Two medics representing the U.S. Army Special Operations Command were named the Army’s best medics after a grueling 72-hour competition at Fort Sam Houston, Texas, and Camp Bullis, Texas.
Staff Sgt. Noah Mitchell and Sgt. Derick Bosley from the 75th Ranger Regiment, representing the U.S. Army Special Operations Command, were named the winners of the Command Sgt. Maj. Jack L. Clark Jr. Best Medic Competition during a ceremony Friday at the Army Medical Department Center and School at Fort Sam Houston. Both Mitchell and Bosley are stationed at Fort Benning, Georgia.
Second place went to Sgt. Matthew Evans and Sgt. Jarrod Sheets from the 10th Mountain Division, and third place went to Cpt. Jeremiah Beck and Sgt. Seyoung Lee from the 2nd Infantry Division. Awards were also presented for the top performing teams in different categories, including the best overall physical fitness score, medical skills score and marksmanship score.
The competition, hosted by Army Medical Command and conducted by AMEDDC&S, is designed to test Soldiers’ tactical medical proficiency, teamwork and leadership skills. The competing teams were graded in the areas of physical fitness – in addition to PT and combat water survival tests, they were required to walk up to 30 miles throughout the competition – tactical pistol and rifle marksmanship, land navigation and overall knowledge of medical, technical and tactical proficiencies.
Wesley P. Elliot of Army Medicine contributed to this report. Header image courtesy of AMEDDC&S.
Medical and technological advances have given modern-day Soldiers who have been injured on the battlefield access to an elite level of immediate trauma care from their fellow Army physicians and combat medics.
But the trek from the battlefield to the next round of care has been a perilous journey — the injured Soldier is typically extricated from harm’s way and into an aircraft, but often without a doctor present and with fewer resources onboard. A 2012 study of 4,600 deaths in Iraq and Afghanistan showed that 87.3 percent of Soldiers died while en route to a military treatment facility.
A recently installed program at the U.S. Army Medical Department Center and School at Joint Base San Antonio-Fort Sam Houston, Texas, aims to bridge that gap. And the program’s NCOs are expected to be a large part of its success.
The program, which began in 2012, is designed to provide flight medics with additional paramedic and critical-care training, and civilian certifications. It meets this end by incorporating high-tech lessons from civilian medical professionals. Though the program is open to E-3s to E-8s, it is NCOs who provide stability and ease the transition from previous flight-medic teachings to the current best practices, said Master Sgt. Michael Cluette, the NCO in charge of the Flight Paramedic Program.
“The flight paramedics who we graduate now will be the future of where aviation medicine goes. So the transition point will be extremely important for those who are graduating here,” Cluette said. “You have to be that mature noncommissioned officer to do that.”
Owning responsibility for battlefield care
The impetus for the Flight Paramedic Program was an Army physician’s nagging feeling.
Lt. Col. (Dr.) Robert Mabry authored a study of service members injured on the battlefield in Iraq and Afghanistan from 2001 to 2011. The study, published in the Journal of Trauma and Acute Care Surgery in 2012, found that of the 4,596 battlefield fatalities analyzed, 87.3 percent died of their injuries before reaching a military treatment facility, or MTF. Of those pre-MTF deaths, 24.3 percent were deemed potentially survivable.
Although battlefield medicine has vastly improved during every war since World War II, Mabry said that 24.3 percent statistic cited in his study — those whose lives might have been saved — kept nagging him.
“That’s where we can make the biggest difference in improving patient outcomes,” he said.
What Mabry found is that no one owns responsibility for battlefield care delivery, meaning that “no single senior military medical leader, directorate, division or command is uniquely focused on battlefield care,” he said. “The diffusion of responsibility is a result of multiple agencies, leaders and units of the service medical departments each claiming bits and pieces with no single entity responsible for patient outcomes forward of the combat hospitals.”
Commanders on the ground own the assets of battlefield care — medics, battalion physicians, physician assistants, flight medics and all the equipment. But they are “neither experts in, nor do they have the resources to train their medical providers for forward medical care,” he said.
