Central Line

Episode Number: 141

Episode Title: Military Medicine

Recorded: September 2024

 

(SOUNDBITE OF MUSIC)

 

VOICE OVER:

 

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

 

DR. ADAM STRIKER:

 

Welcome to Central Line. I'm Dr. Adam Striker, your host and editor. Today, I'm very excited to introduce the guest that we have with us, both medical officers in the United States Navy, Dr. Brian Brenner and Dr. Jeffrey Carness. We're going to learn about practicing anesthesiology in the military today.

 

And a disclaimer for this episode: the views expressed in this podcast are those of the guests and do not reflect the official policy or position of the Department of the Navy, Department of Defense, Defense Health Agency, nor the US government.

 

We have the perfect guest with us here to educate us. So, Drs. Carness and Brenner, welcome to the show.

 

DR. JEFFREY CARNESS:

 

Thank you so much. Thank you for having me.

 

DR. BRIAN BRENNER:

 

Thank you. Excited to be here.

 

DR. STRIKER:

 

Well, I'm excited for this conversation. I think this is something, surprisingly, we haven't really covered yet in our podcast series. I think this is going to be a great topic. I think it's really important for the rest of our listenership to be able to access some of this information.

 

Before we get started. Do you mind both telling our listeners a little bit about yourselves, your roles and your pathways, how you arrived to where you are? Dr. Brenner, let's start with you.

 

DR. BRENNER:

 

Sure. So my name is Dr. Brenner. I'm a lieutenant in the Medical corps in the US Navy. I'm currently a staff anesthesiologist at Naval Medical Center San Diego. Uh, grew up in a Navy family in Pensacola, Florida, where I went to college at the University of Florida. Uh, joined the Navy back in 2016 via the Health Professions Scholar program, where I was originally commissioned as an O1 upon entering medical school at University of Virginia. From there I did officer Development school, an annual Navy trainings before I entered residency. I was selected for the what's called the Navy Active Duty Delay for specialists, or NADS program for my residency in anestheseology where I was placed on IRR, Individual ready reserve status, while I was finishing my residency at UVA, where also served as a Chief Resident. I'm currently working in the anesthesiology department at Balboa, as we call it, teaching medical students and residents. My other duties include being assigned to the platform known as Casualty Receiving Treatment Ship Team Eight, where I'm an anesthesiologist ready to serve aboard one of our amphibious assault ships if the need comes. Luckily I have not yet, but I feel I've been fortunate to have an experience both in the military and civilian health care systems, and hope to get to answer some questions about their similarities and differences for you all.

 

DR. STRIKER:

 

Great. Dr. Carness?

 

DR. CARNESS:

 

All right. So my name is Jeffrey Carnes. I'm a commander in the United States Navy, and I have been in the service for about 26 years now. Did six years in the Marine Corps before I jumped ship and joined the Navy. I went to medical school at the University of Texas Medical Branch in Galveston. Did my anesthesiology residency at the Naval Medical Center, Portsmouth, and then completed a critical care fellowship out at Brigham and Women's Hospital in Boston. And I'm currently working as a critical care anesthesiologist out here at Madigan Army Medical Center. And you heard that right. I'm a Navy anesthesiologist at an Army installation, so I'm kind of really enjoying it out here.

 

DR. STRIKER:

 

Excellent. Well, let's start off around the history of military medicine, military healthcare, specifically anesthesiology, how it's evolved. Dr. Brenner, from what I understand, you're a little bit of a history buff, so I'm hoping you can share with us a little bit of information - how the concept of military medicine has evolved over the years.

 

DR. BRENNER:

 

Sure. So it's a very broad question. I'm going to try my best to make it relatively linear and interesting.

