Episode 060: Healthcare in the Line of Duty - Part 1

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Brian: Thank you for joining us today, my name is Brian Fortenberry and today we are going to be talking about military medicine, something that we have not talked about a lot on any of our podcasts. We have the great pleasure today to have Dr. Missy Givens with us. Thanks for being here.

Dr. Givens: Well, thank you for having me. I consider it a privilege that I get the opportunity to talk about this topic.

Brian: And we are honored to have you with us. Before we even get started really, Dr. Givens, tell us a little bit about yourself, your background and what you've been doing over the last number of years.

Dr. Givens: Well, I'm entirely 100% a product of the military medical education system. I'm an emergency medicine doctor by trade, I was completely trained by the military. I went into the military academy for undergrad, I went to the military medical school for medical school, I've done all my specialty training in the military. Throughout my career I've kind of served in both hospital settings, but then for deployed with combat deployment I served the special operations community and the conventional forces community. So kind of gotten the entire flavor of military medicine.

If you would've asked me 30 years ago did I think I would still be wearing a uniform and doing this, I would have laughed at you. I'm very, very proud and happy with my career in military medicine because taking care of US service members is definitely the biggest honor and privilege I've had in my life. So, I get excited to be able to talk about it and share it with others.

Brian: Right off the top I would like to tell you and certainly all the other physicians and military people, but certainly having this opportunity to speak with you, thank you for your service and all that you have done for our country and our military. How is talking about military medicine relevant to the civilian community? Is there a tremendous difference in how the medicine is practiced? Or is medicine just medicine?

Dr. Givens: Well, I think good medicine is good medicine, and one of the themes we try, and follow in military medicine is one of my favorite things is we're the best at providing good medicine in bad places.

Brian: Yes.

Dr. Givens: But due to the unique nature of what the military does and its mission, we do have some differences. Specifically the trauma system when we're in a forward deployed environment it tends to be pretty massive penetrating trauma that's just incredibly devastating, and a little bit different than trauma here in the US, which tends to be more blunt trauma type things. Again, our operating environment is such which we're often very resource constrained and often have prolonged transportation times and things like that, that challenge the system that make it a little bit different than medicine here in the US. But you could probably find some of those circumstances if you look hard enough in different corners of the US. So, I think there are differences, but there is a lot of similarities and I think if we don't learn from each other, if the two systems don't talk, we're missing an opportunity to really find best practice for everybody.

Brian: I absolutely agree. I think there has been so many different industries in the past that have learned from innovation on the front lines of things like that. I saw something the other day where a lot of the innovative parts of our automobiles today, in particular the safety parts of that, came from like the race car industry. So, they learned a lot from that. That being said, how is the military healthcare system set up to drive innovation or change that has kind of, either in the past, come from the military and found its way into civilian medicine, or anything on the verge of maybe the future that you could see that happening with?

Dr. Givens: Well, we can track all the way back to the world wars in innovation that came out of the world wars, and even back to Napoleon and ambulances. It was ambulances that came out of the Napoleonic era, so warfare's been driving medical innovation for longer than you and I have been around. I'm very partial to the Vietnam era because that's where emergency medicine came about. It was after the Vietnam war that they recognized a need for a specialty that was able to kind-of resuscitate patients and take care of patients in that emergency setting. So, that came out of the Vietnam war.

As you look towards our modern wars, there were so many innovations in the last, you know we've kind of been at war for about 17 years now, so the last one and a half decades there has been just so many advances, and I can't even begin to name them all, but I can give you some perspective. When we look at advances in civilian practice, for a new innovation to go from concept to implementation in the civilian market it averages somewhere between 17 to 20 years.

Brian: Wow.

Dr. Givens: In the past decade and a half of war, we've had upwards of 20 major medical innovations that have started as an idea and are now fully fielded and showing success. So, the system that the military operates under is unique in that it gives a controlled environment to first collect data to see if there is something that needs and innovation, is there a problem, is there an issue, is there an opportunity to do better? It has the data collecting system in which it's organized and routine so that the data actually is meaning something when we look at it. Then we have the ability to try solutions against that data set and then follow that up to ensure that whatever changes we've put in place are leading to improvements.

So, it really is kind of an ideal situation to drive innovation because we have this data set and it helps us be able to sort through those changes and make sure they're good changes, and if they're not then go back to the drawing board and do something again. So, it's a really unique system. During OEF and OIF, so Operation Iraqi Freedom and Operation Enduring Freedom, which is in Afghanistan, we saw the establishment of the joint trauma system, which is basically a large database system that mimics the trauma system here in the US, but it collects massive amounts of data.

Everything from what happened at the point of injury, following the patient all the way through from where they maybe got their stabilization surgery, evacuation back to the United States, and then their recovery afterwards. We can look at all the different data points along the way. What they were wearing, what vehicle they were riding in, what kind of blood products they got in the emergency department, what happened in the operating room, what kind of bandages were used in recovery, we can tweak that system to improve outcomes and survival.