What Mabry concluded from his studies and field experience was that the solution to the gap in care cannot be addressed with a “single-bandage” approach.
A solution, he said, would require “evidence-based improvements in tactical combat casualty care guidelines, data-driven research, remediation of gaps in care and updated training and equipment.”
And to supervise those medics, their training, and the medical evacuation equipment and procedures, there would need to be a specially trained and qualified physician in charge of that pre-hospital phase, he said.
Mabry illustrated the power of patient outcome data by tracking a National Guard medevac unit from California whose members were mostly critical-care trained paramedics in their day jobs — working for the California Highway Patrol and other EMS agencies. They deployed to Afghanistan in 2010, taking their civilian EMS model with them, he said.
“I compared their patient outcomes to the standard medevac outcomes and found a 66 percent reduction in mortality using the civilian medic system,” he said.
As a result of that outcome, the Army has revamped its training of flight medics.
Providing a higher level of care
The Flight Paramedic Program began in earnest at Fort Sam Houston in 2012 under the 187th Medical Battalion and through a partnership with the University of Texas Health Science Center at San Antonio.
The flight medic course taken by 68Ws is six months long and is followed by the two-month critical-care course. The critical-care course includes six weeks of embeds with various hospitals throughout San Antonio as well as with San Antonio AirLIFE, which provides Soldiers with a close look at the high-tech application of medicine in the civilian world.
“Your EMT basic course in the civilian world is about 140 hours of training,” said Maj. Matthew Nichols, director of the Flight Paramedic Program. “Paramedic training is 1,000 to 1,200 hours, and you already have to be an EMT basic. So that just goes to show you how advanced [the program’s civilian-inspired] paramedic training is. It’s above and beyond all the extra pharmacology, anatomy, physiology, hemodynamics, all that kind of more in-depth medical training they get in the paramedic course. Then they go on to an eight-week critical-care course, which is two weeks in the classroom of even higher-level, very intense, very fast-paced critical-care transport medicine akin to what ICU nurses do. They get to see how it is applied by professionals in that field. It’s definitely a much higher level above the EMT basic level.”
That closer look at the civilian side of trauma care is also something that was highlighted in Mabry’s study, which stated that civilian trauma systems evolved after the Vietnam War as a result of Army medics and nurses who returned from the conflict and took on civilian jobs. Mabry said that as a result of this war experience, sick or injured civilians in the United States are transported to a trauma center by an aircraft, accompanied by a critical-care flight paramedic and a critical-care flight nurse, both of whom are highly trained and experienced.
“So the thought is, if a guy who is in a motorcycle accident two hours outside San Antonio is going to get a certain level of care in the back of an aircraft en route to a major hospital in San Antonio, then our Soldiers who have been wounded on the battlefield deserve the same, or as close to the same as we can provide within the Army,” Nichols said.
To accomplish that, Nichols said, the Army is taking the expansive knowledge base available in its hospitals out to the point of injury. Handing flight paramedics the knowledge and training needed to make the proper interventions — and just as importantly, the knowledge to perhaps not intervene — is expected to help decrease mortality numbers.
“A lot of people think that an ambulance driver in the U.S., that’s all they do — they pick up someone and they transport them to the hospital so the doctor can take care of them,” Nichols said. “But, no, those EMTs and those paramedics are conducting care. And the more care they are able to give with their knowledge and their skills, the more likely that that person transported is able to survive their injuries.
“Increasing the level of care provided in back of the aircraft with the critical-care flight paramedic alongside the ECCN (en-route critical care nurse) will help these long transports from point A to point B,” he said. “If anything goes south in that period of time, medically, then you have someone in the back who will be able to treat them better. The aircraft can only go so fast, so you can’t really ask them to go much faster to get them to the hospital. So the paramedic and the nurse in the back of the aircraft are trained to be able to handle those situations and basically mitigate life loss.”
The role of NCOs
The long-term goal of the Flight Paramedic Program is to transition all of the Army’s flight medics to become critical-care paramedics.