 

So back in 1775, before the Declaration of Independence was signed, the army established its first military hospital, which interestingly had an apothecary on staff back then. A few years later, after the Revolutionary War had ended, the Navy kind of ended its operations before we were officially the United States of America. And it wasn't until George Washington led the effort to establish a permanent navy in 1794 that any of these things that would be practiced now kind of became more prevalent. So it was, interestingly, during the War of Tripoli, when Jefferson kind of spearheaded the effort to not give in to ransom demands for pirates in the Mediterranean, kind of messing up maritime trade, that the Navy really began its first test internationally, including hospitals and hospital ships. One such ship, the Intrepid, was our first unofficial hospital ship. That was a small vessel retrofitted to disguise casualties that were coming back from the front. It wasn't until the mid 1800s that the Navy created its official Bureau of Medicine and Surgery, where we officially had roles managing Navy hospitals. And it wasn't until the Civil War that we had our first official hospital ship, the Red Rover, which actually patrolled the Mississippi River, treating patients on both sides of the Civil War conflict up to over 3000 at the end. Interestingly, during World War Two, the majority of hospital ships were operated by the Army, and their main purpose back then was to transport wounded soldiers across the ocean for definitive treatment, which is one big difference from Navy hospital ships that have always been designed to be fully equipped hospitals to receive, diagnose, and treat casualties and also support frontline medical teams, not just evacuate patients. After World War Two, we learned a lot. President Truman and the country saw a need for robust medical services for service members at home and what we call a ready medical force in the event of regional or global conflict. And that was when the first male doctor draft was enacted in the US. And from the mid 50s to the mid 70s, doctors had a two-year service agreement where many served as staff physicians. Here, researchers and frontline doctors during the Korean and Vietnam War. Since then, military service for physicians has been voluntary, but the government still collects information on civilian doctors who could be called to serve if needed. In 87, Congress approves the Healthcare Personnel Delivery System, which gives executive power and legislative power to draft doctors within weeks if needed.

 

You know this altogether is just really important for US practicing physicians and anesthesiologists, especially to understand kind of where medicine has come from in the past of our country and the goals of our healthcare system that, you know, some of them may be called up in time of need, if that were to arise.

 

DR. STRIKER:

 

Well, Dr. Carness, do you mind talking a little bit about the differences between practicing anesthesiology in the military versus what civilian practice might look like?

 

DR. CARNESS:

 

Of course. So I think it's super interesting. And of course, like many of our civilian counterparts, we work at hospitals. We call them military treatment facilities. And we engage in anesthesia care delivery in any number of different places, just in our civilian counterparts do. So we go to gastroenterology and the plastics clinic and the urology clinics and MRI and CT and ER and the main operating room and the labor deck and all all over the place inside the hospital. So our practice there oftentimes looks very similar to a practice that would be seen at a civilian hospital.

 

Where it begins to differ, I think, is when we report to a new unit, when we check in, then we're assigned a billet--it's essentially a title--attached to some operational unit. And when we attach to that operational unit, then we find ourselves attached to maybe a small team, like a damage control surgical team or a fleet surgical team, or we might find ourselves attached to a field hospital or attached to a hospital ship or something else. And so then we're required to train with that unit. And, and that may be aboard ship or that may be setting up our field hospital out in the field. And that requires a little bit of extra expertise. And also if our unit that we're attached to ends up going to the gas chamber, so to speak, for training, or if they go on a hike or if they go to the range, we too go with them and we practice those skills. So it does definitely require some extra expertise, I think. And this this requires an additional degree of physical fitness. They require a specific body composition. They test us every year on these things.

 

And that's because oftentimes when we are activated in support of military contingency operations or something along those lines and we have to go forward, then we may be required to provide austere anesthesiology. And I've had the fortune of bouncing around to a couple of different institutions across the country and talking about posterior anesthesia care provision, and that some of it goes back to our joint trauma system, which was a quality improvement system that was started back in 2003, 2004, and we tried to improve the trauma care delivery that we had going forward. So they created any number, I think there's probably about 70 or 80 clinical practice guidelines. And one of those also touches base on austere anesthesiology. And so what we find that we are called upon to do is dependent upon how we are going to get to the patients. And so they've created what they call a ruck truck house model. So are we going to find our patients using a rucksack and everything that we take with us, all of our consumables and everything goes in a pack on our back? Or do we have a truck? If somebody's actually going to lift us to the location where we're going to find these patients, or is it going to be a house? And we think of that as a fixed structure. And so if we're going with a pack, we have fewer consumables and less capability. If we're going with a truck, we have more. And of course, in a fixed structure we're going to have our greatest capability. And so these are things that we think about. So not only are we providing anesthesia care in a hospital in the traditional sense, but then we have all of this additional knowledge that we take with us going forward. So I think it's it's very different in this regard. And that's one of the reasons why I think of military anesthesiology as its own subspecialty of anesthesiology.

