Residents in a Room

Episode Number: 69

Episode Title: Military Medicine

Recorded: October 2024

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VOICE OVER:

This is Residents in a Room, an official podcast of the American Society of Anesthesiologists where we go behind the scenes to explore the world from the point of view of anesthesiology residents.

You put them on an airplane, and you have this extended travel time at high altitudes with someone who has a pneumothorax. And now you got to place a chest tube in an airplane.

How can we deliver anesthesia and pain services on the battlefield with just possibly a backpack?

Your anesthesia training, where you're able to be involved in that austere environment while also caring for a patient population that is dedicating their lives to our country.

MR. DONALD KEATING:

Well welcome back. This is Residents in a Room, the podcast for residents by residents. I'm your guest host today. My name is Donald Keating. I'm a fourth-year medical student at Kansas City University. I am also an HPSP Air Force student. I'm looking forward to this conversation today. We're going to explore the topic of military medicine, something that is very much so a passion of mine. I'm joined here today with Dr. Meade.

DR. ZACHARY MEADE:

Hi, my name is Zachary Mead. I'm a CA2 out of the Navy Medical Centers, San Diego, where I'm an anesthesiology resident enjoying the sunny weather.

MR. KEATING:

It is sunny weather here in Philadelphia today at ASA 2024. To help educate us. We're joined by Dr. Zachary Buccino and I'm excited to get started. So let's dig in. Dr. Buccino, can you tell our listeners today a little bit about yourself and a little bit about how you got here today?

DR. ZACHARY BUCCINO:

Sure. Of course. I'm Zach Bruscino. I currently work at Madigan Army Medical Center as a staff anesthesiologist. I just wanted to point out that the views expressed here, and my opinions here, do not reflect the DoD in any way, and they are not paying me or sponsoring me to be here for any sort of recruiting purposes. So yeah, I actually did my medical school training here in Philadelphia. I went to Thomas Jefferson University. I was also an HPSP student with the Army. Um, I went to a residency at the San Antonio Uniformed Services Residency Program, and then I just recently graduated, and now I work at Madigan Army Medical Center.

MR. KEATING:

Congratulations. Thank you.

DR. MEADE:

So what does practicing anesthesiology in the military look like? And how does that differ from our civilian partners?

DR. BUCCINO:

So honestly, at least at military treatment facilities, it's not very different than civilian practice. You know we we go and we treat patients, a slightly different patient population than the civilian world. Um, but, you know, we show up every day and we go into the ORs and we do very similar practice to our civilian colleagues, at least in the military treatment facilities.

MR. KEATING:

When you say different patient population, what does a military patient population look like? And kind of how does that differ from a civilian population?

DR. BUCCINO:

Exactly. So most of the patients that we treat are, um, beneficiaries, whether that be active-dutypeople who receive Tricare benefits or their dependents, as well as retirees who have Tricare benefits as well. Those are the majority of the patients that we treat. Um, at some of the DoD treatment facilities, um, like Madigan, um, as well as in San Antonio that have trauma designations, we do get some civilian patients as well through that system.

MR. KEATING:

Interesting. So you mentioned Madigan, which is in Washington. Is that correct?

DR. BUCCINO:

Correct. Yeah. Okay.

MR. KEATING:

And then San Antonio and Texas. So what other, um, areas do military anesthesiologists practice? And I think a common question is in terms of you kind of mentioned active duty, what does that look like in regards to maybe going abroad somewhere or being deployed somewhere? Um, if someone's interested in in military anesthesia, what are what are some of these places that they could end up?

DR. BUCCINO:

That's a that's a very good question. Um, so I would say most Military physicians work at the the military treatment facilities, whether those be at the big medical centers at, you know, like we talked about San Antonio or like Walter Reed versus like smaller MTFs at other places. But we can also work in some of the more broad bases that we have. A big one for the Army, anyway, is Germany. I know some people also get stationed in Korea at some point. But we also have a lot of military civilian partnerships with big academic trauma institutions. The ones that I know of now are at least Nashville, Vanderbilt as well as UNC Chapel Hill, I believe.

