Since Russia’s full-scale invasion of Ukraine in 2022, conventional warfare has been reanimated with a modern flair. New and emerging technologies including drone-borne munitions are being used in tandem with tanks and traditional artillery to wreak havoc and bring the frontline of conflict to anywhere opposing troops are located. These incredibly accurate and lethal drones are changing the patient wound profiles previously seen in armed conflicts, and maiming soldiers with devastating yet survivable injuries – causing a surge in the need for damage control resuscitation (DCR) and damage control surgery (DCS) closer to the frontline.
Civilian health systems and aid organisations are drastically overwhelmed attempting to treat the numerous civilian casualties, and organic military health capabilities have needed to rapidly adjust their practices to treat troops fast enough so that they can return to fighting. In order to achieve this, Ukrainian medics have been up-skilled and work alongside anaesthetists and intensivists, conducting DCR in “ICUs on wheels”.
As the ADF shapes itself to address upcoming adversaries and threats, a pragmatic approach must be taken to understand the health needs of those that we treat in future combat settings. Modern combat will see ADF health personnel working in environments that are foreign to their previous experiences, both in terms of austerity and clinical skills. The Defence Strategic Review urged the ADF to transform our capability, and this can be achieved in part through identifying opportunities to upskill and professionally challenge our existing health workforce.
Taking the approach of ‘one career, many jobs’ serves a two-fold purpose – increased capability is a force multiplier, and it increases the likelihood that we retain our personnel. The Role 2 Basic (R2B), currently being developed at 2 Surgical Company, 3 Health Battalion, has been employing medics in a way they have not been employed before – giving them an increased level of responsibility for high-acuity patients.
As it stands, ADF health services are overwhelmingly made up of medics, nursing officers, and medical officers – each with their own scope of practice and many with a sub-specialty. These clinicians are often expected to be cross-trained or a ‘jack-of-all-trades’ to ensure that a wide range of experience and skills are available should the need arise. No uniformed member is a stranger to the fact that it is difficult to balance expectation versus reality. The tempo demanded of health personnel means that opportunities for meaningful upskilling can be scarce and as such, few clinicians find themselves adequately prepared to venture beyond their base level of training.
Medics are practical, efficient, task focused, and logical in their applied interventions. They are without a doubt, the masters of pre-hospital care in a warfighting organisation; however, their training continuum does not provide the skills to look after critically unwell patients beyond the initial point of care or forward evacuation. They are not afforded the opportunity to undertake patient care in more advanced settings such as a civilian ICU, and rightly so – as that is not what is expected of them in current doctrine and older constructs. However, as evidenced by the Ukrainian experience, modern conflict provides a setting for innovation and advancement.
Currently, medics are often employed in a Role 1 serving in a ‘wet’ or ‘dry’ medic role and may have experience working in emergency departments, some even in resuscitation rooms. Some of the skills learned here are not a far stretch from what would be expected of them working in small teams on critical care patients. What the typical medic lacks is a deeper knowledge of physiology (which would enable their understanding of trends when things go wrong) as well as some important practical skills such as systemic patient assessment, drug preparation and administration, procedure preparation, and preparation for Strategic Aeromedical Evacuation (STRAT AME).
The Role 2 Basic (R2B) is a ‘highly capable, logistically deployable, and versatile surgical capability’, and can get closer to the forward line of troops than larger facilities. Its limited Order of Battle means there are no small jobs, and this has afforded 2nd Surgical Company (2 SURG) the opportunity to upskill, train, and expose our medics to a critical care skill set.
In the larger Role 2E (R2E) facility, patient care is conducted solely by Nursing Officers (NO). Past generations have seen medics used in this space, and they provided little patient care and were often tasked with equipment and stock management – a gross underutilisation of their skills, enthusiasm, and knowledge. Whilst this is still an integral part of keeping the department running, it is firmly a shared responsibility between both medic and NO in the R2B.
In this environment, the medic is afforded a level of influence and an opportunity to flex clinical skills that they are not provided an opportunity for elsewhere. To be clear, any action conducted by the medic working in this environment is caveated by the fact that they are not working autonomously and are always under the direction and observation of their NO counterpart.
