PFC Podcast 267: Why your Medics Suck 2

[Music] Welcome back to the PFC podcast. The views and opinions you are about to hear are the speakers and do not necessarily reflect those of anyone else. Now on to the podcast. This is Dennis and today I'm with Rick. How are you doing today? Oh, doing alright. A fine Saturday morning. Yeah, the snowpots lips is barreling down upon us as we speak. Oh. But, so, you know, thank you for jumping on. What I wanted to go through is essentially a recap of your presentation at SOMSA, what, 23 or 24, on "Why Your Medic Suck" and I'm hoping to find out if anything changed since then. Yeah, why your medic suck and what you can do about it. Right? [Laughter] So, almost two years ago, your presentation, essentially what I got out of it is, your medic actually need to practice. Right. And now things are being graded and they might not get recertified if they don't pass. So, after that bitch slapped to the face, you know, have things improved? They have. They have. It was some units one than others. But the whole idea, we first put it out at SOMTD, the Usock meeting for their medical folks. And we put that presentation out and then we put it out at SOMSA. But we had a conflict issue. We had courses going on last year. And this year we missed the deadline again. So, we're not going to present. Yeah, what we've seen is some units took the advice and started addressing the training issue at the unit. And SOM did not. And SOMT took it and have since changed personnel and changed emphasis on medical training. We've seen an increase in competency and then a decline. So, sorry, it's not just the straight answers, not just yes or just no. But there are things. Yeah, because there's humans involved, right? Yeah, they're messy, messy, messy humans. Yeah, and lazy. But so, let's talk about the units that have been successful. What did they change? Did they get your grade sheets? Did they ask for advice? Like, what did they do? So, while the grade sheet, the good news is $3.50, $29.00 got signed last year. And our grade sheet is in there. It's in the red. And on the back of the grade sheet, it lists the references in the Y. But it is published. It's there for anybody to grab hold of. However, I don't think that that's been the big. I don't think units have been downloading that and saying, "Oh, this is the thing." So, we had a dip with civil affairs medics and them showing up. And a common theme when we asked them was that they weren't getting training at their units. We started pushing this out across the formations. We had the same with AT Delta's. The people who were training and they kind of showed what people showing up while trained look like. You know, Ranger Medics Task Force 160, but we had civil affairs medics, 18 Delta's. And we had a few other medics that would show up. The Morsok guys tended to be somewhere between. And so, we put this out and didn't think it was going to be a groundbreaking news. If you don't train, you're not as good. I thought that was fairly fundamental. If you told an SF guy that, "Hey, I expect you to be competent with your weapons." "Oh, but you can only shoot them every two years." Nobody, no commander would accept that. But there we are. So, what we did, we had civil affairs that Rangers Task Force 160, they have a robust program, they maintain a robust training program. They're not the issue. Generally speaking, every formation has their folks. But, we had an issue, we put it out. And then we had engagement from their medical folks. And they even brought some of their commanders in to audit that come see. And then we spent some time with the civil affairs medical folks showing them how we set up and run a train lane. And they took that back to the unit and they ran training lanes. And we saw an increase in competencies. Now, I think we're kind of on a downslope again because they've had personnel change over people PCS. And I think we may be on a downslope. But that's something that we need to keep an eye on so we can inform. And I'm not talking about the instructors. Our instructors need to teach. But as our course, I see. And as the primary instructor myself need to look at those trends and communicate that. Our NCICs also communicate that with the senior medical staff at each of the units. I came in. We've noticed a drop off. Five of your last six people that showed up were really bad. We've seen a downward trend. What's going on? And have that conversation. We should be running our courses in a void. Like, hey, this is the course. We do this. Don't talk to me. You're distracting me from doing this. Now, we have instructors that do that. But the people that run the course, we need to. Need to be open and. Have those conversations with the customers, the organizations that I lose service. Yeah. I mean, it kind of a general theme. You know, range of medics. 