MR. KEATING:

I know for to my understanding with the Air Force, UAB, University of Alabama at Birmingham does some training with some military anesthesiologists. And then I think also maybe over in at UNLV in Las Vegas is some other medical centers on the civilian side that they partner with.

DR. MEADE:

Kind of along those lines, as a resident, I know maybe like your experience at BAMSI, we have to spend a large portion of our time going to other civilian institutions to get our training because our patient population is different. But how does that look like as an attending anesthesiologist in the military? Do you have opportunities to work at other places? How are you seeing a diverse patient population?

DR. BUCCINO:

So I feel like especially at the bigger med cens, you know, our population is very diverse already. The interesting thing is, you know, active-duty people have their co-morbid conditions, but the beneficiaries, you know, are very much similar to the civilian people that we treat with diabetes and heart disease and all those other things, as well as, one thing that people don't understand is that a lot of military people stay in the military for those benefits. People have like pediatric patients like these children sometimes can be very syndromic, and they stay in the military because they can get all of that care for that pediatric population, uh, paid for, um, which could be a huge burden on other people. So that's why they stay in the military. So we see a large amount of pediatric patients that have a lot of difficult and complex medical conditions.

MR. KEATING:

Interesting. Thank you for that. Can you take us through a day to day in the life of a military anesthesiologist?

DR. BUCCINO:

Sure. Um, so at least at our institution, you know, I'll probably get to work an hour or so before, you know, the first case are starting. Depending on if I'm working with, like, a student or not. I get the room set up, and then, you know, we still have a morning report that I go to, um, get to get a little academics. And then it's very much similar to how you would have in a civilian practice. You know, you do your cases. Um, at least at Madigan, we don't have a lot of add on cases. So kind of once your room is done, you kind of just check in with the front board and then you get to go home.

DR. MEADE:

So if I'm a pre-med student or even an early, you know, M1 and I'm interested in military medicine, can you tell me, like, what the pathway to that looks like?

DR. BUCCINO:

So there's a couple of different ways that people can get into the military system as physicians. Probably the rarest, but the most direct way would probably be direct commission. Going to any of these recruiting booths and just kind of signing up to to join as a physician. Um, like I said, that's probably the rarest way that people end up becoming military physicians. Um, probably the most common way, and the way that I've done and and you've done, is that HPSP program. Right? Um, where, you know, the the military will will kind of pay a lot of your schooling and then afterwards you would owe time after your training is done. Um, another way is going to the military medical school. That's another pipeline that a lot of people get into the military system through as well.

DR. MEADE:

Uh, real quick to that. Again, I should disclose my opinions do not reflect that of the United States Navy or the DoD.

MR. KEATING:

Same with me as well, yes.

DR. MEADE:

But I will say the pathway I took was a little bit different than all of those. And it's unique to the Navy in that it's called the HSCP program. Okay. Uh, most people have never even heard of it. But what it is, is you're an active-duty enlisted member and your place of duty is medical school. The downside here is they don't pay your tuition, but you are getting full benefits. You're getting a salary, you're getting healthcare. So if you're a prior enlisted, if you have a family, if you're planning on having more kids, that healthcare benefit and such, especially if you get into a cheap state school, might be a great route into military medicine.

MR. KEATING:

Interesting. And what was the name of that again?

DR. MEADE:

The health scholar collegiate program. HSCP.

MR. KEATING:

HSCP. And do you know, is that only available through the Navy, or do other branches have that as well?

DR. MEADE:

As far as I'm aware, the Navy is the only one that does. Um, there's a few other routes to maybe you've heard of the like, enlisted to USU kind of program where they put you through a prep school as well.

DR. BUCCINO:

I have heard of that. Yeah. Yeah.

MR. KEATING:

A prep school for. For what?

DR. MEADE:

So let's say you're enlisted, you're a corpsman, you have some college, but maybe you haven't completed all your prerequisites or something. The military will actually send you to get your prerequisites finished at the Uniformed Services University. Then, depending on your scores and how well you do, most of the time you're able to then ascend straight into USU or take a different pathway. Actually, at that point, you're still eligible to do HPSP, HSTCP or other pathways.

