical specialists to teach about all emergency surgery in their specialty. This in the context of “Damage Control”. Another possibility is to teach a “Surgical Skill Set” as proposed by Lcol. Parker (1). This set contains a number of skills that a military surgeon should master at least in order to perform adequate surgery under circumstances of war. Essentially these skills could be taught in classes and with the whole team in order to make sure that the team knows what has to be expected.
For some parts of these skills a “Hands On” training would be desirable. For example: the use of the Gastro-Intestinal Anastomosis Stapler (GIA), opening and closing of the thorax, treatment of heart-, lung- and intestinal wounds and cricothyroidotomy.
To this program should be added an instruction about “Focused Abdominal Sonography for Trauma” (FAST) and the treatment of the combination of penetrating/blunt/thermal wounds (explosives)(2).
Ad 4) Together with the team (surgeon, anesthetist, theater nurse and anesthesia assistant) it has to be exercised to “get the right patient to the right hospital/echelon/role and operation table in the right time”. Triage, resuscitation and evacuation can be practiced very well with “Trauma Patient Simulators” or actors.
As soon as the wounded has landed on the operating table, the work becomes more static. Surgeon and theater nurse are performing the operation and anesthetist and anesthesia assistant take care of the conditioning of the patient.
Management of mass casualties can be practiced during military maneuvers (national- and international-) where surgical teams are in turn doctor or patient. The last being effective to enhance the effect of learning: when you know what it is to wait for hours to have your broken leg mended, you will work faster to help your patient!
At the end of the training an exam can be taken and credentialing could be organized. It has to be thought about refresher courses and whether these have to be repeated after two or five years. From the point of view of skill retention these courses have to take place and possibly also these courses have to be concluded by an exam.
Discussion
Training courses can be extended and compressed at will. The art of teaching is to limit the ballast, to teach the necessary and to stimulate basic knowledge and improvisation. Carrying out this principle has its effects on cost-effectiveness. “Hands-on” and team training are more expensive than teaching classes and therefore most of the teaching matter ought to be taught in classes. Also the candidates have to study hard themselves. For that purpose the evenings of the courses could be used.
By analyzing the topics it can be determined which subjects have to be instructed and in what way. A time table can be established for the topics in order to be able to calculate the total time schedule for the whole course.
The training for military surgery should be confined to the so-called “Damage Control Surgery”: “Life and Limb saving” surgery. When performed adequately the wounded has to be transferred as soon as possible to the next echelon (role) where other medical specialists are standing by.
This does not exclude the fact that a military surgeon has to be trained as a “generalist” in order to be able to treat wounds extending over a whole body. Added to that is the fact that war wounds are becoming more and more extensive (from gunshot to total destruction) which means that also specific (war)treatment has to be performed (for example: “packing”).
It can be chosen to teach a certain set of surgical interventions or having all surgical specialists to lecture on the acute interventions of their specialism.
Besides individual training, team training also plays an important role. When the whole team is informed on all kinds of surgical interventions, the whole organization of taking care of the wounded will be more flexible.
The training can be concluded by an exam (credentialing) and refreshing courses have to be kept in mind.
Summary
For several reasons training military surgeons will become a serious point of attention.
By analyzing the different parts, important for such training, a curriculum can be organized. An analysis like that can also be important with respect to cost containment for such a course.
Involved in the training of military surgeons, also the surgical team as a whole ought to be involved because when deployed the whole team should know what to expect under difficult (war) circumstances.
The different parts can be divided in what is supposed to be known and what has to be taught, both theoretically and practically.
The military surgeon has to be trained as a “generalist” but with the restriction that “Damage Control Surgery” has to performed in order to be able to transport the wounded safely to the next echelon/role.
Training of military surgeons can be concluded with an exam for credentialing and it has to be thought of refreshing courses.
Literature:
1) Training for war: teaching and skill-retention for the deployed surgical team.
P.Parker, JR Army Med Corps 154(I):3-4
2) War Surgery in Afghanistan and Iraq, Nessen et al., Office of the Surgeon General, Borden
Institute, USA, 2008.
Olaf C. Penn, MD, PhD
Colonel MC (R) NLD A
Professor of Cardiothoracic Surgery (ret), University Maastricht, NLD
President-elect Interallied Confederation of Medical Reserve Officers (CIOMR)
…
Hanau, Germany, October 1st, 2011 – From October, Heraeus completes its proven range of precision impression materials with the new Flexitime® Monophase Pro Scan. The new …
Applications for Analytical Tasks in Chemistry and Biology