 

DR. STRIKER:

 

Well, let's follow up a little bit on that. Dr. Brenner, do you mind elaborating a little bit on what kind of career paths are possible for those that are in the military practicing anesthesiology. Dr. Carness mentioned the necessity of remaining physically fit. So it's interesting because A, how long can you realistically spend in the military practicing this way? And then along with that, what kind of career paths are available for those that have come from the military background?

 

DR. BRENNER:

 

Sure. And Dr. Carness, feel free to chime in. He's much more of an expert in this area than myself, but so I kind of have thought about it, especially since I had training and residency in the civilian world, that there's multiple practice environments like Dr. Carness was alluding to, where you can be at a large treatment center that has residents, medical students and other learners. And in that sense, you kind of take on an academic role teaching. You can also get an appointment with the military medical School Ussu out of Bethesda, Maryland, to have those resources and support from the greater USU Anesthesiology Department for Faculty Development, that sort of thing. So it can look very academic in some facets and for some part of your career. It could also feel very like rural private practice-y. If you're the only doc that's hundreds of miles. For example, if you're stationed in Guam, you may be taking care of the patients that are civilians in that area of the world as well.

 

So, you know, we can get placed in multiple different locations in the world where we practice seeing different pathologies that, you know, maybe we didn't learn about in medical school necessarily. So there's some aspects of being adaptable and having to learn how to interact with a global health system when, you know, maybe you're receiving patients from another country, you know, how do you interact with that? That's kind of an interesting thing.

 

Also, the other half of our job, other than the traditional anesthesiologist role in the operational side, is that we're military officers and like all military officers, many of us end up in leadership roles where we have to lead teams of other officers or enlisted sailors and Marines to achieve objectives of the Navy. And that can be many different things: readiness, fitness, medical readiness, that sort of thing. So many of us get kind of put into leadership roles just because we're military officers. And for those of us that choose to serve and use this as a career, many of us develop and gain roles, leading departments or other groups of sailors and marines, which is kind of interesting.

 

DR. STRIKER:

 

Yeah, certainly. Dr. Carness, do you have anything you want to add?

 

DR. CARNESS:

 

Well, I think that's that's exactly it. There's, there's quite a bit of opportunity and it really just depends upon how you want to tailor your career. So we have our academicians, we have our clinicians, we have our executive medicine individuals who are targeting more of that leadership role in our hospitals. We have our health staff and our medical staff within our hospitals, and we cover down on a lot of the same requirements that you would find at a normal hospital with our different committees and our, as we call it, our medical executive committee. So there's any number of different opportunities. And I think it's it's just interesting to note that anesthesiology in the military encompasses probably about a little over a thousand providers. So if you think about a given practice being 50 or 60 providers at a large tertiary care facility, and in our military anesthesiology, we have, um, probably a little over a thousand, inclusive of our CRNAs and our anesthesiologists combined. And so there's really a lot of opportunity, and you can tailor your career to to what it is that you want to do. And the the military recognizes that you may not just be a primary clinician, and they give you time for that, which I think is is really great.

 

DR. STRIKER:

 

Yeah, absolutely. Well, Dr. Brenner, the ship you're currently serving on the casualty receiving treatment ship, can you take us inside that a little bit? Explain how it works. From what I understand, this is fairly new to you, but, um. Is this what you expected? Is it surprised you at all? Just give us a little bit of insight into that, if you don't mind.

 

DR. BRENNER:

 

Sure. So I think what we're alluding to, this is the platform that I'm assigned to that, like Dr. Carness had mentioned, is one of my dual responsibilities as a military anesthesiologist and officer. Um, so I'm on casualty receiving treatment ship team eight, like you mentioned. These are medical teams that get activated in medical times of need that would exceed normal operational medical capacities on our amphibious assault ships. Um, think things like regional or global conflicts, humanitarian effort, natural disasters, or exceptional events like an astronaut retrieval or something like that, where there may be an atypical anticipated medical need from normal operational requirements. Um, LHD amphibious assault ships are warships primarily. But as Dr. Carness has recently written about and I'll reference what he calls these are role two maritime medical vessels that have medical capabilities to remove, diagnose and stabilize patients so we can get them effectively transported safely to our dedicated role three hospital ships, or rear area hospitals, such as Naval Medical Center San Diego, where I currently work most of the time providing for definitive care.

