March 2007
Volume 71 Number 3
Training the Combat Anesthesiologist of Tomorrow
Paul D. Mongan, M.D., Col., Medical Corps, U.S. Army, is Director, National Capital Consortium Anesthesiology Residency Program, and Associate Professor and Chair, Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
Darin K. Via, M.D., Cmdr., Medical Corps, U.S. Navy, is Chairman, Department of Anesthesiology, Navy Medical Center Portsmouth, Virginia, and Associate Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense or the United States government.
While there are numerous academic anesthesiology departments across the nation that have the privilege of training tomorrow’s anesthesiologists, there are five anesthesia-training programs within the Department of Defense (DoD) that have the honor of training tomorrow’s combat anesthesiologists. Therefore DoD Graduate Medical Education (GME) Programs have a unique training requirement not faced by their civilian counterparts. As a result of this requirement, the military has relied on DoD-sponsored GME programs to meet its needs for qualified physicians who also are military officers.
The military’s first anesthesiology residency programs were started after World War II at the major Army medical centers — Brooke General and Walter Reed General hospitals in San Antonio, Texas, and Washington, D.C., and the Naval Medical Centers in Bethesda, Maryland, Portsmouth, Virginia, and San Diego, California. In 1953 the Air Force started its first program at Wilford Hall Medical Center in San Antonio, Texas. While there have been numerous military training programs at a number of other military hospitals over the years, today there are four programs: 1) the National Capital Consortium, Bethesda, Maryland (integrated Army and Navy program), 2) San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas (integrated Air Force and Army program), 3) Naval Medical Center Portsmouth, Virginia, and 4) Navy Medical Center San Diego, California, which graduate 40 residents annually.
Walter Reed General Hospital was constructed in 1909 and used for patient care until the completion of the existing Walter Reed Army Medical Center in 1977. Formal training of anesthesiologists started in 1947
In 1999, Assistant Secretary of Defense Sue Bailey, M.D., instituted Health Affairs (HA) Policy 99-00020, requiring all DoD training programs to offer curricula that will include military-unique aspects that will prepare physicians for the rigorous demands of practice in a wartime or contingency environment. This mission has never been more important than over the last five years. Military anesthesiologists have been deployed at record numbers around the world supporting the global war on terror. Many of these anesthesiologists have only recently finished residency training before they are faced with their first deployment.
As a result of HA Policy 99-00020, and lessons learned by deployed anesthesiologists, DoD training programs continue to implement and improve military-unique training for its anesthesiology residents. This article will review some of the programs that have been instituted at our training programs to ensure that today’s military resident is prepared for tomorrow’s combat zone.
{mospagebreak}
The entrance to the National Naval Medical Center in Bethesda, Maryland. The tower was constructed in the early 1940s. Like Walter Reed, formal programs for training anesthesiologists started shortly after the end of World War II.
The majority of military physicians join the military before or during medical school via the Health Professions Scholarship Program or matriculation into the Uniformed Services University of the Health Sciences (USUHS). A small percentage of military physicians enter service via direct accession. Since all military physicians are also military officers, they must undergo some form of military indoctrination upon commissioning. This indoctrination includes orientation to the military services, customs, traditions, rules, regulations and instruction in the basics of being a commissioned officer. Following this indoctrination, or medical officer basic training, all military physicians undergo training in basic soldiering with an emphasis on medical management of combat casualties. This training includes the armed services combat casualty care course for non-USUHS students and a complete curriculum and field training exercises throughout the four-year medical program for USUHS students.
Once military physicians enter their residency, they learn the uniqueness of their chosen specialty when practiced in a combat environment. DoD residency programs instruct students in operational anesthesia devices, advanced regional anesthesia techniques, total intravenous anesthesia, trauma care with emphasis on combat trauma, anesthesia in austere environments, and the treatment of injuries from chemical, biological, radiological, nuclear and explosive devices. Examples of these training elements from each of the DoD training sites are discussed below.
Forward-deployed anesthesia in a combat setting means no or limited compressed gas sources and limited electrical power. The deployable anesthesia device for this environment since the late 1980s has been the Ohmeda Portable Anesthesia Complete (PAC) drawover vaporizer. This device functions without a compressed gas source or electricity. The PAC is used with the Impact 754 ventilator when electricity is available and ventilation is desired. This ventilator functions with or without a compressed gas source. Military residents undergo didactic, simulator and operating room (O.R.) use of the Ohmeda PAC. As a result of current combat doctrine emphasizing far-forward surgery and the requirements for familiarity with the PAC, the services have launched training programs with new requirements, including successful setup, utilization and testing of competencies on the nuances of the Ohmeda PAC with and without the Impact 754 ventilator during their residency training programs.
