Angry Planet - The Life of a Special Operations Physician Assistant

Episode Date: April 24, 2018

War is a bloody business and few people know this better than the medics, physician assistants, and assorted battlefield doctors. Since Vietnam, the U.S. has gotten a lot better at saving the lives of the fallen.This week on War College, we talk combat medicine with Andrew Fisher. Fisher is a physician assistant with the U.S. Army’s 75th Ranger Regiment. As a participant in more than 600 missions, Fisher knows first hand how to save lives on the battlefield and, with the help of his colleagues, pioneered new life saving techniques.You can listen to War College on iTunes, Stitcher, Google Play or follow our RSS directly. Our website is warcollege.co. You can reach us on our Facebook page: https://www.facebook.com/warcollegepodcast/; and on Twitter: @War_College.Support this show http://supporter.acast.com/warcollege. Hosted on Acast. See acast.com/privacy for more information.

Love this podcast? Support this show through the ACAST supporter feature. It's up to you how much you give, and there's no regular commitment. Just click the link in the show description to support now. So that was our whole goal. If someone's injured, man, I'm not going to cut them open out there. I'm not a surgeon. I can only do what we can consider damage control resuscitation.

You're listening to War College, a weekly podcast that brings you the stories from behind the front lines. Here are your hosts, Matthew Galt and Jason Fields. Hello, welcome to War College. I'm Matthew Galt. And I'm Jason Fields. War has changed, and Battlefield Medicine is still catching up. Upwards of 25% of deaths in Vietnam were preventable with the right pre-hospital care. Unfortunately, not much has changed during the early years of the wars of Iraq and Afghanistan. Andrew Fisher is a highly decorated physician assistant in the U.S. Army.

As a PA for the 75th Ranger Regiment, he saw combat firsthand in Afghanistan and knows better than most what bullets and bombs can do to the human body. He's here with us today to talk about battlefield medicine and the little understood importance of the tourniquet. Andrew, thank you so much for joining us. Thank you, gentlemen. Happy to be here. So first off, I want to ask, were you drawn to battlefield medicine, or do you think it kind of picked you? I think it kind of picked me. I certainly didn't initially envision myself heading down this path.

I had enlisted in the early 90s as an infantryman and was then assigned to the 75th Ranger Regiment once I passed the selection process. And by chance, I just happened to be sent to an EMT course. And it was there. I kind of found my desire to work in medicine. So I feel like it kind of came to me versus me kind of seeking it out. You know, I was just kind of fortunate at that time. We were training.

We take infantrymen in the 75th Range Regiment. We send them to an EMT school or EMT course, and they will then come back, and they would be able to assist the medic, the platoon medic company medic or whatever, with battlefield casualties. And it was kind of ahead of the time, you know, kind of ahead of where we are from what we've been doing now, what the conventional

forces do, and utilizing the infantrymen as kind of like that first line provider versus what we kind of see in the conventional forces at that time. Of course, I think they are the conventional forces are trying to catch up now and do some similar training within some units. So kind of drawn out a story there, but yeah, I kind of felt that was my path to medicine. Can you elaborate a little bit on the differences between what you were doing then and what the normal infantry were doing at the time? Well, the, like I mentioned, so we would send the 75th Ranger, we would send one person per

squad to an EMT course with the goals of coming back and being able to assist the, the platoon medic, whatever roles or task need to be done in the pre-hospital phase of combat casualty care. And we're obviously the EMT train at that time, and it still is based on a civilian model of medicine, which isn't necessarily applicable to what it happens in the pre-hospital phase of combat medicine, but it still kind of gave us the a little bit of medical knowledge and a little bit of understanding of what needed to happen in order to care for casualties. So we were able to kind of follow some of the basic direction that the combat or the Patoon medic gave us. But we weren't that full spectrum combat medic like as they kind of filled that role. The conventional forces at the time did have a combat lifesaver program, which is still being used today.

And essentially, that is a 40-hour block of instruction where they're kind of taught, back in those days, kind of a condensed version of maybe an EMT class. So it's a very, very brief overview of kind of just basic first aid care. And back in those days before we were the, you know, before tactical combat casualty care came in, it was more about, hey, let's start some big IVs and, you know, let's, you know, maybe put so you can put a chest seal on, maybe we're going to do needle decompression. But it wasn't necessarily about, you know, identifying and treating life during hemorrhage as we're doing tactical combat casual care. And like I said, the EMT course I went to wasn't necessarily focused on that either, but certainly we had more training than some of the conventional forces. So were you also carrying a gun at the same time? If you were in combat, did you just have a medical bag, or were you also fighting at the same time?

