ARMY MEDICINEOne Team…One PurposeConserving the Fighting Strength Since 1775
Leveraging Mil-Civ Collaborations to Achieve Zero Preventable Deaths from Injury
US Army Opportunities
2019 AMSUS-Annual Meeting“Transforming Healthcare through Partnership and Innovation”
COL Jason Seery, MD, FACS
Army Medical Skills Sustainment Program-Clinical Advisor
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1. The opinions in this presentation are those of the presenter and do not necessarily represent the official opinion of the Department of the Army or the Department of Defense.
2. The presenter, Department of the Army, and the Department of Defense have no official preference toward specific products, manufactures, or facilities found in images or bullets within this presentation.
3. The presenter has no financial ties to the products, manufactures or facilities discussed in this lecture.
Disclaimer
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Disclaimer Objectives Army
Historical Info Current Info Concept Processes Challenges Future
Defense Health Agency/Joint Trauma Education and Training Discussion
Outline
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Identify the various Mil-Civ clinical partnership program opportunities across the services, and the objectives of each
Discuss the criteria necessary to initiate a Mil-Civ partnership
Recognize and prepare for future initiatives
Objectives
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1991 - 1993 AARs / GAO Reports / Articles
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1993 IG Report
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Mil Med. 1996 Mar;161(3):137-42.The peacetime trauma experience of U.S. Army surgeons: another call for collaborative training in civilian trauma centers.Knuth TE1.
Mil Med. 1997 Aug;162(8):iv, xiii.Training for operational readiness.Knuth TE.
Mil Med. 1998 Sep;163(9):608-14.Military training at civilian trauma centers: the first year's experience with the Regional Trauma Network.Knuth TE1, Wilson A, Oswald SG.
Mil-Civ Literature
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1995 & 1996 GAO Reports / 1996 NDAA
•Demonstration Training Program NLT April 1996
•Termination NLT March 1998
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1997 Combat Trauma Surgery Committee
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1998 GAO Report
• CTSC Recommendations / 1996 NDAA Section 744– Demo Program
• Naval Medical Center Portsmouth, VA and Eastern Virginia Medical School (Surgeons Only)
• Wanted more specialties, not just surgeons• Other organizations / locations did their own similar pilot
programs
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Joint Trauma Training Center
• Sustainment training within the DoD wouldn’t work– 1996
• BAMC-Level I, but only 600-800 trauma admissions per year
• Ben Taub in Houston, TX – 1996
• 2800 admissions per year– Became the Level I Trauma Center that would execute
the next phase of implementation
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Joint Trauma Training Center
• 30-Day rotation– Didactics and Clinical time– All health care specialties within the team attended
• One Army and one Air Force team rotated in 1998• Other teams rotated through in following years• Issues:
– 30 day TDY deemed too long for some rotators– Competition with in house students/residents/fellows– State not fully reciprocating license– Hospital provided minimal privileges/limited scope of practice– Not allowed to fully care for the patient– DoJ and DoD had concerns with malpractice coverage– Did not included Compo 2 or 3 healthcare providers– One location couldn't meet tri-service needs– Other facility staff and military cadre challenges
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JTTC - Articles
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Service Specific Training Centers
• ATTC (Army Trauma Training Center) – Miami, FL-2001 (>5000 TA; 30% P; >20% ISS
over 15)• ATTD (Department and then Detachment)
– 4, then 3 and now 2 week rotation– 32-84 patients over 5 days ~ 54 (27/team)
• C-STARS (Centers for the Sustainment of Trauma and Readiness Skills)
– Baltimore, MD-2001– Cincinnati, OH-2001– St Louis, MO-2002
• NTTC (Navy Trauma Training Center)Los Angeles, CA-2002
-- 3 week rotation
3 week rotation
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Key Events:• GWOT
• CTSC• JTS / JTTS
• DoDTR• PI• CPGs• DCoTs (CoTCCC / CoSCCC / CoERCCC)
• PDTT requirements• Other Mil-Civ Partnerships• Numerous AMEDDC&S, BUMED, AFMS, DMRTI, etc courses• New technologies and TTPs• RAND, Booz-Allen-Hamilton, and other reports• Published articles/editorials
Additional Factors
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Current:• 2003-Senior Visiting Surgeons program
• Support of the AAST, EAST, WTA, ACS-COT, AAOS, OTA and others• LRMC• Various OCO locations in Iraq and then Afghanistan
• 2014-ACS Scudder Oration• Winds of War: Enhancing Civilian and Military Partnerships to Assure Readiness
• 2014-Military Health System Strategic Partnership with the American College of Surgeons
• 2015-Booz-Allen-Hamilton Report
• 2016-National Academies of Sciences, Engineering and Medicine• A National Trauma Care System-Integrating Military and Civilian Trauma
Care Systems to Achieve “Zero Preventable Deaths After Injury”
Recent Factors
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2017 NDAA
17
“Public Law”
• 2017-NDAA, Section 708• “Joint Trauma Education and
Training Directorate”• Paragraph C
• Establish and embed combat trauma teams, like forward surgical teams, into ”Mil-Civ Partnerships”
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Nested Authorities
NDAA 2017, 708C
AMCT3 Task Force CharterMEDCOM OPORD #18-78
*AW NDAA 17 Section MEDCOMauthorized the execution of Medical Training Agreements (MTA) with civilian Level 1 trauma Centers
Commissioned 27 October 2017
Published 07 August 2018
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2019 NDAA, Section 719
Removed verbiage for partnerships to be at only at:
“large metropolitan teaching hospitals and academic center's”
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Training the way we fight: supporting and sustaining our armed forces with a ready medical force able to fight and win today and prepared for the battlefields of the future!
