Training multinational medical teams for deployment – proposal for a course.

Introduction

the intended outcome of the concept of medical support is:

a) To minimize morbidity and mortality among deployed forces (hence contributing
to sustaining the force) and others for whom healthcare is provided on operations.

b) To contribute to improved health outcomes, and thereby to stabilization, where this is appropriate within those fragile states in which NATO operations are concluded.

c) To build and sustain a culture of multinational co-operation and trust, and a commitment to continued development in healthcare excellence among the community of military medical
services in NATO and partners including host nations.

During deployment to war regions medical personnel is being confronted with an extreme surgical workload as well a surgical case mix that could exceed standard competence (1). The latter being partly the result of far reaching medical specialization in their homeland. In The Netherlands even hospitals are specializing in a way that not all subtypes of surgery are
being performed in every hospital anymore. Moreover there is a continuous shift of types of wounds, for example from shot to blast to total destruction. So far, one of the solutions has been to put more surgeons (2-3) at the operation table which is not very cost-effective of course. On the other hand, not only the surgeons but the medical team as a whole ought to be capable of treating complicated cases.

NATO has the possibility to ask for complete teams from certain countries. Other NATO countries however are not capable to provide complete teams but separate medical specialists instead. These single medical specialists could however prove to be valuable parts of compound teams.

Therefore the demand for training of all this multinational medical personnel might be obvious and the question is how to train them best for deployment, including skill retention and credentialing.

As already mentioned it might be clear that several countries have their own systems
for training military medical personnel.

However in the USA there exists no uniform pre-deployment training but there is a Readiness Skill Verification. On the other hand it can not be denied that US military surgeons have the greatest experience altogether. Training courses are offered in ATLS, Expeditionary Medical Support, Emergency War Surgery and C-STARS. Nevertheless I understood that surgeons
ask themselves for some kind of elective secondary care provision and they are temporarily placed in trauma centers. DEU has its military hospitals and military surgeons (Einsatzchirurg) are involved in trauma management. There are courses in Sonography, Basic osteosynthesis techniques and an Emergency Surgery Course. GBR has an excellent Definitive Surgical Trauma Skills (DSTS) course. In FRA they have courses in Expeditionary Deployment, Basic Military Training including tropical medicine and a War Surgery course. As a matter of fact the specialty of General Surgeon will even be abolished this year. NLD has a DSTS course which is given every two years and has become compulsory. Also the MASCAL course is compulsory. NOR has an excellent course on how to train peaceful citizens for war.
This course in Damage Control Surgery is compulsory for trauma specialists, is taken place in the animal lab and a whole team of surgeons, anesthetists and operating room nurses is trained simultaneously in communication, collaboration and team based problem solving. I was told that one of the results that came out of this training was how insufficient surgeons proved to be regarding to teamwork! After followup it also turned out that these courses
even contribute, in daily practice, to an increase of 43% with regards to expertise and teamwork. Other countries do not have courses like that and have to depend on others, but
they could be able to provide specialists that could be incorporated in compound teams.

Proposal for a course in deployed hospital care

Based on the above the proposal is to devise a course for NATO in deployed hospital care. This kind of pre-deployment training should provide individual training, collective training, mission rehearsal exercise, skill retention and credentialing for military medical teams. The possibility to work in an animal laboratory ought to be investigated. This course in deployed
hospital care could well take place in the NATO Military Medical Centre of Excellence (MilMedCoE). With relation to R1 medical support, such as enhanced First Aid, pre-hospital
emergency and primary health care (bleeding and airway control within 10 minutes) the course Battlefield Advanced Trauma Life Support ([B]ATLS) is available. 

(B)ATLS certification could be a prerequisite to participation. Otherwise a (B)ATLS course could be set up as well at NATO MilMedCoE. With regards to R2LM, R2E and R3 deployed hospital care it is advisable to instruct the Surgical Skill Set, as suggested by Lt Col P. Parker (1). These subjects could be instructed by the concerning specialists, being active duty or reservists.
They should be willing to do so for a travelling allowance only. Each specialist should also instruct the emergency procedures as far as the own specialty is regarded.

Abdominal surgeon (± 3 hours): aortic cross-clamping during resuscitative laparotomy
(Thoracic and abdominal), simple ligation of any major vessel tear, liver laceration
packing, small intestinal perforation stapling, colonic perforation control with terylene tape, arterial injuries shunted/ligated + fasciotomy/cooling, venous injury ligation or repair, pancreatic bed leaks multiply drained, peritoneal soilage copiously irrigated and contained,
abdomen temporarily and/or rapidly closed, visceral compartment syndrome treated with plastic sheet or iv-fluid bag closure (Bogota Bag).