MR. KEATING:

Interesting. And for those of you listening, I think we've been saying hpsp. That's the Health Professions Scholarship program. It's through the branches of the Navy, the Air Force and the Army.

So there seems to be a lot of different routes that people can go to military medicine and military anesthesiology that we're kind of listing off here, and some new ones that I was unaware of as well, as for the residents that might be listening to this if they didn't do HPSP, um, if they wanted to get more involved in military anesthesia, would the next choice be that direct commission, or are there any resident programs that they can get involved in that you're aware of?

DR. BUCCINO:

As a resident, I do believe there is a program that you can commission and they would pay you some sort of stipend. You would finish off your residency, and then you would then become a military physician.

MR. KEATING:

Oh, interesting. This is it's something that you start, I guess, after you, you match somewhere and then you would start it for residency, I would assume.

DR. BUCCINO:

I would assume, yeah. I don't know all of the ways.

DR. MEADE:

Right. And if you just want to put the toe in the water with military medicine, the reserves is always an option as well. They can give you a stipend throughout medical school and definitely give you some good training.

MR. KEATING:

So are there any myths or misconceptions about practicing in a military context that you'd like to share about?

DR. BUCCINO:

Definitely, yeah. The misconception is we don't treat a diverse type of patient population, which in fact, I feel like we treat some of the most diverse patients in the sense that, you know, we're treating, you know, healthy, active duty people as well as retirees who come with their comorbid conditions, the peds patients, we deal with a lot of women as well in the military and their unique needs. So we deal with a lot of different types of patients who have unique needs. So I feel like that's always a big misconception is that we don't treat a diverse patient population, that we only treat healthy, young, active duty men.

MR. KEATING:

And I can second that as well. The rotation I did at Brooke Army Medical Center this past July for my active duty rotation in a sub I there I saw a wide variety of patient population. So I'm hearing a lot of similarities between a civilian anesthesiologist and a military anesthesiologist. I think one of the unique opportunities within military anesthesia specifically, is maybe some opportunities to get involved in some other areas of training that maybe some people here are interested in some level of operational teams or tactical training. Is there opportunities to kind of get involved in that for people who are involved in going down the military anesthesia route, but maybe want to not only use their skills on the medical standpoint, but are looking to get training in some of these other operational areas?

DR. BUCCINO:

Yeah, definitely. There's lots of combat operations or more tactical avenues that people can go through. From the Army side of things, I know we talked about doing like a joint medical augmentation detachment. Um, I know you can definitely go to a decent amount of the schools that the the Army offers. Um, airborne school, air assault school. Um, those are definitely options for people who are interested in those. Yes.

DR. MEADE:

What about the finances of being a military anesthesiologist? How does that work? And if I'm evaluating this as a career option, I mean, what would you what would you tell me?

DR. BUCCINO:

Yeah, that's that's a that's definitely a good question. I would say that in our current state, military physicians probably make significantly less money than our civilian colleagues do. Um, there are definitely different ways to, to kind of supplement that versus like doing, you know, locums on your own time. We call it off duty employment. But there's a lot of other intangible benefits with the military that I don't think people realize. Like having your medical care coverage. Um, having the VA loan to pay for a house is actually an extremely great program that is afforded to us. Um, as well as accruing a GI bill, um, which you may or may not want to pass off to your children. So I think a lot of people like look at the dollars and cents, very like straightforward, but don't look at all the other intangible benefits that you have in the military, as well as all of the other programs that we have and all of the other discounts and financial incentives we have through the military as well.

DR. MEADE:

Absolutely. I love my 10% discount. Um, I will say too, one of the best, I think reasons, in my opinion, that I've seen from my colleagues and the peers doing military medicine is the motivation to do it because you want to serve your country and really not doing it for the financial reason, because, um, if you just do it for a scholarship, I think you will lose the purpose of course.

DR. BUCCINO:

And, you know, like the the military, they call it, you know, the, the biggest fraternity in the world. And it really is, you know, you see people walking down the street when you're wearing your military uniform, people come and stop you and talk to you, and everyone wants to tell you where they served or how they served or what they did. So it's always a great way to, you know, meet new people and kind of network a little bit. And there's I can't think of any institution that hasn't had at least one current or former military physician.