Deployments on Exercise (EX) RHINO RUN and EX PREDATORS RUN provided two significant opportunities for proof of concept in 2024. During these exercises, medics were provided education in advanced systemic patient assessment, fundamentals of ventilator use, haemodynamic monitoring, cardiac monitoring, documentation, lessons on drugs rarely seen outside an ICU, and assisting with procedures.
These exercises provided clear proof that the medics were able to practice safely and successfully alongside their NO counterpart. Over the course of the two exercises, the medics working in this space were able to increase their own knowledge through the provision of a draft version of a theory package on critical care nursing and anatomy and physiology.
They were trained to do all emergency and equipment checks required for the admission of patients and shift change over in the High Acuity Holding, assist with manual handling of a simulated ventilated patient, conduct patient assessments and feed that information back to the NO for interpretation. Furthermore, they were taught about the principles of cardiac and haemodynamic monitoring and how blood pressure regulation is achieved using potent medications.
All the information and skills taught were tested on a regular basis and by the end the medics were expected to be able to teach-back that information as a confirmation of learning. Thanks to the invasive skills program at 2 SURG, one of the medics was able to insert a naso-gastric tube into one of the NO’s, a skill they had never had a chance to do before on placement.
These experiences clearly demonstrated that when medics are placed into the critical care environment and given the required resources, training, and exposure needed – they thrive under pressure. They can successfully apply their knowledge and skills under the watchful eye of their NO counterpart. Having a second set of trained eyes in a critical care space within constructs such as the R2B allows the NO in charge to not only have a second opinion, but someone to aide in patient treatment who understands the unique needs of critical care patients.
It should be clear by now that the medic truly is the right hand of the NO in this small team setting, especially once they have been given the training and exposure to build their abilities. Once trained the medic will be able to act to some degree on intuition allowing the NO to continue patient cares that are reserved for their wider scope of practice.
To ensure they are prepared for the critical care environment, on-going education and training is conducted at 2 SURG which provides initial exposure to equipment, required concepts, and skills. Of course, the military training environment is very limited in its ability to produce high-fidelity critical care scenarios compared to the experience gained by even short duration civilian ICU clinical rotations.
To address this, efforts are being made at 2 SURG to have medics conduct shadow placements in civilian ICUs to facilitate real-time learning and exposure. However, upskilling at a unit level can only go so far, and if a construct such as the R2B is to be widely adopted then changes to the training continuum will need to be formalised, either through the Joint Medic Course and Joint Medical Advanced Course continua or some other dedicated course structure.
There will always be a sibling rivalry between close health and general health. Some clinicians are fond of close health and some have the required skills, personality, and attributes to work in a critical care space. Medics working in critical care are required to be mature with a good attention to detail and ability to work well under pressure.
It is also paramount that they understand trends in patients and can confidently escalate concerns to senior clinicians in the facility to advocate for their patient. The military soft skills that medics have developed through their training (that NOs and MOs often have not fully developed simply by virtue of their reduced military exposure) – make their opinions valid and even with less training they still provide valuable insight.
Our experiences so far show that a trained to work in R2B High Acuity Holding is an integral and valued part of the team and is paramount not only to the success of the capability but also the professional growth of its members. It is an exciting new potential concept of employment and provides an opportunity for members to be upskilled and utilised in fresh ways. It presents a possible new job option that could be intertwined throughout a medic’s career (‘one career, many jobs’) and may just be one small way to increase retention amongst our personnel.
We were just talking about this on my last day pre-leave - that Defence medics would benefit from the same training/education as civilian paramedics but delivered in the more effective (IMHO) and more intense military training environment.
Not only would this generate broader mil medics, it would make them more employable in the civilian emergency medicine environment. This in turn would, as you say, reduce current staff workloads pre-hospital and in EDs, improve patient care and expose mil medics to a much broader range of practice - and more applicable in HADR and other not strictly mil environments.
Of course, there is a risk that equivalently training mil medics will exodus to the civ world but that's on Defence to enable two-way transition between mil and civ worlds, and keep the mil environment competitive and attractive. Train them to leave, treat them to stay.