{mospagebreak}
As casualties move from the battlefield through the different levels of care, the availability and reliability of compressed gas sources and electricity increase, as does the footprint of the medical facility. Though the weight and size of the anesthesia delivery device is still critical, the anesthesia machine is similar to what is used in O.R.s across the country today. Since the early 1990s, the anesthesia machine has been the Narkomed M. Training on both the Ohmeda PAC drawover anesthesia device and the Narkomed M allow military-trained residents to enter the battlefield familiar with the devices they will be using, thereby ensuring the already stressful environment of combat casualty care is not complicated by the use of new and unfamiliar devices and equipment.
Deployable anesthesia equipment. The Narkomed M anesthesia machine is pictured with the Armed Forces Drawover Anesthesia Device, the Ohmeda Portable Anesthesia Complete (PAC). The Impact 754 Ventilator is shown in connection with the Ohmeda PAC, which allows for controlled ventilation during surgical procedures.
The Ohmeda PAC, Impact 754 and a portable oxygen generating system on deployment. Photos by Capt. Bruce C. Baker, M.D., Medical Corps, U.S. Navy.
Total intravenous anesthesia (TIVA) also has come of interest to military anesthesiologists trying to decrease dependency on anesthesia machines for providing anesthesia care. Again, due to reasons of weight, space and requirements for compressed gas sources and electricity, TIVA has been used actively in deployed medical care over the past five years. As a result, our military programs make it a requirement that all graduating residents understand the use of TIVA in both minor and major elective surgical cases during their residency, along with didactic training on the use of TIVA techniques in a combat setting. In fact the program at the San Antonio Uniformed Services Health Education Consortium has started a center of excellence for TIVA investigation and training. Lessons and techniques learned there are promulgated throughout the DoD programs for the teaching and training of our military residents.
Before or after surgery and anesthesia, pain management is one of the greatest problems affecting our combat casualties. The biggest advancement in pain management for our soldiers today has been the revitalization for regional anesthesia, including the approval of infusion devices for nerve catheters and patient-controlled analgesia during air transport. The placement and utilization of regional anesthesia catheters has allowed for improved pain management without the CNS depressive effects of parenterally administered opioids. These techniques are taught to all residents during their training programs on both combat casualties who have reached academic military treatment centers for tertiary care and elective surgical patients at facilities that do not have the large influx of casualties from the global war on terror. In addition residents have rotated on the acute pain service at Landsthul Medical Center, Germany, the major evacuation route for casualties injured in Operation Iraqi Freedom. Here residents learn firsthand the indications, techniques, risks and complications of providing complex regional anesthesia techniques while providing service for our wounded soldiers, sailors, airmen/women and marines.
Only one DoD academic center is a level 1 trauma center; therefore, providing experience in civilian, peacetime trauma care is more of a challenge for the other facilities. All programs have developed affiliations with other academic programs with level 1 trauma centers, and it is through these arrangements that the residents receive the majority of their civilian trauma care experience. Before or after returning from these rotations, it is the responsibility of the military academic staff to ensure that residents understand the differences between civilian trauma and combat trauma casualty care. Residents undergo further didactic sessions educating them on these differences, and all programs have instituted simulation programs that have military trauma care as part of their curriculum.
Deploying with an operational unit means deploying into an austere environment. Limits in equipment and supplies are what are first noticed, but bigger questions soon arise as one learns that a deployment is inevitable. What equipment will I have? How will I resupply? Will there be a consistent power source or compressed gas source? What personal gear can I or should I take? The best way to learn these lessons is to experience similar operations in noncombat settings prior to the first military deployment.
The National Capital Consortium has instituted a program that allows residents to participate in extended humanitarian missions in South America, Africa and the South Pacific. During preparation for these two- to three-week deployments, anesthesiology residents plan, pack and transport all of the equipment and supplies they will use during their mission. They also are instructed in the care, cleaning and maintenance of all equipment. Proper preparation and planning are critical to having sufficient supplies and meeting stringent weight restrictions. Other programs have used already-established civilian programs or participated in similar military programs.
Finally, as stated previously, every military physician also is a military officer. It is the responsibility of the training program to ensure the professional development of the military officer for advancement and promotion. Residents and their programs are responsible for maintaining the resident’s official officer records and their officer fitness reports detailing medical and military accomplishments. All military residents also are required to maintain rigorous physical readiness standards comparable to all members of the military. In this regard, program chairs and directors are responsible for ensuring their residents are not only well-trained anesthesiologists but also well-trained and well-prepared military officers capable of performing their future duties.