S.M.A.R. T
Expeditionary Combat Medic Course
Aeromedical Evacuation Training
Military-Civilian Combat Trauma Team Partnerships
Simulation & TrainingMSTC, MTFs &
Civilian Facilities
Global Medic / JRTC / NTC / VR
Emergency War Surgery Course
Surgical Team TrainingER Physician/Nurses, CRNA, OR Techs, Paramedics, PAs
Joint Forces Combat Trauma Management
Course
Brigade Combat Team Trauma Training Course
& Tactical Combat Medical Care Course
Army Trauma Training Course -
Ryder Trauma Center
Combat Casualty Care CourseJoint Enroute Critical
Care Course
OCONUS Training
Bridge to Readiness
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Expert / Mastery?
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1. Total number…hundreds2. Focus varies from
1. Initial Training, Refresher, Skills Sustainment, Just-In-Time, vs other 2. Individual vs Team3. Enlisted vs Officer4. Conventional vs Special Operations5. Patient care only, Didactic Only, Mixed6. Simulation vs No Simulation7. Clinical vs non-clinical vs research8. GME/SoN vs Military Units
3. Modern “708” Mil-Civ Partnerships1. Army Medical Skills Sustainment Program (AMSSP)
1. AMEDD Military-Civilian Trauma Team Training (AMCT3) Program (Team)2. Strategic Medical Asset Readiness Training (SMART) Program (Individual)3. *Local MTF Agreements (various medical staff, SOCOM, etc)
Current Army MCPs
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SMART Program Concept(Strategic Medical Asset Readiness Training)
• The program was piloted at Hackensack University Medical Center, (HUMC), Hackensack NJ.
• Expansion into several hospitals in Cincinnati Aug 18• 68K, 68P, 68V, 68W; adding 68X and others• Collaboration with Civilian Universities/ VA Hospital Systems
– Soldiers work with their civilian counterpart for 15 day rotations.– Interactive observation and hands-on training documented
through an Army provided checklist.• Incorporate program across all Components, Services,
Branches• Possible expansion across CONUS• * one weekend EOM vs 15 days annually
Total Force Concept: All Compos/ All Services
• Hackensack, NJ• Cincinnati, OH (x4)• Laredo, TX (x2)• San Jaun, P.R. • Camden, NJ*
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ARMY MEDICINEUNCLASSIFIED//FOUO
Operation SMART Training Frequency
Time
Skill
Sust
ainm
ent
Time
Skill
Sust
ainm
ent
Annual Training (AT)
One Team…One PurposeConserving the Fighting Strength Since 1775
Current Guard/Reserve Training Model
SMART Guard/Reserve Training Model AT
04 January2019UNCLASSIFIED//FOUO Slide 24 of 11
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ARMY MEDICINEUNCLASSIFIED//FOUO
SMART Program Questionnaire
04 January2019UNCLASSIFIED//FOUO Slide 25 of 11
The questionnaire offers a better understanding of the Soldier as in individual and as a medical professional.
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ARMY MEDICINEUNCLASSIFIED//FOUO
Scope of Practice Information
04 January2019UNCLASSIFIED//FOUO Slide 26 of 11
Individual scopes of practice for each MOS is provided to better understand daily duties, roles, and responsibilities respective to each job.