So your role as an EMT within the regiment at that time, and still today, is, you know, you packed on some extra equipment and you can. When the medic needed you, you went. So, yeah, I still had, it was just an extra duty. I'm sure you guys are, everyone was kind of familiar in the military about some of the extra duties that everyone has within, within a platoon or a company or even within a squad. You know, maybe, you know, maybe you're, you know, carrying the demo or, you know, whatever, whatever else role may be assigned. It's just an additional duty that that squad member had to carry out and besides, you know, the regular duties as infantrymen. So, yes, I carried, I was actually a sawgunner at the time. So I lug that around along with some extra medical stuff.

That's a lot of gear. Oh, man, I'll tell you, they didn't make it easy on me, that's for sure. What kind of changes have come to battlefield medicine since the opening of the Afghanistan War? Let me start back a little bit, just a few years earlier, that in 1996, Dr. Frank Butler and colleagues had published a supplement in the Military Medicine Journal, and it was titled Tactical Combat Casual Care and Special Operations. And this supplement, it was a pretty long, substantial supplement. And there, you know, they went back and they kind of looked at the data from Vietnam. They kind of looked at some previous conflicts, some overall, you know, military deaths, military medical data, and kind of came, decided that there were three really big preventable causes of death in combat,

and specifically in the pre-hospital phase of combat. And this had already been kind of outlined in some previous studies, but it certainly hadn't been updated to kind of reflect what we were doing in the mid-90s. And they identified that the three leading cause of rental death were massive bleeding from an extremity, airway obstruction, and tension with oryx. And when I say tension with oryx, I mean that you get this any sort of trauma to your lung that makes it collapse and you build up a whole bunch of pressure on the chest and you decrease the amount of blood return to the heart and overall that's what kind of killed you. So those are the three leading causes of

criminal death. And what he did is he published this, like I said, in the military medicine journal. And there wasn't a whole lot of people got to kind of picked it up. You saw the 75th Ranger Regiment pick it up. You saw the seals pick it up. You saw some other units in special operations. But overall, there wasn't a whole lot of interest in it. And then we get to 9-11, and this happens, and we still don't have a whole lot of interest. We did have in 2001 the development of the Committee for Tactical Combat Casual Casualty Care, but you didn't see at the unit level a whole lot of support for this by conventional forces. And so as we enter into the battles or the wars in Iraq and Afghanistan, we see that we're starting to have casualties.

We're starting to see people die and we're starting to recognize as we look back at some of this autopsy data and these preventable deaths. studies that would eventually come out that people were dying from bleeding. And we saw that in the early GWAT, we saw that even in special operations, there was up to 15% preventable death rate. And we saw within the conventional forces that about 25% of the deaths were potentially survivable or preventable. And so that kind of spurred some kind of, you know, interest that, hey, maybe we can do something about this.

and then we had the development of these commercially made turnicates that really made things a lot easier because before then we saw a lot of improvised tourniquets. And even it wasn't really talked about and recommended to use tourniquets a lot. As we saw tourniquets become more available and we saw the tactical combat casualty care guidelines kind of be pushed out to the conventional forces. And you saw actually a lot of great success in some of these units that really took it seriously. was a unit out of third ID on the invasion of Iraq that that was noted that they didn't have a single preventable death or death from hemorrhage and such because they they had been using tactical combat casual casualty care. So we saw the like I said we saw the kind of implementation of the cat and soft tea tourniquets and the the tackle combat casual combat casual care

guidelines and we started to see a big drop in death from bleeding. And this was kind of outlined that, hey, Ternicus do save lives. John Craig published this in 2008, 2009. We saw Brian Eastridge published this stuff in 2011. And that's kind of a big study that people often references Colonel Brian Eastridge's data from 2011. But there was still some significant death, but certainly not as much as within the first, you know, four to five years after 9-11. I mean, so that's really dramatic.

So overall, if we look at, say, before 2000. and six. We saw that overall death from extremity bleeding was 7.8% of all battlefield fatalities. And once we saw that with the increase in availability

tourniquets, we saw the implementation of the tactical combat casualty casualty care guidelines, that this death from external bleeding decreased the 2.6% of all battlefield fatalities. So overall

that was a 60% there was a 67% decrease in deaths from extremity hemorrhage. So that's very significant that we were able to kind of get that implemented. We saw that drastic change. It's just unfortunate that it took until about 2006, you know, like I said, four to five years into the conflict before we really started recognizing the fact that, you know, using tourniquets and being able to identify and treat like they're in hemorrhage was, you know, you know, would have to happen.