160th. They have dedicated medics. Their job is to medicine in an austere environment. You know, civil affairs. SF, Marsock, I guess. They have, they throw in some extra jobs. And if you don't forget them. I did forget about them. Because they don't they don't have assigned medics anymore. They did away with the corpsmen that were assigned to seal teams that went through buds a long time ago. And now they they have their own course. And they have seals. They're seals first. And they go through some medical training. But the ones that maintain their ATP that show up in the field. The ones that show up in sockmas. They're a mixed bag. Yeah. I mean, as to be expected. But I would imagine if you're putting in the in the effort. As a as a as a as a seal. Medic. If you're putting in the effort to come back to sockmas, you probably have an interest. And you when you don't really have to necessarily anyway. I would imagine that they they seem like the type of people that would practice a little bit beforehand. Yeah. Yeah. So yeah, the other day overall not too bad. I did forget to mention the 528. I don't want anybody feel left out. 528. They're their medics. You know, again. Yeah, the mixed bag. They don't have as robust a training. Program for trauma lanes. Like we run. But they do. They are medics. Not not a. They do. They do. They do medical training. So it's not like Ranger 160th level when they show up. But it's not. Usually they're 18 delta. Yeah, or whatever. Sometimes sometimes they're pretty bad. But for the most part. Yeah, we're talking the average is here. We've never been part of the 528. So the medics that occupy that what would be what would be their role. I would imagine it's go get the patient and stabilize them so that the surgeon who's the main effort can do the thing. So, usually the patient gets evacuated to them. From an SF team or a Ranger, it gets evac to them. Whether that is a couple of hundred meters behind or off the objective, because they're like the ghost teams and all that back in Afghanistan, to receiving the patient that came in on the helicopter or vehicle miles away. So, they're going to be part of that team. They're going to receive the patient. They're going to do, you know, help the team address the needs of that patient, get them ready for surgery if they need it, and which if they're coming to them, they probably do. And, you know, we kind of work it like that. So, these people that do fail, especially their first lane, because that's probably the most honest look about how they arrived. Right? Is there first lane? What do they fail over? Like, not splinting or? Yeah, because now it's. The biggest things we see is they have problems with IVs. So, they have trouble getting an IV, which leads to if you have a patient that needs blood. Now, you don't have a route to give that blood. So, they'll fill the lane because they did not resuscitate the patient. The patient would probably have died because you did not do something that you're supposed to be able to do. Another common reason is delay of treatment. So, they don't get critical tasks done within the time limit because they're unorganized. They're not familiar with their kit. They're digging around. Their organization is in. They haven't practiced. They're out of practice. They're rusty. That compounds the failing IVs, not getting meds on. The medical administration, we see a lot of ice fell for that because they don't read the label. They draw up drugs. They yell out, "This many milligram!" And they didn't look at the label. And we actually look at how many CCs what the concentration was. And if you say, "I push 5 milligrams of versaid, but you push 5 CCs, and it's 5 to 1," you did not push 5 milligrams. You pushed 25. And in real life, if you do that, that could be detrimental to your patient. It's a very significant emotional way. So, that's what we give them. We give them those signs of symptoms. They don't do the things to correct. You damage your patient. You killed your patient. So, you did something that was detrimental to the patient. So, this is what we're seeing across the board, people that fail. But we just see it more in the first run. By the time they get to their second run, if they do a third run, usually their organization is a little bit better. They're tuned up. And if they make a mistake, it's a. It can still be one of those. But we're not failing people because they didn't get their Teachable C card filled out completely. Stuff like that. Yeah, we're trying to keep the criteria. What we're seeing is, yeah, people are showing up and the ones that are having the most problems are just rusty. And when you look at before you came here, the week before, you could have been pulled in that coach. And you could have had this patient. And this is how you did. So, that's kind of what that first run looks like. It doesn't have to be perfect, but there is a standard. We've tried to take as much subjectivity out of it. So, you have written standards. But that's what we're seeing. So, let's talk about those standards. Like you said, 350-29, they have the grading sheet. I guess how did you come up with that criteria that somebody deserves to not get their renewal based on what? Well, the course before that was pass fail and there wasn't a published standard. And