The Physician and the Medical Unit


This is some notes from a few talks with family practice residents. I hope it provides some awareness of various problems and priorities for military physicians when assigned to field medical units. Sorry for the outline form.

 

MAJ Tom Garigan, USA MC



Physician Behavior Patterns:
The Blissfully Ignorant
Unaware of:
military duties
organization and function
communication requirements
the amount of work involved in planning and operations
the way things work- supply, etc.
military history
the nature of military operations
The Rigid Clinician
unable to adapt clinical care to field setting
unwilling to accept responsibilities outside of clinical care
The Head in the Sand
Denial of harsh reality
Lack of involvement
Acting Out
unprofessional behavior

Unit Cohesion: an oft ignored factor
Fragmentation of Reserve units in the Gulf War: analogous to the difficulties of the PROFIS doc:
 
 
Mangelsdorff AD, Moses GR: A survey of Army Medical Department reserve personnel mobilized in support of Operation Desert Storm, Military Medicine, Vol. 158, pp 254-8, April 1993
 
ORIENTING TO THE UNIT
Learn the TOE and names- learning names is vital for morale, communication, and ultimately effectiveness

 

Personnel to meet in Battalion/Company level command
Commander
1SG/CSM
XO
Chief Nurse
Company Commander
Intel Officer
Adjutant
Supply Officer
 
Field Hospital:
Technical Personnel
Lab
Pharmacy
X-ray
Cast Tech
Respiratory Therapy
Support Staff
S-4
Supply
Clinical Areas
Each Ward
OR
ER
Preventive Med Unit
Dental Unit
 
Medical Platoon
PA
Platoon Sergeant
 
Policies and Procedures to Review
Evac Policy
Patient Tracking/Record Keeping
Reports
Communications
Alert Notification
Challenge and Password
Other Signals & Security Measures
Radio Nets
Wire Communications
Sick Call
Meetings
SOP's
Supply and Maintenance Procedures
Emergency Response Drills:
NBC attack
Fire
Enemy Attack
Indirect Fire
Direct Fire

 

 
COMMUNICATION,
COMMUNICATION,
COMMUNICATION!
"This survey and Army lessons learned indicate that effective communication may be the single most important factor related to mobilization of reserve soldiers"
Mangelsdorff AD, Moses GR: A survey of Army Medical Department reserve personnel mobilized in support of Operation Desert Storm, Military Medicine, Vol. 158, pp 254-8, April 1993
Unit
to build cohesion
to reduce stress
Individual
to reduce family stress
to improve coping

 

 
Establish Unity of Command
"Organize a sensible command structure ahead of time" The Mercury, Feb. 1996 from "Guantanamo, Panama teach medics valuable lessons for humanitarian missions"
 
Open up channels early
Include yourself in all planning and communication
All soldiers should know their chain of command
Beware of Multiple chains:
Command
NCO
Nursing/MOS
MSC
Cadre vs. PROFIS
 
PROFIS Issues:
Potential Roles of the FP Doc
Commander
Unit Surgeon
Staff Physician
Responsibilities
Formally defined
Not so well defined
Freedom of Action- can be extraordinarily used or abused
Pitfalls
Multiple lines of communication
docs
nurses
MSC
enlisted
Chain of command
PTMS dept in garrison
Differing agendas
non-clinical operations
clinical operations
control of nursing personnel
Patterns of physician behavior: A Herd of Cats
Before Deployment
The Denying Doc
The Avoidant Doc
During Deployment
The Lazy Doc
The Separate Agenda
The Ego
The Entitled Doc
The Selfish Doc
The Reckless Doc
Lack of Confidence/Fear of Failure
 
Personal Preparation
Avoiding getting caught unprepared
 
Preparing the family
finance
legal
morale
communication
role-modeling
 
Training Responsibilities
of self
long-term career development
short-term- in response to notification
of unit

 

 
Volunteering
Opportunity Knocks
Making the Best of It
Travel
Culture
Clinical experience
Leadership experience
Leadership
Humility
Service
Courage
Caring
Mentoring
 
Setting The Example
Endurance
Mental prep
Intestinal fortitude
 
The Ultimate Military Physician
Research
Articles
Lectures


Some Memorable Quotes on Being a Military Physician:

"I don't want ever to be caught again as ignorant as I was about the conduct of the Medical Department activities in a theater of war and not know what to do. I was strictly a professional man and I just wasn't capable." as quoted by Cowdrey, Albert E., in "The Medic's War" Center of Military History, United States Army, Washington, DC 1987

The aidmen "can be credited with a greater salvage of manpower than the surgical hospital." Col Ginn, 8th Army Surgeon, Korean War