Process Items for SterilizationOperate a Steam Sterilizer
Put on Sterile GlovesAssess a Patient's Pulse Rate
Measure a Patient's Blood PressureMeasure a Patient's Temperature
Perform Cardiopulmonary Resuscitation (CPR)Perform Rescue Breathing
Operate an Automated External Defibrillator (AED)Ventilate a Patient with a Bag-Valve-Mask System
Establish a Sterile FieldPerform a Surgical Scrub
Put on Sterile Gown and GlovesPlace Gown and Gloves on Surgical Team Members
Assist Surgical Team Member in Donning/Doffing Sterile GarmentsReplace A Glove Using Open Gloving Technique
Select Equipment, Sterile and Unsterile Supplies for a Surgical ProcedureOrganize Prep Set Items
Position Draped Equipment Prepare the Electrosurgical Unit for a Surgical ProcedureRemove Contaminated Items from the Operating Room
Clean the Operating RoomPrepare a Patient for Movement to the Operating Room
Place a Patient in the Lithotomy PositionPlace a Patient in the Kraske (Jackknife) Position
Prepare Specimens for ProcessingPass Medical Items During Surgical Procedure
Prepare Field Suction MachinePrepare Field Scrub Sink
Prepare Field Operating Room Light for UsePrepare Field Operating Room Table
Prepare Field Steam Sterilizer for UsePlace a Patient in the Lateral PositionPlace a Patient in the Prone Position
Perform Sponge, Instruments, Sharps, Needle CountsDrape the Patient for an Upper Extremity Procedure
Discard Disposable Sharps/Soiled SpongesInspect Surgical Instruments Prior to Use
Assist in Draping the Patient for a Lower Extremity Procedure Assist in Draping the Patient for a Laparotomy
Assemble Sterile Drills and SawsPrepare Sterile Dressings
Pour Solutions in the Appropriate Receptacle on a Sterile Field.Perform Comfort and Safety Measures for the Patient in the Operating Room
Hold Retractors or Instruments as Directed by the SurgeonAssemble Surgical Stapling Devices
Provide Surgical Sharps Using Hands Free TechniquePlace a Patient in the Supine PositionAssemble Fiberoptic Surgical Scopes
Transfer Specimens from Surgical Technologist to Circulator
Operating Room Specialist (68D) Job Functions
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ARMY MEDICINEUNCLASSIFIED//FOUO
Critical Task List
04 January2019UNCLASSIFIED//FOUO Slide 27 of 11
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SMART Program
SMART-Way Ahead
Current Sites
Future Sites
Representation of potential spread
Puerto Rico
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AMCT3 Concept Plan
• 1-3 months• Pre deployment training• Simulation and training
programs• Complement ATTC
**FRST
Just in Time• 2-3 years • Embedded as staff
members• Simulation and training
programs• Leverage fellowship
program• Manage/supervise rotating
teams
**Forward Resuscitative Surgical Team (FRST)
Sustainment• 3-6 months • Rotate
individuals/teams • Simulation and training
programs• May support pre/post
deployment trauma/non-trauma skills training
**FRST
Refresher
*Primary Team: Surgeon (GS/TS/OS), ER Physician, Anesthetist, ER Nurses, ICU Nurse
Benefits:• Increase surgical team’s deployment readiness and skillset • Enhance surgical team’s operability and capability • Gain necessary case volume, mix, complexity, and acuity
Secondary Team: PAs, NPs, Medics, Paramedics, various Techs, other physician and nurse specialties ** Owned by FORSCOM
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Compo 1 Role 2* / Role 3 Locations
Fort with FST only
Fort with CSH only
CONUS FST/CSH Units
Fort with FST(s) & CSH745th FST31st CSH
127th FST555th FST21st CSH 115th CSH
14th CSH
240th FST274th FST (A)541st FST (A)759th FST (A)28th CSH
SORT-1SORT-2SORT-3
JMAU-*
8th FST
102nd FST250th FST758th FST47th CSH
772nd FST86th CSH
2nd FST10th CSH135th FST
121st CSH
Korea67th FST160th FST212st CSH
Germany
OCONUS FST/CSH Units
Future additional FRST Units
CONUS SOF Units
42nd FRST10th FRST
*Some FSTs are now FRST**Some CSH are now HC/FH
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Legacy Emanuel
University of Chicago
Grady
Vanderbilt
Oregon Health & Science Univ.