And you yourself pioneered some life-saving, some new life-saving measures on the battlefield, correct? Can you tell us a little bit about that? I was able to kind of help build a program within the Department of Defense that is still becoming more prevalent and has now started to become being used within the EMS system here in the United States. And that is the Group O low-tider whole-blood program. What I did with the help of Ethan Miles, the Colonel Andre Cap, Lieutenant Colonel Jason Corley, Colonel Audre Taylor, and Colonel Sean Kane was we developed a program using some of the programs from around the country, from different countries, and also looking back to our World War II and Korean War data, to where we said, hey, if we can identify all our group O people, our typo blood people, which is roughly about 40 to 45 percent of the United States. United States population just by statistics.

So I can take those people, and of every one of those, I can then test them for a low amount of antibodies in their blood. And if they have a low amount of antibodies, because we know we consider group O like the universal donor. Well, that's usually talks about red blood cells. But if we have whole blood, the plasma has antibodies in it that can sometimes react with your patient. So, but if we have a low amount of the antibodies and then I can test them, I can identify those people, then I can have a list with me that says, hey, these are my universal group O low whole blood donors.

And so we took this idea and we put it into practice. And what happened was we didn't transfuse any fresh old blood utilizing this protocol because it sometimes takes a while to kind of draw the whole blood and then administer. it. So we probably had maybe a couple casualties that maybe could have received the fresh whole blood. They did receive the plasma in the pre-hospital setting, which we've been carrying since 2011. So they didn't, they, nothing, there was no bad outcomes or anything, but certainly they, they may have benefited from fresh whole blood. So what we did was the results of why can't we just ship the whole blood from the United States over to Afghanistan? So we did. We developed this program where we took the whole blood that they drew, they drew all the donations up in Fort

Lewis, and then they packaged it up and they shifted to us overseas. And we're able to carry it on missions with this, just like any other cold blood products. So when you store things like packed red blood cells at a temperature of 1 to 6 degrees Celsius, so if I put in a cooler, I can take it on target and I can administer it to the critically wounded casualties. And I did that. I did transfuse the first unit in March of 2016. And this has become significant. So they have transfused hundreds of units of this whole blood because it's now spread

throughout the entire DOD. And we're starting to see on Medevac helicopters. We see it in the role twos and the role threes and the caches and these little surgical teams. We see other special operations units doing this. So it's become a very big program within the Department of Defense. And like I said, we now see it within the EMS systems in the United States. So in Houston, there are two ambulance services that are utilizing the same exact concept of using this cold-stored group O, low-tider, whole blood in the pre-hospital setting. And we also see in San Antonio within the helicopter service there.

So it is a very, I'm very proud to be a part of that development and actually continue to work on the program and try to make it better and try to make it. make it where everyone should be able using this. So there's no reason why the conventional medic shouldn't be carrying whole blood in his aid bag, just like I can within the special operations community. There's no reason why this can't be everywhere. Will you tell us what it's like to be a PA on the ground during combat? Yeah, yeah. So being a PA within the military, you don't usually find yourself at the point of injury.

You don't usually find yourself, you know, carrying your weapon, you know, with all your kit on just next to, you know, the regular infantry guy. But we say that in the 75th Range Regiment that you are Ranger first and then whatever your job is second. And you're expected to do the same things everyone else does. They also expect you to, you know, be able to perform. at the point of injury and be right next there. They have a lot of great trust in their PAs. Of course, a lot of great trust in their medics too. But it's just something else.

It's just another part of what I think makes the regiment great and have to be part of it. There are other units that do the same thing. So we're not the only ones, but I feel that it's not a regular thing that happens on a regular basis. I felt like having the experience of the information. infantrymen, although I never deployed or went to combat as infantrymen, I felt like I had that unique understanding of what I was supposed to do, or better yet, what I wasn't supposed to do as a PA. So I knew what the infantrymen was probably supposed to do, even though it had been many years since I'd been infantrymen.

So I knew where I probably shouldn't be. And that kind of changed over the years as I became more comfortable and worked with different patoons for a significant amount of missions. You know, some of the, some of the tunes I probably did, you know, 100, 150 missions with them. So I really felt, you know, close to them. And I understood their TTPs and how they were going to, you know, conduct themselves on targets.

So I would then position myself in different areas to where I felt like I would be the most benefit. And sometimes that was kicking indoors. in the lower, you know, lower risk areas, but that would free them up, you know, free the regular infantry guy up to go and, you know, take care of business where it's the most high threat was. So it was a lot of fun to be part of such an organization to where they had trust in me to be able to do things that wouldn't normally be done by IPA. And I felt comfortable knowing that I, this is where I shouldn't go and I shouldn't be doing this, but I know I can do this and I can benefit the platoon and I can benefit the mission by doing this.