what we're seeing was from small group to small group, there were differences in what that standard was. So, we wanted to standardize that. So, com was, did you hear that? Okay, sorry. Anyway, let me. Sorry, I turned that. Okay. But, yeah, the. So, com was pushing for some sort of recredentialing metric to measure. They wanted a written test. And then they wanted to develop some sort of metric that they could actually measure performance. And so, we got the instructors together and we decided to come up with a kind of a standard, minimum standard. And then we, we hashed out a lot of heated arguments. A lot of instructors are very passionate and they wanted the standard to be up here. I was like, oh, this is a minimum standard. We encourage metrics to be up here to aspire to be up here. But this is the minimum standard. Let's, let's keep it very basic and then very achievable. And then we hashed that out, pushed up to so com and they liked it. And they approved it and they published it. So that's kind of how that came about. So, I mean, I guess based on, based on what? So, like one of them, you have to get one unit of blood in within 30 minutes or the end of the lane, 30 minutes. Yeah. I guess. Did you guys just make up 30 minutes or? Actually, they were say prolonged field care, CPG, Stacey Shackleford was the lead on that. And it recommended, I think 36 minutes. And so we kind of use that. We've rounded to 30 minutes to get the blood in. What we did is we, among the instructors, we practiced that. And we found it with an IV, even with an 18 gauge or 20 gauge. 30 minutes is an incredible amount of time, long amount of time to get one unit of blood. You press your infuse that you can get it in five minutes, you know, or less. So, the biggest challenge is, what, when we developed a 30 minute standard, from signs and symptoms of needing blood, of hemorrhagic shock. So, what I didn't want was, you know, as an instructor, ha ha ha. Patients been bleeding for 10 minutes before you got here. You know, I got you. Now, 10 minutes into your 30 minutes and then, you know, go. And, well, we even want that. So, from recognition signs and symptoms, that doesn't mean you can ignore them. It's a sign symptoms or their screaming in your face. And, you know, the clock still on you. But it's from when you show up and should be recognizing those a clock starts. And, yeah, and so it's 30 minutes, if you're, if you evac before then, then it's still 30 minutes. So, but the way the lanes are designed, we usually go and evac before 30 minutes. There's a couple of scenarios where we do, and it's, you know, then there's, there's not, you know, that takes that into account. But for the most part, yeah, they're over 30 minutes. And, yeah, that's, that's, we got the standard from that CBG. I forget the name of it. I think it was DC or the DCR. Yeah. Yeah. Are there any other things that have like a hard line like the crack timing and things like that? Um, not a, a hard time. It's, it's kind of common sense. So if the guy's not breathing this airway is blocked. He's not breathing and he needs a crack. I mean, four to six minutes. Yeah. And if you, yeah, I mean, that's, that's real life. And so if you don't get that airway, Steve, Steve, no more. As, as we'd like to say, and then he deteriorates from there. And, and very quickly, you're going to lose your. patient. It's not that death is the punishment. It's a preventable death that is, you know, so if you should have done something, you're trained to do it, you're expected to be able to do it and you don't. That's where that's a critical failure. So other things, blood in before blood out, generally speaking. So what we found is that needle d's, finger thores, all of that, we've created training scores at the schoolhouse. We have signs, symptoms of advanced tension popping up within the first five minutes and triggering the student to do an intervention. When in reality, it takes, generally takes more time for attention to develop. So if they had other blood loss and they need blood, they probably need that before they need a intervention in the chest. So we try to set up the lane so that that's, that's the story it tells. Okay. You may have some, you may have a chest wound, the patient may have a chest wound, but not really have signs, symptoms of attention. Yeah. And then as the clinic progresses, they'll develop them and they'll progress, but his hypovolemia will progress faster. And if you look, the patient's signs, symptoms will talk to you and will lead you down that road to success. If you don't listen and you have this thing in your mind, I've got to do all the procedures or whatever, then you're going to have a harder time. What about things like the narcotics? I know like there's five, at least I've heard of guys failing for their five rights kind of violations. I guess what kind of criteria went into that? So I mean, there are some people are like, ah, six rights, so you violate those because that's what's in the course. Now, and I get that, but one of the six rights is documentation. Personally, I