DR. MEADE:

Absolutely.

MR. KEATING:

I agree with that. And that's something that I talk to people about as well in regards to some of these scholarships that are available, is that if you are doing it solely for a financial benefit or you're trying to make the numbers work, you're never gonna have a good time because there's a lot of training that goes into it. There's a lot of paperwork that you have to deal with. You have to have some level of interest in serving your country. And if you do have that, then it becomes a very unique opportunity to be around a group of people who have high values, strong morals, determination, selflessness and get to be around an elite class of medical professionals and operational professionals in a great community. And that stays with you throughout the rest of your career and the rest of your life.

DR. MEADE:

Absolutely. And what other anesthesiologists can say they get paid to jump out of airplanes occasionally or something?

DR. BUCCINO:

Very true.

MR. KEATING:

So that's that's actually a great thing to kind of hone in on jumping out of airplanes. So you, Dr. Buccino, kind of mentioned earlier, airborne school, air assault school. What what are these schools? Is this something that you have to take extra years, like a fellowship or something that you have to go to school for? Or is it a school that you're actually kind of learning some of these skills that we're talking about--jumping out of airplanes and things of that sort? Can you kind of expand on that? Because that seems really interesting.

DR. BUCCINO:

Yeah, definitely. Um, I will say, although those are options, you also have to get like your command to let you do that, and getting them to let you do that is hard, because it's not specifically built into what we do on a day to day basis. Like like when you're deployed, you're not being deployed jumping out of an airplane, like they send you in an airplane with your bag, and you go and you drive over to where your base is. And and that's how it really works. You have to negotiate for the schools. Yeah. So there's like a little bit of give and take about it.

MR. KEATING:

Yeah. That's that's very true. There are very few anesthesiologists that probably also have their wings to be able to do that. Speaking of which, actually, can we talk about some of the unique places and things that military anesthesiologists have that might be unique to the military? I've heard of different austere environments that, uh, different medical professionals in the military get to practice in. Dr. Buccino, can you maybe share some of your experience in practicing in different places?

DR. BUCCINO:

Yeah. Of course. You know, as a military physician, we have to be, you know, ready to practice medicine pretty much anywhere in the world at any given time. So we do a lot of training, and we do a lot of different types of missions to help us prepare for these austere environments. I know personally, I was able to do a medical mission trip to Honduras when I was a resident, and it was an extremely austere environment. Um, a lot of the disposable equipment that we use, just throw away, they were reusing and cleaning because they don't know when their next supply of things are going to happen. And, you know, they had to change the way that they practiced. You know, how a lot of cases we would do under general anesthetics. You know, they did a lot of cases with neuraxial techniques, like it's easier to do a spinal anesthetic--you just need a drug, some antiseptic solution, and a couple of needles versus a general anesthetic where you need a ventilator and you need more invasive monitoring and and waste system. I know specifically when I was in Honduras, the waste system was essentially just a duct plugged into the wall that I'm pretty sure didn't go anywhere because I got a huge headache while I was doing the one general anesthetic we did there. So.

MR. KEATING:

Were you a part of a greater medical team? I assume there were, there were some other medical professionals there. How did you get involved in the medical mission to begin with?

DR. BUCCINO:

So that's a good question. Um, we used to do a lot more of them before Covid happened. And I know at Brooke Army Medical Center, where I went to residency, we were trying to kind of reestablish those. So we were making, we were making ties with Honduras and their army to try to build better relationships. So specifically, the mission trip I went on was just us as anesthesiologists and anesthesia residents working with their surgeons and and their people. But a few of my other friends went to a different place in Honduras, and they brought their own surgeons and they brought their own equipment. And so they were doing cases for the local people with their own surgical unit, essentially.