Through May 2014, 124 Soldiers have become nationally registered paramedics and 115 have graduated the Army’s critical-care course. Another iteration of the course began in July and is expected to conclude in March. Plans for expansion are being made in 2015. The quickening pace of training goes on despite the expected drawdown of troop levels in Iraq and Afghanistan in order to be prepared for disaster missions at home as well as for any future conflicts.
In the meantime, the transition to a new kind of flight medic training isn’t leaving legacy medics behind.
“I’m one of the legacy F3s (flight medics),” Cluette said. “It isn’t so much that we didn’t know how to use the combat gauze or how to stop a bleeder or put our hands in someone’s chest. What we don’t get as the legacy individuals is a lot of the why-not-to-do-it or why-we-are-doing-it. We know the physiology from Baby Whiskey Land (medic school), we get the anatomy from Baby Whiskey Land, but what we don’t get is when to do it, when not to do it. We just go by the numbers, and the thought process for the legacy [medic] is, ‘When fear gets in your head, training takes over.’ You know just to follow the numbers, because I was trained to do it that way.
“The paramedic, we are now telling them, ‘Yeah, you were trained this way. But I need you to understand why you’re doing it, what you have to do if it doesn’t work and understand why it’s not working in order for you to fix it.’ An EMT might understand he may have to do it, but I may do it way too early or unnecessarily simply because I didn’t get enough of the understanding that what I was currently doing was enough.”
The bridging of the gap when flight medics of the old and new discipline come together will be eased by NCOs, Cluette says.
“NCOs will bolster that leadership to help coach and mentor the F3s when those Soldiers move out and junior Soldiers come in” Cluette said. “They will provide that leadership to help coach and mentor them on how to interact with each other. Because in an aviation company for flight medics it kind of varies, so if I’m a F2 (critical care flight paramedic) and I’m an E-3, and I have a F3 who is an E-5 or an E-6, and I’m having to train them, you have to be mature enough in order to understand that isn’t a leadership, this is a professional mentorship where I have somebody teaching me something that I need to know to help save lives on the battlefield. NCOs can do that.”
Knowledge sustainment is a key tenet of today’s Army. That notion is not only harbored by the NCOs that are part of the Project Warrior program at the U.S. Army Medical Department Center and School, or AMEDDC&S, at Joint Base San Antonio-Fort Sam Houston, Texas, it is practiced on another level.
The program is geared toward taking battle-experienced Soldiers and putting them in positions where they can pass on the insights and knowledge they’ve gleaned from combat training centers, or CTCs, to benefit Army schools as well as the rest of the force. One vital component to foster this learning is the Lessons Learned program, a compilation of reviews and research that helps provide combat health service support on the battlefield.
Project Warrior, which was introduced in 1989, garnered the spotlight again in May 2013 when the Army Chief of Staff, Gen. Raymond T. Odierno, announced its re-establishment in an effort to infuse the force with seasoned officers who had completed rotations as an observer, coach and trainer, or OCT, at a combat training center.
Though, the program had previously been largely suspended throughout several Army disciplines because of the operational requirements of Iraq and Afghanistan, it never stopped at Fort Sam Houston, where up to 42 AMEDDC&S NCOs at a time have continued honing the skills necessary for success in the highly technical world of Army medicine.
“We haven’t stopped in the NCO realm,” said Master Sgt. Mike Eldred, the senior enlisted advisor for AMEDDC&S’s Center for Pre-Deployment Medicine. “In the rest of the Army, they’re re-establishing. But we’ve been doing it the whole time.
“When the rest of the Army stopped their programs, AMEDD decided to keep it, because it was beneficial for the way ahead into the future for 2020-type Soldiers,” he said. “They would learn and be able to apply those lessons learned and those insights that they’ve gained from their peers that have been gone that could be applied to training down here.”
Evolving with changing times
The precursor to the U.S. Army Medical Department Center and School was established in 1920 at Carlisle Barracks, Pa. For more than 25 years, the Medical Field Service School developed medical equipment and doctrine for the battlefield before having its mission transferred to Fort Sam Houston in 1946.
