Hospital Rotations Critical Facet of Training Special Operations Combat Medics

Emergency medical services workers wheel a male patient with multiple gunshot wounds into the emergency department’s trauma bay. The patient has been shot in the back, and the bullets have penetrated into his chest and abdomen. In less than 30 seconds, Specialist Noah Smith performs an endotracheal intubation, which is the placement of a flexible plastic tube into the trachea to provide a secure and stable airway. Next, he moves to place bilateral chest tubes for the treatment of pneumothorax (the collection of air or gas in the chest cavity), then continues to assist with further assessment and treatment of the casualty.

In another urban location, Specialist John Olson’s experience reinforces the importance of situational awareness and expecting the unexpected as he rides with first responders to the point of injury in a “rough neighborhood.” When they arrive, the situation on the ground is much worse than reported by dispatch.

Smith and Olson are students participating in clinical training as part of the Special Operations Combat Medic Course, or SOCM, conducted at the JFK Special Warfare Center and School’s Joint Special Operations Medical Training Center, or JSOMTC, at Fort Bragg, N.C.

The JSOMTC is a 75,000-square-foot, tri-service facility that is staffed by the Special Warfare Medical Group and has under its auspices the Naval Special Operations Medical Institute. The staff and cadre train more than 1,500 students annually from all subordinate units of the U.S. Special Operations Command and from allied special-operations units.

In addition to SOCM, the JSOMTC conducts four other medical-training courses: the Special Forces Medical Sergeant Course, the Special Operations Independent Duty Corpsman Course, the Civil Affairs Medical Sergeant Course and the Special Operations Combat Medic Skills Sustainment Course.

SOCM is the prerequisite course for all special-operations medical training. During the academically demanding 26-week course, students receive more than 1,200 hours of classroom instruction and hands-on training.

SOCM is divided into six phases: medical fundamentals, three progressively intense phases of trauma training, training in civilian urban-trauma centers and a block on military medicine. During the first phase, medical fundamentals, students receive training in anatomy and physiology, pathophysiology, pharmaceutical calculation, physical examination and medical patient assessment.

After completing medical fundamentals, students begin their trauma training, where they learn how to assess and manage trauma patients from the point of injury through casualty evacuation. From that training, students must demonstrate proficiency in a wide array of life-saving skills, including advanced airway management, hemorrhage control, splinting, vascular and intraosseous access (access through the marrow of the bone), medication administration, shock management and a variety of emergency surgical procedures. Those procedures include cricothyrotomy (an incision through the skin and cricothyroid membrane to secure a patient’s airway during certain emergency situations), chest-tube thoracostomy (the insertion of a flexible plastic tube through the side of the chest to remove air or fluid from the area) and venous cutdown (the surgical exposure of a vein in order to gain vascular access in trauma and shock patients).

Students receive training in combat casualty care as well as certification in civilian-recognized programs, including Basic Life Support, Pre-Hospital Trauma Life Support, National Registry of Emergency Medicine Technicians-Basic, Pediatric Education for Pre-Hospital Professionals and Advanced Cardiac Life Support. These civilian certifications are paramount in the SOCM students’ ability to train in civilian urban trauma centers. That training composes the fifth block of SOCM training.

The highlight of SOCM is the training conducted during a comprehensive four-week deployment to one of three metropolitan areas: Richmond, Va.; Tampa, Fla.; or St. Petersburg, Fla. During those four weeks, students deliver health care to ill and injured citizens of those communities while completing a 144-hour clinical rotation of hospital training and a 144-hour field internship of pre-hospital training with emergency medical services, or EMS.

During the hospital clinical rotations, conducted at Richmond’s Virginia Commonwealth University Medical Center, Tampa General Hospital or through a combination of St. Petersburg’s Bayfront Medical Center and All Children’s Hospital, SOCM students provide care to the full spectrum of medical and trauma patients. They spend a significant amount of their clinical-rotation time working in the adult emergency department, where they become proficient in emergency assessments and life-sustaining procedures.

Training in other departments is crucial to the development of well-rounded special-operations combat medics. Students obtain further training in areas such as labor and delivery, where they assist with deliveries and learn how to manage newborns and obstetrical complications; the operating room, where they obtain and manage patient airways and assist in surgical procedures; various intensive-care units, such as neurosurgical and burn, where students assess and monitor patients who have traumatic brain injuries and assist with the management of burns; and the pediatric emergency department, where students treat patients ranging from infants to adolescents.