Our younger men were thrown into combat without a day's training- similar to taking a boy out of a drugstore and saying 'I'll give you a gun- go fight the Koreans.' We did this to our young doctors. They were pulled out of the specialty programs, arrived in Japan, because we had nothing else; given field equipment which they had never seen before, told they were going to be assigned to field units the names of which meant nothing to them. Those young men, within five days after their arrival, were being shot at by the enemy.... That, I think, was one of the most disgraceful things in the military service." BG Crawford Sams p. 189 The Medic's War- transcript of the Armed Forces Medical Policy Council meeting 18 June 1951

In a survey conducted in Korea during March 1951, Eighth Army doctors reported that they needed more training in a variety of basics: in map reading, in setting up and packing medical and dental chests under field conditions, on the chain of command, and on their "specific duties as Battalion or Regimental Surgeon[s]." Additional training, they felt was needed in field tactics and the organization of a medical company. A division surgeon opined that medical officers should learn more about tactical defense of a medical field installation, how to set up a perimeter defense, and how to use the hand grenade and bayonet. The Medic's War

For existing deficiencies the doctors admitted that the Medical Service was not alone at fault. "All officers," concluded the report, "felt that the course [in field medicine] would have been of more value if they had been impressed with its usefulness." But "at that time the majority were preparing to specialize in surgery, X-ray, laboratory, therefore[they] had little or no interest in field medicine." [quotation from EUSAK Report of the ETMD, March 1951, pp. 30-33] p. 191 The Medic's War

"I went to the Medical Field Service School in 1947 and I feel that it was a complete waste of my time. I didn't learn anything about taking care of people in the Army; and I didn't know what a gun looked like; I didn't even know how to head up a medical unit." CPT Sidney Esensten of the Medical Corps: p. 191 The Medic's War

Field training with a division is an indispensable ingredient of [the medical officer;s] education, especially if he is in the regular service, no matter how rarified and sacrosanct his MOS[;]... along with knowledge and skill, a young medical officer must be taught a sense of mature responsibility toward his patients which comes from experience and from living with his mistakes. General Ginn, Korean War

Inspections of medical installations in the X Corps during September 1952 showed that poor appearance and absence of spirit were the rule. "Mess halls and kitchens were disorderly and unattractive. Equipment and supplies were poorly segregated, stored, and maintained. Police was poor.... There was no unit pride.... The standards usually expected of medical units and installations were not, in general, being maintained." The military, as opposed to the professional, training of the medical officers was "generally poor.Pulled from budding practices and thrust by their lack of rank to forward stations in an uninviting land, young doctors displayed unconscious arrogance and a refusal to adapt to the necessities of a live that the despised. Such men failed to understand their responsibilities in respect to "equipment, maintenance, supplies, records, reports, training of enlisted personnel, and other non-technical activities... A deep sense of responsibility toward the military service seems never to have been gained. As a result, even their professional skill sometimes showed poorly, in part because their enlisted subordinates either did not know or did not practice their jobs. Enlisted men showed a lack of courtesy, looked unmilitary, maintained equipment in a slipshod manner, and expected their failings to be overlooked or condoned. 8209th MASH, Annual Report of Medical Service Activities, 1951, p. 4, file 319.1-2 The Medic's War p. 208

"Military medicine is a well conceived, well advised, and well established device, system, or mechanism, the mission of which is to provide the Armed Services with a quality or brand of medical coverage that is not only essential to the proper and efficient function of the military but is moreover essential to the best interests of the individual and of the national welfare." Rear Admiral Lamont Pugh, USN, Surgeon General of the Navy in an address before the Association of Military Surgeons of the United States November 17, 1952

"One would need only to go to Korea, as I have been during the past two summers, and there observe the manner of living and of the activity being engaged in by medical personnel serving with the combatants in the theater of war. One would not need to remain long there to appreciate the essentiality of service doctors being psychologically agile, emotionally stable, professionally genuine, and physically able and tough." Rear Admiral Lamont Pugh, USN, Surgeon General of the Navy in an address before the Association of Military Surgeons of the United States November 17, 1952

"Since when has the doctor of medicine and dentistry become such a pantywaist as to require that a bald responsibility others accept with good grace must be diked out with certain frills before he will buy it." Rear Admiral Lamont Pugh, USN, Surgeon General of the Navy in an address before the Association of Military Surgeons of the United States, November 17, 1952

"During my sojourn at the combatant front in Korea this past summer I failed to detect evidence of any special effort being made on the part of anyone to make the service more attractive to the soldiers and Marines who were fighting, bleeding, and dying in the heat and dust on a barren Korean hillside." Rear Admiral Lamont Pugh, USN, Surgeon General of the Navy,in an address before the Association of Military Surgeons of the United States,November 17, 1952