The school underwent significant changes in structure throughout the years while incorporating the functions of the Army Medical Department. In July 1991, the Army surgeon general, Lt. Gen. Frank F. Ledford Jr., established the AMEDDC&S and in 2005, the Base Realignment and Closure process co-located a large portion of enlisted technical medical training (the Army’s, Air Force’s and Navy’s) at Fort Sam Houston.
Project Warrior, which has had a presence at the post since the mid- ’90s, has been a vital part in helping Soldiers evolve with constantly changing tactics and technology, Eldred said, ensuring AMEDDC&S can meet its mission to “envision, design and train a premier military medical force for full spectrum operations in support of our Nation.”
“Basically, what we’re doing with the program is we’re taking experienced Soldiers who have already taken a little bit of ‘baptism by fire,’” Eldred said. “They’ve been out there in a combat zone or in some significant training events that really set them apart as experienced Soldiers. We draw them in through a voluntary program. We go out and advertise and recruit. Once we bring them in, they go to the CTCs. They basically get those big wrinkles knocked off; their tactical and strategic skills are refined. Then they come here for two years and start to spread that higher education and are better able to articulate the needs of advanced training.”
Building a Project Warrior
The process of developing a Project Warrior is relatively the same for both officers and NCOs.
In the case of AMEDDC&S NCOs — most of whom are Army MOS 68W health care specialists — Soldiers who are identified as candidates and pass review from the program’s command sergeant major serve a 24-month assignment at a combat training center such as the Joint Readiness Training Center at Fort Polk, La. Upon completion of their rotation, they are assigned to positions at Fort Sam Houston and Fort Rucker, Ala., where they can make the biggest impact and dispense the knowledge they’ve accrued.
“The CSMs have been very good with the Project Warriors when [the program’s graduates] PCS,” said Master Sgt. Michael Cluette, the former AMEDDC&S Project Warrior program manager and current AMEDD Flight Paramedic Program NCOIC. “They don’t send them in a downward spiral. What I mean is while they were at the CTCs, they were a platoon sergeant trainer and they were training platoon sergeants how to be better at what they do. So when they come here after they’ve learned and start pushing these tactics through doctrine and everything else, the last thing you want to do is take this guy and put him back as a platoon sergeant or as an aid-station NCOIC. You want him to continue forward with his knowledge.
“A lot of times, they’ll look to try to get [Project Warrior graduates] into those brigade positions or somewhere with a higher position, if possible. Sometimes it may not be possible, and that’s just where the cards may fall. But their knowledge won’t be lost, because it’s like a virus. If I teach my 38 soldiers in my platoon what I know, as they grow up, they’re going to take their knowledge and spread it. So it just festers like a virus.”
To ensure knowledge sustainment and adaptability, Cluette said, Project Warrior candidates must be well-rounded and not focused on one role of care.
“We don’t want somebody who has only been in a CSH (combat support hospital). We don’t want somebody who has only been mechanized,” Cluette said. “We need to get that soldier and that medic who has diversified and not just somebody who is in that tunnel.”
The diversification proves helpful in tying together the multiple medical assets on a battlefield, knowing their respective expectations and how those assets work together.
“At that training event — when they get to teach somebody and they’re coaching them at the CTCs — they have to be able to talk to them at a strategic level and say, ‘Look, when you do your piece here and when you look forward, you’ve got to know what that next guy is going to do for you and provide for you,’” Cluette said. “You’re going to have to link, ‘Well once it gets there, he’s going to have to go here.’ And you have to know what’s on that battlefield to do that.”
“It’s not just tactics or strategy. It’s also equipment,” Eldred said. “So we have people that go evaluate new equipment. They assist these highly experienced Soldiers who are going out and actually fielding this equipment. They’re testing it and seeing what the future of equipment in the Army is. But also, if there’s a problem with equipment out in the field, we capture that, bring it back and help them make modifications to the current equipment or change a set kit and outfit so what we give to Soldiers and the units is better.”