Cardiothoracic surgeon (± 2 hours):
rapid emergency thoracotomy, nonanatomically stapled lung resection, pulmonary tractotomy, circum-hilar rotation for lung hemorrhage control, en-masse lobectomy, skin staple closure of cardiac wounds, en-masse closure of chest wall muscles, patch closure of thoracic wounds
(using an iv. fluid bag).

Neurosurgeon (± 2 hours): intracranial bleeding-emergent arrest and control, adequate
early exposure via 4-into-1 burr hole technique, intracranial hematoma evacuation/
limitation of contamination, CNS superficial bone/metal fragment removal, CNS infection control using early antibiotic therapy, CNS infection prevention with primary dural and scalp closure, postsurgical swelling control with decompressive craniotomy.

Trauma surgeon (± 3 hours): femoral fracture control with rapid unilateral frame external fixation or Thomas splint, unstable pelvic ring fracture-pelvic ring binding or external fixation ± pelvic packing,junctional zone bleed control with urinary catheter tamponade, articular racture
temporization with bridging external fixator, rapid amputation-decision making and  performance, fracture reduction with approximate alignment, pin site skin tenting prevention with wide skin incision, soft tissue damage-rapid primary debridement with physiological control, contamination minimized by high volume fluid lavage, musculoskeletal infection control using early appropriate antibiotics, compartment syndrome prevention-wide area
fasciotomy, soft tissue coverage temporary dressing (packing), primary wound management
with vacuum drainage packs.

Urologist (± 1 hour): urologic emergency procedures, bladder ruptures catheterized and drained.

Gynecologist, opthtalmologist, plastic and reconstructive surgeon and pediatric
surgeon: emergency surgery for their own specialty.

The course could be completed by instruction about:
 MEDEVAC (request-“9-line”), TACEVAC and STRATEVAC
 Most relevant STANAGS (for example 2087)
 NATO medical vocabulary
 Medical rules of Eligibility
 Medical engagement with reconstruction and development (R&D)
 Medical engagement with host nation Security Sector Reform (SSR)
 Humanitarian assistance
 Ethics (why keeping to the rules when the enemy doesn’t even know them)

In fact a course like this could be extended endlessly but it should be kept compact. Written information can be provided and one could expect already some basic knowledge from the side of the participants. The course should be concluded by an exam and credentialing. It has to be decided upon the durability of the qualification, whether it should it be two or five
years? Examples of both terms are present and courses for skill retention should be kept in mind.

Summary

A weak point considering deployment is that the need for all-round general surgeons
not always can be covered because of nowadays extreme surgical specialization.
Also decreasing deployment leads to loss of surgical expertise and an increasing
demand for training.

Several NATO member-states have their own systems for Deployed Hospital Care training. These are good and comparable to each other. Nevertheless other NATO countries do not have comparable training facilities and have to depend on training elsewhere.

In the mean time it has been proven that training courses in Damage Control Surgery, by improving communication, collaboration and team based problem solving, contribute to an overall increased level of expertise for medical specialists (NOR 43%).

The proposal is to develop a NATO course for training, skill retention and credentialing
with regards to surgical teams for deployment. This can be done by teaching a so called “surgical team skill set” by specialists but also surgical specialists could instruct emergency procedures with regards to their own specialism. The instructing specialists (multinational)
could be recruited from the group of active duty doctors or from the group of military medical reservists. Instruction could be given as well at the same time in MEDEVAC, TACEVAC, STRATEVAC, medical rules of eligibility and the most appropriate STANAGS. The course could be concluded by an exam for credentialing.

Training, skill retention and credentialing could well take place in the NATO Military Medical Centre of Excellence (MilMed CoE).

Courses like this could contribute in the meantime to a culture of multinational co-operation and trust. Participation could be extended to PfP countries of even to doctors from, for example, Afghanistan.

Conclusion

Because of the fact that deploying allround trauma surgeons and surgical teams becomes more and more difficult, a course is proposed to train available surgeons and teams in NATO context. This course should be given for whole surgical teams because the whole team should be able to take care for severely wounded soldiers. Therefore it ought to be a training in patient care but also in communication, collaboration and team based problem solving.

Because it is not always possible to have available surgical modules from certain countries the proposed course could be very useful for compound teams, teams composed of  specialists and nurses from several NATO countries who can act as a team when deployed. This could lead to an improvement in multinational co-operation and trust between NATO medical personnel. Even civilian medicine in different NATO countries could profit from
the attainments of the participants. Courses like this could be put up as big and as small as desired, but the art is to keep it simple. Parts of the course could be taught in classes, some parts should be of avail with a hands-on method and team training could be practiced with a trauma patient simulator. At the same time credentialing and skill retention could be taken care of. A course like this could well take place in the NATO Military Medical Centre of Excellence (MilMedCoE).

Reference:
1) Training for war: teaching and skillretention
for the deployed surgical team.
P.Parker, JR Army Med Corps 154(I):3-4

Date: 09/23/2011

Source: MCIF 3/11