 

For reference, these LHDs can accommodate up to 600 patients at a time. Uh, the ship's corpsman also provide routine medical and dental care for the crew, and also embarked personnel with them. Uh, these ships have four operating rooms with two emergency ORS and x ray blood bank labs and provisions for patient wards. In comparison to our rule three hospital ships like the Mercy Dr. Carness has served on, these are dedicated hospital ships that have 12 operating rooms and can manage up to a thousand patients at a time.

 

Fortunately, thus far, I've only been engaged in training, preparing for deployment readiness for this aspect of my job. If the need comes for my CRTs team to be activated, I'll be ready. But the majority of my day to day role right now, this time is at Naval Medical Center San Diego.

 

DR. STRIKER:

 

Okay, Dr. Carnes, how was it working on the Mercy Ship?

 

DR. CARNESS:

 

Well, you know, I think it was an excellent experience. It was just a wonderful opportunity to provide some humanitarian aid while we were out there floating in the South Pacific. We went to some more remote areas, some underserved areas of several different countries, and we found any number of different patients that were out there with chronic conditions that had been there for years, that they've been suffering from for years. And we were able to provide direct anesthesia care, direct surgical care, and alleviate some of that suffering that they were dealing with from their conditions.

 

It was super interesting because they they were a little bit more remote, so they didn't have access to an adequate amount of preventive health care, if you will. So they would show up with very little preoperative evaluation. And we didn't have a whole lot to to do for them preoperatively. There was a making an assessment or a judgment on our ability to safely provide anesthesia care for them based on some vital signs. The use of translators in discussing their histories and their employment of point of care ultrasound. And it was interesting to see them in different stages of convalescence from any number of different illnesses that we don't see too much over here in the United States.

So patients that were suffering from dengue fever and convalescing, or patients that were convalescing from malaria, an increasing amount of tuberculosis in the area. So it was a it was a really wonderful experience.

 

Of course, being on the ship, it's a it's a deep draft ship. So we weren't able to get up skinny to get into some of the areas that would have facilitated probably a little bit easier movement of patients since we had to have some logistic foresight and we had to think, how do we get these patients on board the ship, and how are we going to disembark them from a floating dock onto a water taxi to get them back to shore? But being on the mercy itself, they do have 12 operating rooms. It's kind of interesting because you have to think about the differences of being in essentially a floating operating room. So so the operating room tables are strapped to the deck, the anesthesia machines are strapped down to the deck to make sure that nothing is moving or going to run away from you. And we have an oxygen generating plant which takes liquid oxygen and converts it into gaseous oxygen. And so we have your normal pipeline oxygen as you would think about. We have our normal volatile anesthetic capability on board. But if that were to go down we have it's not just E cylinders, but we have the large H cylinders. And maneuvering some of those large beech cylinders into place. And then ensuring that they didn't present a danger to to our staff was also extremely important. It was a it was a little difficult at times to to move and maneuver them and to move them around.

 

So it was definitely a different kind of experience. What I would say is that we did employ a lot of point of care ultrasound when we were ashore, which I think was wonderful, to have some individuals that had that kind of background and skill set. And we certainly used it to help us to rule out and found some interesting pathology. But unfortunately, we were unable to provide anesthesia services and surgical services to a few patients based on some of our findings with point of care ultrasound. So it was it was just it was a remarkable experience. And if I had the opportunity to do it again, I would do it in a heartbeat.

 

DR. STRIKER:

 

Now, you don't have to be in the military to serve on the mercy ship, is that right?

 

DR. CARNESS:

 

So there's two different types of mercy ships. I think there's the Mercy Ship, which is a humanitarian organization that does civilians. And and then there's the USNS mercy, which is the hospital ships there. The crew of the USNS mercy is a civilian crew. So they're the ones that are sailing the vessel, so to speak. But but all of the what we call it, again, a medical treatment facility. So it's like a floating hospital for us. And that's how we look at it. The individuals that were on the floating hospital, they were serving in, the capacity of clinical care providers, were all military members.

 

DR. STRIKER:

 

Okay. So it's a different Mercy. The one I'm thinking of.

 

DR. CARNESS:

 

Yes, sir. Okay.