don't think that should be a hard fail. If you did not write it down, but you communicated it to the hand during the handoff, or you know, is that, is that going to kill your patient? Because you didn't write it down. If you gave the right amount, if they're off on their mask, if they gave the wrong amount of ketamine, ketamine is fairly forgiving. However, it's not the night. So if you give some crazy amount, then you're going to fail. But if you gave just a little bit over a little bit under, it's probably going to be a critique point. If you gave the wrong route, if you use something totally off protocol, hey, guys in pain, I'm going to give Verset. Okay, well, that's not appropriate. That's not going to help your pain or your patient's pain. So the patient's going to reflect that he's his pain's not relief. However, he may, may be in and out of consciousness, depending how much Verset you give. But he's still going to be in pain. He's going to give a pain response when stimulated. So those things, when you talk about your five rights, six rights, it's kind of a fine line, but it is, I think it's kind of common sense if you're causing harm to your patient, then there's a potential for failure there. Like the instructors themselves, you know, you get a new instructor, whether that be civilian or a green suitor, what does it take for them to before they actually get through to stand in front of students? You know, is it like you've got the, you've got the cert you went to the course, so you're good enough now or do they actually have to do something? Yeah, so the first step is selection of instructors. We're very fortunate that the command has allowed us, you know, right, a first refusal on, on instructor, so to speak. So if we get, hey, there's a new guy coming in, you know, what we look for is people that want to work in refresher. And then we want people who have a good reputation, people care. It's, it's, it's incredibly impactful. You see all the medics come through our course, our courses every two years. So you have a direct impact on those medics when they come through. And that's, that's incredibly rewarding, but it is, we see more students than probably the rest of the schoolhouse come on coming through. Our courses are much shorter. So I'm, I'm not saying that however, we do have a regular sock, miss 20 classes a year, yeah, whole of cow. So if I'm not refresher, 10 classes, but three weeks, three, three week course. So there's a lot of work that goes into that. And yeah, we want people to be aware and to want to do that work and put the effort in and put the work in. So recreating the, the right people initially. And then we have a train up program for that. Each course has their own train up program, but they're, they're kind of similar, but they are different because the courses are different. So with sock miss, there's a, a train up. So first you go through the courses for both courses. You have to go through the student. Go through and even if you came here six months ago, you go through the city and go through this is the latest update. Okay, boom, your search are updated. Everything's good. If you haven't gone to an instructor trainer course, we send you that at we get your A change instructor search updating and start doing the paperwork for that and and it start running you through. Now you're going to shadow an instructor. You're going to shadow an instructor. You're going to do that. And we'd like to have you shadow shadow more than one instructor. As instructors are different or we're not all the same. And you'll pick up different things as you shadow different instructors. And then when you're shadowing as you become more familiar, those instructors will have you kind of step in and do something instruction as we go along. We also have instructor train ups. So we'll have on a day where we don't have students. We'll run a trauma lane. You may go through as a medic. You, but eventually we're going to have you go through as the instructor proctoring the lane. And we'll start off with a base lane, a one of our like DCR lanes. You know, you guys got a partial lamp, gunshot wound, whatever. And stop the bleeding. View the things, but you've got a proctor that you build the lane and you procurate. So running through that usually the first time they run that, they kind of suck. I mean, so we run them through that. And then, you know, we do a couple of those and then have them introduce them to some non DCR lanes. And eventually we have them run a small group with a senior instructor with them to help even things out. And then eventually when we feel they're ready, their training wheels are off and they get to run their own. So sock miss, we, we spend a little more time training up because they're in the small group by themselves. As a FMS refresher, we can shorten that up a little bit because there are two instructors in each small group. So we get them to a certain level and then with the two instructors, the one that's been there longer will help the new guy buff things out. And we we end up spending about the