DR. MEADE:

So the, I haven’t done this yet, but the Navy has the ships, the USS mercy, USS comfort, um, and you get to deploy on those and see all these different things. And some of my, you know, staff have told me stories of they go to these countries and you can operate on the ship with your own equipment, but then also you go to the local hospitals and you and you teach and you operate there. And they were telling me they saw this propofol and it was it was yellow. And they were like, guys, I think this is expired. We can't use it. And and they were like, well, then we're not going to operate today. So like we use it or we don't. Exactly. Yeah. And that's it. Right. And they're using like things like Halothane. That's one of the unique things that you'll probably won't see much on the civilian side.

MR. KEATING:

That's fascinating. I know from the Air Force standpoint, there are different operational teams that Air Force anesthesiologists can get involved in, one of which is a highly trained medical staff and operational staff called SOST, which stands for Special Operations Surgical Teams, which is a highly trained elite group of medical professionals, usually a general surgeon, emergency medicine doctor, an anesthesiologist, a critical care nurse, a respiratory tech that will deploy with special operations teams to, um, be able to set up an OR just in in a tent with the things that they can carry on their back. And because they go to medium to high level threat areas, you also get an intense amount of tactical training and firearm training. So for anyone who's, that sounds interesting to you, there's that route to go as well as well as something called Seacat, which is critical care air transport teams, which more or less I've heard it described as an ICU in the back of a plane.

DR. MEADE:

Seacats are awesome, and the people who do that are great. And that's another, I think, unique thing about military medicine is we have these bases everywhere, right? Like Okinawa, Japan, all these places, and we have to take care of them. But those hospitals aren't equipped, you know. They're not level one trauma centers. So when things like that happen, sometimes host hospitals also can't take care of these troops. So what do you do? You put them on an airplane and you have this extended travel time at high altitudes with someone who has a pneumothorax at 30,000ft. And oh, yeah, you didn't recognize that until you got to 30,000ft, and now you got to place a chest tube in an airplane. And then, you're receiving that person, right? That was just in the air for like 12 hours. And they did in-flight refueling. Like, it's just pretty crazy.

MR. KEATING:

It really is. And there's few opportunities, probably with your anesthesia training where you're able to be involved in that sort of austere environment while also caring for a patient population that is dedicating their lives to our country, or being a part of a humanitarian mission where the US is able to come in and really help make a difference. I think that's one of the most incredible benefits of being a part of military anesthesia. And so with that, how do you see, Dr. Buccino, military anesthesia evolving over the next couple of years?

DR. BUCCINO:

That's a that's an absolutely great question. Um, so as we move towards more peer to peer or near-peer warfare, we need to adapt and evolve how we're going to deliver care on the battlefield. We're not going to have conditions where we have absolute air superiority, where you can pick someone up and bring them off the battlefield and treat them at the drop of a hat. We're going to have to learn how to treat people on the battlefield, but then also hold them for possibly an extended period of time. So we have to be able to figure out how can we deliver anesthesia and pain services on the battlefield with just probably a backpack? Like, how are we going to be able to do that? I don't think we're quite at the time where we can answer those questions yet, but we definitely have a lot of people thinking about it and trying to figure out, like, what is the best way to deliver medicine when you can't just grab somebody and bring them out of the out of the fight?

DR. MEADE:

So I feel like what you just described, in my opinion, makes an anesthesiologist an absolute invaluable asset, because we were one of the few specialties where we can take care of a patient in the operating room and then continue taking care of that same patient in a critical care role outside of the operating room. Right?

DR. BUCCINO:

Correct. Yeah. The military definitely highly understands that anesthesia as a specialty is highly coveted, and we have to try to keep the people and train the people to do anesthesia as much as possible. They really value us as a specialty and our role to play in in future and current fights.

DR. MEADE:

Absolutely. I mean, if I was, you know, if I was in charge and I needed to I had limited space, right? I needed a role for critical care and an anesthesiologist and a surgeon. Right. Like one person can do two jobs, like exactly. Picking them. They're on my team.

DR. BUCCINO:

Definitely.

MR. KEATING:

Well, I think that's a great place to wrap up here. This has been a fascinating conversation. Thank you, Dr. Meade, for being here with me and Dr. Buccino. Thank you for letting us pick your brain on on military anesthesia. And thank you to our guests and our listeners for joining us here today. Please tune in again for for more Residents in a Room, the podcast for residents by residents.

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