 

DR. STRIKER:

 

Gotcha. Well, um, what do you both think about the collaboration of the different branches of the armed forces? For instance, neither of you works in the Air Force. And how integrated are they? How collaborative are they? Just like to get your thoughts on on how how that all works. Uh, Dr. Brenner, let's start with you.

 

DR. BRENNER:

 

Sure. So I guess starting with, like, medical school, the Armed Forces medical school is not one specific service. It's tri service. And you could commission into the Navy, Army or Air Force and be a physician and train at the same medical school and then go do, uh, residency at various different locations. But I think the big thing, and Dr. Carness knows this very well, working in an Army facility currently, but is that we're trying to integrate care for our service members so it's easier for patients and family members of patients to navigate care in this system. That's one big facet of it. I think that's been a goal of DA's since kind of grabbing the reins of the management of a lot of our mtfs. And what I mean by that is we've created like an electronic medical record that could be used in Yokosuka, Japan, or in Germany. And, you know, if the closest facility for an airman, for example, is a Navy hospital, we could have their records, treat them effectively, and get them back in the fight or back where they need to be safely. Um, the second facet of that is going to be operational aspects that Dr. Carness knows much better than I do.

 

DR. STRIKER:

 

Dr. Carness?

 

DR. CARNESS:

 

I think that's exactly it. You know, we're looking for interoperability. We're trying to encourage this collaboration and the sharing of expertise between the Air Force anesthesiologists and the Navy anesthesiologists, Army anesthesiologists. We call it going purple. So if you think about the Green Army and the navy blue navy and that white blue Air force, we're trying to blend those three colors together and we call it going purple. And so we have certainly we have our anesthesiologists that are familiar with provision of care on some of these air platforms, like our C-17s. They're the critical care air transport teams, and we have our individuals that go out to sea and are more familiar with the provision of care on a large deck amphibious vessel. And so there's certainly a degree of collaboration that has to occur if we’re ever in one of those large scale conflicts. Or if there ever is a significant event, a large scale natural disaster, that we're called upon to utilize all of these services together. And I think that's what we're moving towards. So I joke around with my colleagues that I'm still looking for my ship here at Joint Base Lewis-McChord, here in Washington, because I can't find it. And but it's just, you know, helping to to blend and come together.

 

And I think Dr. Brenner said it perfectly in terms of our electronic medical record systems and our and our equipment. So imagine if you had a patient and they sustained some significant injuries requiring surgical intervention and intubation, and now they're sedated and intubated. And maybe they need plus or minus and and you have your pumps and then an aircraft lands to take your patient and you roll up and your pumps aren't the same as the pumps on the aircraft. And your consumables aren't the same as their consumables. And now you're taking time with this unstable patient that you're trying to quickly mobilize and move and evacuate from this location. And here you are. Okay, well, let's set up new pump. You know, we'll set up your consumables on your pump. They'll switch over from mine. And if we can, we can find a way to streamline that transport as much as possible. I think that's going to be to the benefit of all of our service members. So that's that's the goal for the future to to try to blend the services both operationally as well as clinically back here in the States.

 

DR. STRIKER:

 

Yeah, that makes sense. Going back to the differences between civilian anesthesiology and military anesthesiology, Dr. Brenner, is there anything you wish that we not in the military understood better about what it is you do?

 

DR. BRENNER:

 

Sure. Um, yeah. So, like I said, I did residency at a civilian hospital. And the biggest thing that comes to mind for me is for our civilian colleagues, understanding that, you know, there's a distinction between veterans like VA anesthesiologists and military anesthesiologists, it's a different system. So, you know, I think a lot of my colleagues, when I was training thought that I was going to work at a VA and didn't understand some of the facets that, oh, you know, you're not just going to be working at a veterans hospital or just taking care of 20 year old Marines. I think, um, a big thing for our anesthesiologists practicing out there is that at these big military treatment facilities especially, we take care of a, you know, broad, uh, breadth and depth of physiology, pathology, patient populations. We're taking care of current active duty service members, their families, uh, retired service members. So we see the extremes of age. Obstetrics, really everything. And services depend on the facility. But overall, I think the patient population is more diverse than many civilian anesthesiologists think we may take care of. And also that, you know, a large portion of our role is, as we've kind of alluded to, preparing for the potential need to deploy with one of our platforms in assistance of our sailors, Marines or other service members.