same amount of time training them up when you look at calendar days because the course is longer. So when you're shadowing a course, you're shadowing for three weeks as opposed to two weeks. And so yeah, it kind of evens out. However, the sock miss instructor has to be a little more switched on because he's going to be alone and probably afraid running his small group when he's when training wheels come off. So I guess overall, one, are there any adjustments in the course that you foresee coming down in the pike in the future? Yeah, there's always adjustments. We're always tweaking things. So one of the so when we develop a standard for grading, the standard, the minimum standard, the minimum standard. there was four eighths, a student that failed to pass his two runs of the small group and we run that in a very specific way. So the instructor that runs that small group still runs the lane for a third run but he's not creating it. So the feedback's the same that the guy's been getting throughout but but that instructor is not creating it. Myself, our OIC, Cam Shelley, NC OICs and we try to have at least three instructors, senior instructors that are grading that lane and we're grading the student and we're also grading the instructor. So the first thing we look at after Lanhei did the instructor do anything that would mislead or misrepresent the scenario to the student. And if he answers no then we go into the student that they meet the criteria and so we don't know this you know we haven't been in a small group with the student we don't know you know we have no opinion of them. So we haven't developed any bias so we'll go on there and do that. So it's a it's a good honest look. It is nervous for the student because it is a third run and it's it's for and one of the things we we stress is we're not decredentialing you. We're just not renewing your credential, your ATP, your SO ATP. So if you have six months left on it it's still good for six months. We're not taking it. However you're not getting a a fresh date on it. You're not getting a new one you'll have to come back and try again. We we ask that you go back to the unit and retrain and come back in six months. You can come back earlier with a memo from your unit saying that you've done XYZ training and we'll do an exception and get you back in and and put you with a different instructor and you'll you'll go and hopefully do great things. But as far as changes coming to the course the standard for the other runs for run one and run two. We're working on trying to standardize that and what I mean by that is we're we've got the instructors involved in developing critical criteria. So we'll have a list of you know as we're going through we think of different scenarios, different wounds sets. What are the critical criteria? What should it be? And it's usually like okay if they didn't stop the bleed. Yeah massive hemorrhage they didn't stop it. They didn't put the turn it on correctly. They didn't put a turn it on whatever. And that is measurable by checking disciplines. If they didn't take away the disciplines it's still bleeding. The instructor gives a feedback that bleeding has not stopped. And if they don't correct that that's that's so that's a critical. If they don't secure their airway when it's indicated. So if there is a loss of airway. So if there's a loss of airway there is yeah you have a time limit to secure that. And if you don't then so these are you know kind of common sense critical criteria. And you know we have some pretty lively discussions and we'll on a second. Trying to turn this off. Okay. Sorry about that. Stupid signal chats. But so yeah we we try to look at the you know the criteria and you know people have opinions about hey you know this should be the criteria. And kind of my job is the okay why? Well it's obvious. No show me why. Show me why. Why? You know like the four to six minutes you know get an airway that you know that's supported by literature. That's not just my opinion you know that is like age a standard that is you know across the board you know you have to open airway or bad things happen. You have to stop the bleeding or bad things happen. So some of those are no brainers but I want especially some of the tougher ones is I want literature quality literature behind it. That way it's not just my opinion it's not just hey I think you should be doing this. It is look man hey this backs this up. So like the 30 minutes we took from the CPG and and you know we may have made it a hair stricter however after running not just our instructors but students through it and and ATOTs and stuff like that we've seen it is very very achievable. And if you don't hit that 30 minutes it's because other things have gone wrong. You have done other things wrong it wasn't sort of you could not get an IV. So you went I/O your I/O didn't work you didn't have a backup. So now you're back to trying IV or you know all these things stack up. But the standard gives us a hard one of the hardest things as small group instructors and we saw this just recently now instructors