A synergy of information
Once Project Warrior NCOs are in place, they have proved to be able teachers, an invaluable source of knowledge and a vital asset for officers, Eldred said.
“[The Project Warrior Soldier] knows what that team needs in order to accomplish the mission,” Eldred said. “They’re helping an officer see what their needs are. We, as NCOs, teach those individuals and teams. We understand that mentality. So if you’re only pushing officers through this program, you’re only going to get an oversight, you’re only going to get the planning aspect, you’re only going to get the overall project idea. But if you get the NCOs injected in there, like we are now, then you’re giving the rest of the project or program a perspective of what it takes to get the individual and the team trained. They put it in the ‘Blue Book,’” he said referring to the key job that NCOs perform. “This is what we do; we do drills. That’s what we’re still doing. It’s just that now, this is a highly refined level of how to do drills.”
But one of the important facets of Project Warrior is that it is not a license for top-down training approaches. It is cooperative learning with all Army branches at its best.
“We really don’t dictate to anybody or give orders on anything,” Cluette said. “It’s more of the teaching, coaching and mentoring of our peers, and even some of the seniors that are here who ask us questions. We have Project Warriors who teach [Basic Officer Leadership Course], who teach the Captains Career Course. We have senior NCOs who influence those officers. So it’s a strategic-level oversight that we’re trying to influence and not just at the squad-level or company level. We’re trying to do that broad strategic planning kind of thing to where we can get that information out.”
And getting information out is critical in the domain of Army health care, where mere minutes can make an enormous difference in the outcome of tending to an injured Soldier.
“We’re so technically heavy,” Eldred said. “When you’re talking about a program of instruction like we have in the 68W training that covers things like anatomy, physiology, pharmacology, the Tactical Combat Casualty Care course — all those things and we have to get certification for emergency medical technician. It’s a very intense amount of training and knowledge base that they already have to have. So if we don’t front-load that information (through Project Warrior) as far as tactics and strategy, they never ever get it. They just get focused on just the technical aspect. That was a problem in the old Army. We had leaders who were coming up with no strategic and tactical knowledge because all they did was just technical. So we’re trying to overcome that and get these guys past that level and widen their knowledge base.”
‘You’re keeping people informed’
The resurgence of the Project Warrior program Armywide comes during a lull in the near constant deployments that have been a fixture throughout the past 13 years. As the Army shifts focus away from Iraq and Afghanistan, Eldred and Cluette said, it is a prime time to get a firm grasp on lessons learned during the past decade and prepare to apply them to future conflicts.
“The different platforms for lessons learned are expanding. We’re trying to reach the individual,” Eldred said. “We’ve been able to assist in creating programs like the BCT3 (Brigade Combat Team Trauma Training course), which is a mandatory train-up for all 68Ws before they deploy. So the combat medic gets this training because of Project Warrior’s influence. Down the road, we want to put a lot of the lessons learned straight from the field — not just into the manuals that people sometimes read — but into training at the lowest level. We’re trying to inject that information and keep people relevant, keep their tactics and their concept of combat relevant.
“The future is mobility and flexibility,” Eldred said.
Ensuring that an eye is fixed keenly on the future will pay dividends for the Army’s future Soldiers, Cluette says.
“I think the CTCs are going to be very advantageous to all the brigade combat teams,” he said. “This time around was a COIN fight; the next time around, we might be back in a linear battlefield. These Project Warriors are going to be those guys who learn how to do the strategic linear battlefield. But we’re going to be gone. So as we phase out, those younger Project Warriors are going to have to pick up that knowledge and be able to push that out. There’s so much that we do, medically, to support the warfighter that the Project Warriors have a wider, strategic grasp on then, say, maybe one of the Soldiers down in the trenches. The Project Warriors just understand it better. And that’s why we’ve pulled them in to teach that at the CTCs to teach that.”
Adds Eldred: “If you’ve ever read The 360-Degree Leader, it’s this great book on leading from the middle. That’s what this is. It’s teaching people laterally, not just vertically. You’re keeping people informed. If someone has a tactical or a strategic question, they come to us. They come to a Project Warrior.”
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