 

DR. STRIKER:

 

Before I get to my follow up question, Dr. Carness, is there anything you want to talk about with regard to what we should know on the civilian side?

 

DR. CARNESS:

 

Well, I always talk about the, and again, just to reiterate, military anesthesiology being a subspecialty in and of itself, recognizing that austere anesthesia care provision is is very different. And we actually train our resident physicians while they're in the operating room to also think about, okay, well, this is how we're doing the case here, and we're stateside and we have all of these resources available to us. But how would you do the same case if you were forward, if you were in the Middle East, if you were on a small team, if you let's say you didn't have Rocuronium or you didn't have Succinylcholine and you were using Vecuronium, does that change your plan? What if you didn't have fill in the blank this you don't have a video laryngoscope, you only have the capability for direct Laryngoscopy does that change your plan? How would you approach it? And what if you don't have blood or how would you get blood?

 

And one of the things that that I like to talk about is how we think of ourselves as one part nurse, one part pharmacist, one part physician. And that's very, very true when we're providing care and we're forward, because oftentimes we are the ones who are responsible for our narcotics, and we're responsible for all the medications. So you essentially show up and they give you your narcotics, and you take accountability for them and you maintain that chain of custody. But on top of that, you're also looking at whatever kind of medications, pharmaceuticals that you have available to you, and then also looking at aspirations and how the quantities and resupply and considering how you're going to get more. It's not something as simple as, I'm just going to pick up the phone or talk to my perioperative nurse and ask them to call the pharmacy to get me what I what I want or what I need. But this may actually be something that I'm just not going to have, or something that might not come in and I might might not have access to for anesthesia care provision. So something that we have to think about is the pharmacist in us. But then also, as the nurse, some of our patients, when we care for them, then we might not have immediate medical evacuation, requiring us to actually care for this patient for a period of several days. And then during that time, we have to think about things like wound care, and we have to think about bathing the patient. Do we have to think about IVs in the patient, whether or not we're circulating IVs. And do we have enough consumables for circulating IVs at the 72 hour mark like we're supposed to or like, as is often times the case in, in any number of civilian hospitals. And so that's that nurse part as well that we have to think about in combination with our physician anesthesiologist role. So so I think we put all of those things together. And I think it's just very different in that practice. So that's that's why I just express and stress that military anesthesiology seems to be a subspecialty of its own.

 

DR. STRIKER:

 

Along those lines, what I was going to follow up with is, demographically speaking, of the military anesthesiologists, how much extra subspecialty training, aside from the military piece do your colleagues have or yourselves, whether it's pediatric or obstetrics, um, neuro anesthesia, cardiac, etc.?

 

DR. CARNESS:

 

So so I think every year we have a joint service graduate medical education selection board, and we're given a certain number of billets to attend to any number of different fellowships. And and of course, we always want more. We always wish there were more, but we are restricted in terms of how many folks that we can send to fellowship, but we still have the entire collection of all of those subspecialties. So we have cardiothoracic trained, critical care trained, obstetric trained, pediatric trained. We have pain anesthesiologists. We have folks that have done trauma anesthesiology fellowships and, um, just all all across the board. We would always be happy to have more. Undoubtedly. But but I think we have a good selection of some specialists.

 

DR. STRIKER:

 

Okay. Well, my last question to both of you, and Dr. Brenner will start with you. What is next for military anesthesiologists? How do you see these roles evolving, the military evolving as it pertains to healthcare. What do you think?

 

DR. BRENNER:

 

Sure. So one thing that's fascinated me about military medicine in general is just how, over the years, this cohort of physicians and researchers have always innovated out of necessity to solve unique problems that have faced our country, our service members and our patients. And my hope and things that excite me is that going forward, we continue that foundation and use it to, you know, continue to do things like, how do we shrink ventilators to get them closer and closer to the patients, and how do we help take care of these patients who come back and have disabilities from their time in service and help them live meaningful lives with chronic pain they may develop? Or how do we keep patients alive longer and safer in the intensive care unit so we can get them back to their homes and families? And I'm sure just based on the history of what we've been a part of and what we've seen over the past couple hundred years in military medicine and military anesthesiology, will continue to push the envelope and hopefully be people on the front line solving some of these problems for our patients and our nation.