like man I had a couple of guys in my small group they ran really good lanes but they missed a critical criteria and I had to fail them and that's fine nobody no questions that but then I had this guy who ran a horrible clinic absolutely horrible but he just barely made the critical criteria and I have to pass him and he ran a horrible lane but the criteria is the criteria. So when we look at changing the course codifying that is you know the criteria is the criteria we have to develop that and so what we're doing is we're developing a menu of critical criteria for match up the wound sets for scenarios and you get to choose your own adventure as an instructor. So we let them know hey man let's put a cap on this you can't have 27 critical criteria in this lane that's I don't like this guy I'm gonna stack the deck yeah this guy smells funny. So we say hey limited to three critical criteria so if you have a chest wound okay I started to turn that off so if you have a chest wound it's is you know the critical isn't identified tree a chest wound because is that gonna kill them? The chest wound itself it's what what happens next so does he develop signs symptoms of attention is he bleeding internally is he you know the lung collapsing you know what's going on physiologically that's what's gonna kill. The gunshot wound the wound calls that but treating the wound putting a sticky on it is not gonna fix that recognizing the tension and treating that that's going to by time and until they can either get evac to something much more competent or you put a chest you've been if he ended up sitting on the guy because that's what he needs and so with that if there's signs of internal bleeding of internal hemorrhage the second critical that goes with that is give them blood DCR you want to resuscitate them with blood so that's that's two critical criteria if you have the internal bleeding part if your scenario doesn't you don't have signs symptoms and you only have one so now you can kind of choose how you build your lane okay I need a third critical criteria I'm gonna go with you know external hemorrhage I'm gonna go with an amputation or something like that okay there's three boom lanes done I've built this or you know so to have a menu for them to choose from with critical criteria that you know we've kind of sat out and hashed out once we hash it out which we're we're not even close to if we're going to have it reviewed by people not us people much smarter than us and have it reviewed and and once we have that set I think we're going to have a more consistent product when we run great at late that's key I think yeah that's one of the things going forward there there are other things that are are going on so but that that's probably the biggest the biggest thing is trying to trying to standardize the grading criteria materials or all the lanes and yeah, the cost for their harm you can kind of get into gray area with that. Yeah, definitely. Definitely. You cost for their harm, you fail. Yeah. You didn't put BSI on. Yeah. Yeah. Yeah, I don't know. But yeah, that's probably the biggest thing that's coming down the pipe at some point. We have to find time. Like I said, 20 classes a year for Sockmas doesn't leave a whole lot of time to develop these things. So the instructors work incredibly hard. And now that's where we're at right now. And I know that yeah, I was just saying, I know you can't wait to get into that conversation. Yeah. I guess. I think that should be a lot of fun. That's just because I'm a jerk. Awesome Rick. I really appreciate you coming on and walking us through this. Yep, I also work there. So I happen to have the inside scoop on it. But I think it's important just to be completely transparent that this is not just random stuff and opinion. We actually argue pretty hard. And you have jerks like me that like to throw a monkey wrenches and people's perfect ideas. But I think that overall makes things better. One of the things that you asked early on, you know, when we kind of danced around the failure rate, the actual failure rate has ebbed and flowed from, you know, 1 to percent to a half a percent. You know, it kind of ebbed and flowed right in between. I think it's more between a half percent and a percent that actual failure rate between the two courses as we go through. So it's not as I said, the standards not so high on the table, we don't have a high failure rate. Probably a 50, 60 percent first time run failure rate, first run failure rate and up and then as people go through, you know, knock the dust off the rust and they do just fine. So in the positive note. Right here exactly. Cool. Well, again, I really appreciate you jumping on and walking through this. Yeah, no problem. Thanks for having me. That's it for today's podcast. Make sure to go to our website, www.prolongfieldcare.org. Check out our free downloads and a ton of other helpful information. Grab a bag of our fresh roasted PFC coffee, links in the description below and stay on the bleeding edge of combat and austere medicine. Is it Dennis for the PFC podcast? Out.