"The manner of man requisite to filling the bill that needs to be filled by the Medical and Dental Corps of the Armed Services is an individual who to himself clearly realizes that it is a privilege and not a penalty to serve in a uniform of his national defense establishment, that it is his establishment and his nation for the defense of which the establishment exists and that he may be no more honorably distinguished than by wearing that uniform, and that by abhorring ignoble ease he can perform no more worthy mission than that of protecting and restoring the most priceless element, that of health, in our most precious national resource, the men and women who comprise the Armed Forces."Rear Admiral Lamont Pugh, USN, Surgeon General of the Navy, November 17, 1952

"The manner of man requisite to filling the bill that needs to be filled by the Medical and Dental Corps of the Armed Services is an individual who to himself clearly realizes that it is a privilege and not a penalty to serve in a uniform of his national defense establishment, ...........and that he may be nor more honorably distinguished than by wearing that uniform, and that by abhorring ignoble ease he can perform no more worthy mission than that of protecting and restoring the most priceless element, that of health, in our most precious national resource, the men and women who comprise the Armed Forces." Rear Admiral Lamont Pugh, USN, Surgeon General of the Navy in an address before the Association of Military Surgeons of the United StatesNovember 17, 1952

"There must also be on the spot excellent doctors, skilled in healing wounds and extracting missiles, equipped with the appropriate medicines and instruments, and provided by teh city with ointments, honey, bandages, and lint, not only to prevent the wounded from dying but also to render them, having rapidly recovered their health, useful in subsequent encounters, being ready to court danger in the knowledge that they had been healed and well looked after." Philo of Byzantium, at end of 3rd century BC

"The controversy that surfaced in the Gulf War re-emphasizes the long recognized importance of training some physicians in military planning and administration to guide the operations of the Medical Department in a war theater."RADM Ben Eiseman, MD, USN (Ret)

"We must not ever expect that the protected hospital environments of the Korean and Vietnam conflicts, bought with very necesary air superiority, will necessarily be present in future conflicts."Thomas J. Whelan, Jr. BG (Ret) MC US Army, NATO Emergency War Surgery Handbook

"Intelligent planning and appropriate training in anticipation of the needs of the battlefield have resulted in enviable and ever-improving military medical results."Thomas J. Whelan, Jr. BG (Ret) MC US Army,NATO Emergency War Surgery Handbook

"The controversy that surfaced in the Gulf War re-emphasizes the long recognized importance of training some physicians in military planning and administration to guide the operations of the Medical Department in a war theater." RADM Ben Eiseman, MD, USN (Ret)

"The problem is further complicated by mistaking civilian trauma care with that of the experience in the combat zone." RADM Ben Eiseman, MD, USN (Ret)

"Although undoubtedly to the benefit of the injured, it means the vast majority of both active duty and civilians clinicians are largely inexperienced in caring for the injured." RADM Ben Eiseman, MD, USN (Ret)

"Only a few doctors have worked in metropolitan emergency rooms and have experienced wounds made by knives, bullets, and explosions." AMEDD Enlisted Lessons Learned, After Action Report, Operation Desert Storm

"Units did not have equipment supply listings for refugee support, pediatrics, and obstetrics." AMEDD Enlisted Lessons Learned, After Action Report, Operation Desert Storm

"In the ETO, I never hurt for clinical talent, but I was constantly hurting for leadership of this talent half as good as the talent itself." MG Paul R. Hawley, Chief Surgeon, ETOUSA

"Almost everyone - officer and enlisted- on the reserve OM teams lacked adequate soldier (field) skills." COL James Martin, MS

"Joint service interface was complicated by differences in policies, procedures, equipment exchanges, and working knowledge of how each service operates." AMEDD Enlisted Lessons Learned, After Action Report, Operation Desert Storm

"Military medicine has developed into a sophisticated specialty..(and) includes such disciplines as tropical medicine, nuclear warfare, chemical weapons, flight surgery, industrial medicine, hygiene, disaster triage, transport and the care of the wounded during transport, combat nutrition, immunizations, epidemiology, management of venomous bites and stings, and the emotional disorders of military life." COL Walter J. Pories, MD, USA (Ret)

" Medical personnel must have adequate time to train with the people, the equipment, and in the facilities they will utilize in war."MG Michael Scotti

"[The medical officer] must possess and exercise leadership. He must be able to adjust psychologically to difficult and discouraging situations and finally, he must be adequately trained in military matters to insure efficient operation of his own unit and to understand directives received form higher echelons." LTC John A. Sheedy, USA MC, Military Medicine October 1956


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