 

DR. STRIKER:

 

Dr. Carness?

 

DR. CARNESS:

 

I agree. I think that mortality on the battlefield has dropped substantially, and I think it it decreased from Vietnam and certainly has decreased over our time with Operation Iraqi Freedom and Operation Enduring Freedom. And I think that our joint trauma system and our clinical practice guidelines and our improvement in the application of technology has significantly decreased that mortality rate. And I hope that we continue to to decrease that mortality rate.

 

I think one of the things that we have to do is we have to combat what we call the peacetime effect. So we have any number of individuals that gain a certain amount of experience in providing care for these combat wounded individuals. And then we enter into this period of peace time, which is what we all desire. But then that skill set starts to atrophy a little bit. And so we we have to find ways to, to maintain that skill set. And I think we're going to see more engagement and more relationships with our civilian counterparts. We refer to them as military civilian relationships or mil-civ relationships. And I think we're going to see more of those. I think we're going to try to move forward with pushing our military anaesthesiologists into those tertiary and quaternary care facilities, trying to get them involved in more trauma care delivery in those large facilities so that we can maintain that skill set that is so important. We always say that we never want to be fighting the last war when the next war occurs. And so we need to make sure that we are maintaining throughout and combating that that side effect.

 

I don't think that anesthesiologists in the military are going anywhere. We call them a critical wartime specialty. So I think that they will continue to be needed for years and years and decades to come. And but I agree with Dr. Brenner that we will find new ways and innovative ways to provide care, and we will hopefully find new technologies. And I alluded a little bit to point of care ultrasound and video laryngoscopy. And now they even have new devices that are trying to combine video laryngoscopy, point of care ultrasound and vital signs machine. Get them small enough, put them in a pack and really move that care delivery closer and closer to to the point of injury to decrease that mortality rate moving into the future. So I think that's what we're going to see.

 

DR. STRIKER:

 

Well, that's an excellent point. Hadn't thought about that with regard to skills keeping up whether it's peacetime or wartime. Uh, very interesting but makes perfect sense to try to vary the experience during those lulls, if you will, where your acute skills need to be kept up.

 

DR. CARNESS:

 

Yeah. And a great case in point is where we brought blood administration into World War Two when we learned that patients are military injured or combat injured, patients did better with blood administration than without. And then we moved into Vietnam and we had fractionating of our blood products as our blood system came online in the late 60s, if memory serves me correctly. And then we identified that they still did better with whole blood, but we were fractionating our products. And and then we moved forward into OIF and OEF. And we're still learning that patients just do better with whole blood. And I think the trauma systems across the United States are starting to see that. And there's some additional low tide or whole blood that's being administered in the setting of trauma and trauma resuscitation. And when I talk about that, because that seems like something that we learned, and then the folks who learned it move on, and then we forget to and then we relearn it, and then maybe we forget a little bit and then we relearn it again. And so what we're trying to do is, is hopefully maintain that skill set, hopefully maintain that knowledge. And there's a program right now that we've created within the Department of Defense through the Uniformed Services University looking at knowledge, skills and abilities. How do we maintain that knowledge? How do we maintain those skills and abilities, and how do we combat that peace time effect? So I think it's I think it's an interesting topic discussion for the future.

 

DR. STRIKER:

 

Yeah, absolutely. I mean, as is usually the case in a lot of these podcast episodes, we could talk for hours. So hopefully we can get you guys back in the future to talk about some other aspects of your practice. But this has been a fantastic conversation. Um, so not only thank you for joining us, but certainly want to say thank you for what you do every day, not only your service, but also your expertise that differs so much from what we do on the civilian side. So thank you both for for all those things.

 

DR. CARNESS:

 

Yes, sir. Thank you so much. It's been wonderful chatting with you, and I look forward to potentially chatting with you guys more in the future.

 

DR. BRENNER:

 

Yeah. Thank you guys so much for having us. This was an awesome experience.

 

(SOUNDBITE OF MUSIC)

 

DR. STRIKER:

 

Well, and hopefully we get to see each other soon and talk soon. Thank you for all our listeners who have tuned in to this episode of Central Line. Please don't forget to leave a review or some comments, or tell a colleague about the podcast and tune in again next time. So thanks again. Take care.

 

VOICE OVER:

 

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