During the field internship with EMS, students assigned to Richmond work with the Henrico County Division of Fire, and those in Tampa and in St. Petersburg work with Tampa Fire Rescue. Field internships give SOCM students vital experience in providing medical care at the point of injury or illness. It’s important that the medic be able to provide medical care, but he must also be able to lead a cross-trained team in providing that care, especially in the event of a mass-casualty situation. Therefore, a critical element of SOCM training is teaching students to perform a variety of team-leader roles throughout the clinical experience.

It’s also important to note that although the special-operations combat medic must be able to assess a patient and perform acute life-saving interventions, he must also be able to manage the patient through the myriad of complications that can arise during a prolonged delay in casualty evacuation. He must develop medical critical-reasoning skills by monitoring and assisting in the management of patients from the point of injury or serious illness, through the emergency department and through the first 24-48 hours of ICU care, in order to recognize and appropriately treat potential complications.

The coordination and provision of the necessary clinical training to ensure that SOCM students acquire these skills is an incredible undertaking. The SOCM program assigns an active-duty-military or government-service employee as a clinical coordinator at each of the three sites for program management. It relies heavily on dedicated civilian preceptors at the sites to train the medics. On-site clinical coordinators have established an incredible relationship with their respective hospitals and fire departments.

In November 2009, Danny Yakel, a retired Special Forces medical sergeant and the SOCM clinical coordinator in Richmond, was asked by Virginia Commonwealth University’s Department of Emergency Medicine to give a presentation at the National EMS Symposium, held in Virginia Beach, Va. The convention is the largest of its kind and is attended by representatives from EMS departments throughout the United States. Yakel’s presentation portrayed a real-life comparison of civilian EMS and special-operations medicine to give the civilian EMS departments a better understanding of the training and capabilities of special-operations combat medics.

Clinical coordinators are primarily responsible for educating the preceptors on the SOCM training level, scope of practice, requirements and objectives of the clinical experience. Preceptor education became especially imperative during the past year, because of the establishment of new program requirements and patient-management goals. It is one thing for preceptors to receive a briefing on the training and capabilities of the combat medics, but their comprehension is taken to a new level when they experience the training firsthand. Annual preceptor site visits to the JSOMTC to observe SOCM training have significant affects on preceptor buy-in.

After a recent site visit, Dr. John Cha, a trauma surgeon from Tampa General Hospital, said, “It was a real eye-opener to see the medics perform technically complex clinical maneuvers a mere six months into their rigorous program, particularly considering that a significant number of them had no prior medical education. I am confident that I was nowhere near the SOCMs’ level of proficiency after medical school and even several years into my surgical residency. As for the SOCMs’ performance during their rotation with us, it is a testament to their training that they integrate well with the trauma resuscitation team. I have found the SOCMs to be always ready, motivated and professional in conduct. I only wish that they rotated with us for a longer period of time.”

Site visits also provide preceptors with a better understanding of the combat medics’ typical work environment and available equipment. Tracy Brown, a registered nurse and a preceptor at Tampa General, said, “I have all the most advanced equipment and unlimited access to many specialty services, and yet these boys go out with a backpack and save many lives.” That understanding allows preceptors to ask students thought-provoking questions, such as, “How would your treatment of this patient differ if you were in an austere location with limited resources?,” further expanding the development of students’ critical reasoning.

Dr. Kevin Ward, the program director at Virginia Commonwealth University Medical Center, noted, “Even the challenges that exist in an inner-city, level-one trauma center and busy EMS system will pale in comparison to what they will experience later in the field.”

Ward pointed out that members of the faculty, residents, nurses and members of the paramedic staff involved in training the SOCM students uniformly consider themselves to be beneficiaries of the program because of the model behavior of the SOCM students.

“The professionalism and hunger for knowledge that these young men demonstrate to us, day in and day out, while they are with us, is a true inspiration for all. While we are not on the field of combat, the presence of the SOCM students is a constant reminder to us of the War on Terror and the importance of constant vigilance. … We are one of the few civilian medical centers who can say we are truly contributing to the war effort. We try to constantly remember that because of what the SOCM students will be doing, we can continue to do what we do without fear.”

Clinical rotations and field internships are essential elements of SOCM training. SOCM students rely on civilian health-care providers to assist in perfecting the critical medical skills acquired at the JSOMTC. When SOCM students return to Fort Bragg, they complete the sixth and final phase of training, a one-week block on military medicine. After that, Special Forces Qualification students go on to the second half of training in their military occupational specialty, but the remaining SOCM graduates report to their units and are subject to being deployed within weeks of their departure from the JSOMTC.