And sometimes, you know, yeah, you had to pull the trigger when the time came, but it was often rare, but it sometimes had to be done. I took care of a lot of guys on Target and that's just part of the job. I work with a lot of great medics and we develop a lot of great programs, a lot of great rapport also to be able to kind of take care of these guys and expedite their care along the way to make sure that they got back, you know, to the surgeon. Because that was our whole goal. If someone's injured, man, I'm not going to cut them open out there. I'm not a surgeon.

I can only do what we can consider damage control resuscitation. So I can only do my best to stop the bleeding and then resuscitate them a little bit in order to get them back to that surgeon who's going to end up, you know, providing that definitive care. So it was a great experience. I loved every minute of it. and I'd probably still be doing it if I didn't feel I was so old and kind of probably getting a little past my prime out there, but it was certainly exhilarating, and I had a lot of fun doing it. Well, it was almost, you participated in,

if the information in front of me is correct, almost 600 combat missions. Yeah, definitely over 500. I'm not sure. I'm somewhere between 500 to 600. Yeah, so again, they really relied on their PAs, And when I was, you know, in Kandahar, you know, there were seven other patoons across, you know, three different, three different outstations. So three different areas, helicopters would be going out every night.

And, you know, because I worked hard, I developed the relationships, and I was shown to be an asset, I believe, I felt I was an asset to the platoon. I would be put on the manifest to go on the mission often. I never took the place of a medic. And I think that's important that, you know, as a PA, I didn't take the medic's place. The medic, that was that medic's platoon. And if there was only room for one medic, that meant the platoon medic went. I was there to augment what the platoon medic did. I was there to augment and benefit the platoon as a whole and make the mission a success.

Could you explain the difference just real quick between a medic and the PA? Sure, yeah, yeah. So, you know, as a PA, I went to the military's PA program or a physician assistant. And the military's program is a bachelor's to master's program. And, you know, the PA provides about 80% of the primary care for the Army. I don't know about the rest of the DOD, but I wouldn't be surprised if it was similar. every unit has or most units have PA assigned to them and they're responsible for overall the health and welfare they're in charge of medical training for the unit and you know so I'll see patients you know in the clinic prescribed medications x-rays the right consults and just like you would see your family doctor is sort of similar now PA does have a physician oversight within the Department of Defense

So I had a battalion surgeon. If I didn't have a battalion surgeon and I would have in congressional forces, I would have a brigade surgeon, a physician who could oversee my practice and ensure that I was doing the right thing, which is always had a great relationship with the physicians who I worked with. A combat medic, specifically within the regiment, we had the special operations combat medic, and they would go to a school at Fort Bragg. once they pass our selection process, first they went to the AIT, which is several weeks long to where they become an EMT there, and they take some additional training, and then they go through our selection process, and then they would go on to the Sockham course. And at the Sockham course, it's about depending on when you went, anywhere seven, nine, ten months long, and there they learn some advanced anatomy and physiology.

They learn a lot of great stuff about trauma care. And then they go out and they go do clinicals at big city EMS systems and these big trauma centers so they can learn to really become experts at trauma care. So the difference is, you know, as a PA, I'm a practicing provider and I do a lot of more in the conventional kind of sense, I do more of just taking care of the unit and ensuring that they, you know, stay healthy. In the deployed setting, I'll do sick call, and sometimes they kind of mourn these small little outpost where they can kind of take care of people, where the combat medic is the one who is usually going on the missions. You know, they're with the boys every day providing that continuity of care.

So when their boys come up to the sick call and say, hey, this is my guy, he's got this and this and this going on. So they really provide a lot great continuity care beyond just being, you know, real trauma, guru. there at the point of injury. Why don't we pivot and talk about tourniquets? Because that's been, that's kind of something that you are now known for, is you were a big tourniquet advocate. Why? And why do you think tourniquets have gotten such a bad rap?

So if you look back previous to the T-T-T-T-T-T-T-T-T-T-T-E stuff and the implementation of it across the board, for many years, we were told how tourniquets were bad and if you apply a tourniquet, you're going to lose your limb, you shouldn't, you should only apply it as a last resort

to be able to control hemorrhage and this is a lot of stuff that we do or I should say that we did medicine was based upon bad studies and poorly designed studies and bad

anecdotes and poor observational information And so we kind of learn that by using a more what we call evidence-based medicine to where we kind of look at the data and we look at the outcomes, wherever the desired outcome of the study is, or whatever the desired outcome of whatever I'm doing, and I kind of then make scientific conclusions, you would think that would be regularly happen in medicine, but for many years it wasn't as well designed and well upheld as you might think. So for many years, no one used tourniquets. Well, you know, we'll teach you how to use a tourniquet, but you're never going to apply one.