Harborview
University of Colorado
**Columbus Regional
***Cape Fear Regional
Mass General
INNOVA-Fairfax
Capital Regional
Cooper Health
John Strogger-Cook County
UPenn
PennState
Temple
Milwaukee Regional
Carolinas
Johns Hopkins
Kansas University
AMCT3: The Partnerships Landscape
Fort with FST only
University Health
Fort with CSH only
Primary embed site-FY18
MTA signed-possible embed site-FY20
Visited-Possible site for SOF
Visited-Possible local rotation site
Fort with FST(s) & CSH
Visited-Possible embed site-FY 21
Future site visit-Embed
Future site visit-Rotation
Regional One
University Medical
Queens Medical Center
Rutgers
Unknown x 2
WakeMed
Hartford
Denver Health
** Level II Trauma Center*** Level III Trauma Center
San Juan SMART
University Medical
Ryder Trauma Center***Laredo
***McAllen
Cincinnati SMART x4
Hackensack SMART
SMART site-Rotation
Pre-existing Army Role 2 MCP site Cox Medical
Wake Forest
UNC
Del Sol Medical Center
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• 2 initial team programs • Cooper University Hospital, Camden NJ• Oregon Health & Science University Hospital, Portland OR
• 5 specialties from MTFs• General or Trauma Surgeon; Emergency Medicine• CRNA; Critical Care; Emergency • No Orthopedic Surgeons• Assigned for ~3 years• No enlisted tech specialties at this time• Perioperative Nurse x2 (FY19)• Neurosurgeon x1 (FY19)• CT Surgeons x 2 or more (FY20)
• 3* initial individual programs• Vanderbilt University Medical Center, Nashville, TN; with Blanchfield Army
Community Hospital, Fort Campbell, KY• Del Sol Medical Center, El Paso, TX; with William Belmont Army Medical
Center, Fort Bliss, TX• Cape Fear Regional Medical Center, Fayetteville, NC; with Womack Army
Medical Center, Fort Bragg, NC
Initial Roll Out
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UNCLASSIFIED 07 June 2019Name/Office Symbol/(703) XXX-XXX (DSN XXX) / email address [email protected]/[email protected]
AMCT3 Team Overall Battle Rhythm
PCS*
PCS*
*PCS• MEDCOM / AMEDDC&S• FORSCOM / SOCOM• PME / DARPA / KD / SB /
Other• ETS / Retire
Deploy as
“PROFIS”
FRST
Role 2
Function as “Cadre”(Phase II)
Deploy as
“PROFIS”
FRST
Role 2
Refresher Rotations
T/NT)
FTX/STX FTX/STX
PHASE I• Orientation• Onboarding• ICTLs
Initial 90-120 days
PHASE II• ICTLs / KSAs• MUC
-CPG/TCCC-Literature
• Interprofessional Team Development
• Trauma Simulation
• FTX/STX• PDTT• Military Duties
Next 180-270 daysPHASE III
Next 2 years
PCS• GME• MEDCOM /
AMEDDC&S• FORSCOM /
SOCOM• PME• Deployment /
Mission
AMCT3 Staff
Refresher Rotations
(T/NT)
Function as “Cadre”(Phase II)
Just-in-Time
Training
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Full FRST
AMCT3 Staff
FORSCOMFST
MEDCOMMTF
5-6 vs 10 vs 20 (2x10)
• Two 10 Person elements (Entire 20 person Team)1. Can Alternate Deployment and Cadre phases2. 75% at Host Partner Facility : 25% at Base* (return
to their home base every 2-4 months for a one-two week TDY)
1. FTX/STX2. Inventories/inspections3. Mandatory training4. Face to Face meetings/training5. Range6. Jumps7. Etc.
*TBD
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• GME collaboration• Trauma/Critical Care Fellowships• Emergency Medical System Fellowships• Orthopedic Trauma Fellowships• Advanced Nursing Training Opportunities
• Supporting Compo 2 and Compo 3 rotations
• Integration of other specialties:
• Integration of MBA/MHA interns
• Supporting DoD related Research and Process Improvement
Other Considerations
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Future program• RHC-A OPORD 18-78
• 5 additional programs in FY 20 (Goal of 15 total)• Goal of 1:1 ratio for each CONUS Role 2
• Currently have 16, but will grow to 18 over next three years• FORSCOM
• FRST• Field Hospitals• Head and Neck Detachments• Lab Detachments
Future Concept of AMCT3 Partnerships
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Future considerations/impacts to the program• Mission Zero Act H.R 880/ Pandemic All-Hazards Preparedness
Act H.R. 6378 (Passed, but unfunded)• Teams• Individuals
• DHA Joint Trauma Education and Training Directorate
Future Policy Impacts
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[email protected] Director
[email protected] Clinical Advisor
POCs
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Discussion
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Latest Borden Institute Text
CHAPTERS1 - Casualty Care From the Revolutionary War to the War of 1812
2 - Surgery and Medicine in the War of 1812: A New Nation Challenged
3 - The Civil War: Military Medical Care in the War Between the States
4 - Transitions: Army Medicine in the Post-Civil War Period to the Start of World War I
5 - Forward Surgery in the Great War: A War of New Technologies
6 - World War II: Army Forward Surgery on a Worldwide Scale
7 - Forward Surgery in the Korean War: The Mobile Army Surgical Hospitals
8 - Vietnam: The Rise of Helicopter Medical Evacuation in a War Against a New Kind of Enemy
9 - From the Falklands to the Balkans: Toward Formal Designation of the Forward Surgical Team
10 - Put to the Test: Forward Surgical Teams Challenged During the Global War on Terrorism
11 - Homeland Defense, Contingency Operations, and Future Directions