I remember being in a combat life's and recourse back in the early 90s, and we were taught how to put it on tourniquet. I remember, I think even in basic train, they taught us how to do the tourniquet. But again, it was don't use it because if you use it, you're going to lose your limb. I remember getting out of the Army and working as a paramedic saying, you'll never use a tourniquets. They're not good. They're not safe. You'll probably lose your limb. You know, you're going to have ischemia and you're going to have compartment syndrome and everything is going to have bad outcomes and such.

Well, we found that historically that we used to have them, but then they kind of fell in favor. And then we saw that we know they use tourniquets and orthopedic surgeries, right? So if you go do certain orthopedic surgeries, they're going to put like a turniquet on your arm and it's going to be up for a long time, like much longer than we leave. a tourniquet on and a regular tourniquet. They are slightly different tourniquets, but still, they put on tourniquets in the OR for a long time, and there's no bad outcomes. So this all goes back again to Frank Butler's paper where you said, use a tourniquet in order to control massive hemorrhage.

And like we talked about, 7.8% of all battlefield fatalities were due to extremity hemorrhage early in the war. And it was then that we implemented these tourniquets. And I'll tell you, a lot of great work from Colonel John Craig, Colonel John Holcomb, and a lot of great people down at the ISR that kind of took all this data from the use of tourniquets in Iraq and Afghanistan and kind of said, hey, we can, we actually are saving lies by utilizing these tourniquets. So we know tourniquets, these commercialized turnics are good for two hours. And most people are not, don't have these turnicits on for nearly that long. And so what we saw was that was we implemented this program within the DOD. Now we started seeing these big studies happen here in the United States because we've been in war so long

and we have all this great data about trauma deaths and hemorrhage and all this stuff that a lot of people here in the United States, civilian medicine, started doing the same. And there was a study in 2016 that demonstrated that up to 20% of the trauma deaths of the United States are potentially survivable if they had, you know, the right care, which the right care is optimally going to be aggressive hemorrhage control. So taking the data we know from Iraq and Afghanistan and saying, hey, turnics are safe, and taking the data from the 2016 study that said that, hey, we got a lot of deaths from bleeding. So we need to utilize kind of merge these together, I guess, and say, hey, we need to do the same thing

we did in Iraq and Afghanistan and do it here in the United States. There was a, there's a program called Stop the Bleed. And this is a program and initiative that was developed to kind of inform and kind of educate and train the bystander to kind of serve as those immediate responders, just like, you know, the average soldier at the point of injury could be able to, you know, put a tourniquet on their buddy. Now we have, you know, we're training these people in an hour to two hours. how to identify and then treat, you know, that life during hemorrhage.

So we teach them, hey, put it on a tourniquet. We know it's going to be safe for two hours. And beyond that, so we also teach them also to, you know, you can pack a wound with a hemistatic agent or, you know, if you don't even have, if you don't have some sort of fancy, you know, medical dressing or gauze and you can use your clothing. Or, you know, we teach them out of, you know, put direct pressure on these wounds in order to control the hemorrhage. So it's really applying what we've learned over the years and here the United States and really trying to get more people involved because still there's a lot of

people out there that don't understand how to put on a tourniquet or not even aware of the programs out there that train people how to put on tourniquets and how to identify the massive bleeding and then treat it appropriately. So it's a passion because I don't want to see needless deaths to the United States. There's no reason why someone should ever bleed out from an extremity ever in combat or here in the United States. If you look at what we did in the regiment, where we taught every single person how to identify and treat the three leading causes of preventable death in combat, we have zero preventable deaths. So no one died in the regiment due to what are those three major causes, which again are life-threatening hemorrhage,

airway obstruction and tension in with orax. So the DOD may still have some sort of preventable death rate, and it's kind of hard to say what it is at this point. But, you know, we demonstrate that if you teach everyone, you can eliminate preventable death. So we need to teach everyone as many people as possible how to identify and treat that life that ain't hemorrhage. Andrew Fisher, I think that's a great place to end on.

Thank you so much for coming back on. Yes, thank you, gentlemen. I really appreciate it. That's our show for this week. Thank you so much for listening. War College is me, Matthew Gull, and Jason, Jason Fields. Our website is warcollege.colle. From there, you can follow us on Twitter at war underscore college

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