We know that in our modern military era we were able to decrease our wartime mortality by almost half in these last wars, so we're doing something right. We've improved outcomes for our service members and that's what it's all about, so I think looking at that systems approach that the military provides, is really a good way for us to partner with the civilian community and see if we can share.

Brian: I can imagine things that you are going to see in a war environment, the type of injuries and the type of complications, and the things that you're going to deal with I that theater of operation are going to be somewhat unlike things that you're going to see back at home, at least hopefully. Some are going to be the same, but some are going to be very different. So, I can only imagine that you learn a lot of stuff in those traumatic, drastic situations that are applicable to being brought back in the civilian community to deal with disasters or any other type of stuff. I would think that with the advent and the technology of medicine since the Vietnam era, now in these more current conflicts or wars we're seeing soldiers that are coming home that back during Vietnam would have sustained injuries they couldn't have come home, and now they're coming home with other issues. Can you speak on that a little bit?

Dr. Givens: I sure can. It's actually one of the points I wanted to highlight. One of the big advances that we have done is we've improved our medical evacuation systems, and from putting the right person on helicopters that are responding to the point of injury, to establishing basically mobile ICUs, they're called CCAT teams, and that stands for critical care air transport teams. So you take a team that would normally work in an ICU-like setting in a hospital and you put them in the back of a large jet, and you bring all the resuscitation and monitoring equipment on that aircraft.

We've been able to get patients out of an overseas location and back to the United States within 24 to 48 hours of injury, getting critical care the entire time. They can have transfusions done, they can have chest tubes placed, all in the back of an aircraft, and then get to a US based facility to get the definitive care they need. But we've managed to do that with a mortality rate lower than 0.25% for those most critical patients that are being moved like that. So, it's really just an amazing feet of both a combination of technology and personnel and then just the desire to provide better care for our service members. So that's been a major success story that we're really proud of.

Brian: That is phenomenal, and I think you're right. I think it probably has to do with advancements in healthcare and technology, but also we have incredible men and women that are out there providing this care and these healthcare services that are doing just a fantastic job.

Dr. Givens: Well I'm incredibly proud of all my colleagues, so I'll brag about them all day long.

Brian: Absolutely, and you have to think that that kind of experience that they get in those types of situations, that only helps make them strong physicians and healthcare providers, if at any point they leave the military side and come more into the civilian side of healthcare. Is that the case?

Dr. Givens: I think so. I think that's probably one of the things that a lot of military providers can bring to the table. They've been in situations where there might not have been an obvious answer or solution to a problem, and they had to innovate. They had to look at what was available, come up with a solution, and then not only apply it but lead an entire team or organization in the ability to implement that solution. That's one of the things that I think military physicians can bring back to the community is that leadership model in which, hey let's bring this process along, also that energy and that drive and that belief of we can do this, and background of team work and experience that they can bring.

But I think the civilian community also brings that same thing the other direction for the military. We really learn from the civilian community by some of the processes that have been perfected in the civilian world that we need to take back into the military. So I think it's an exchange either way.

Brian: And I think that's when it's at its best, too. Like you say, there are things on both sides of this that can feed each other. We've talked about the advances starting in the Vietnam era for emergency medicine, what do you see as far as the future of military medicine? Do you see anything out there that you think is going to change? If so, how the change of healthcare in the civilian arena is, day by day is seems at times, what does that look like, how does that translate to the military?

Dr. Givens: I think the most important this is that we don't relearn old lessons. In this war time we relearn stuff we learned in previous wars. So, the use of whole blood products for resuscitation, that was done in every war prior to this, and then we stopped doing it and we had to relearn it. The use of tourniquet, for years, oh tourniquets are bad, but if you look back on our history we used them successfully in the past, so we had to relearn how to use it. So, I think part of the future is making sure we don't have to relearn what we leaned in the past. Keeping a living learning system.

I also think the world will always have wars, you know I wish we didn't, I wish that would go away, but that's just a reality of mankind that we seem to be facing for our future. So, looking at what does that warfare look like and when we look at we're now reaching into space, and the political dynamics of the world are very different with the leveling that technology has provided, and introducing other power players as opposed to nation states and to the world. So when you talk about somebody who has control over IT and infrastructure and those kind of things, will that influence warfare? Will we be fighting a video game war, will it all be done by remote control things and then what does the medicine look like? Not for the people that are maybe being affected by it, but also for the people that are controlling it remotely that creates a whole different type of psychological injury and things like that.

Brian: Yes.

Dr. Givens: So we have a lot of unknowns, but we can kind of get glimpses of them and start to look at what are the problem solutions, and we can capitalize on a lot of that, too. We can really exploit that technology, exploit those changes in the world to find ways to stop injury and to care for it before it happens. I'm really actually very personally excited about some of the technology that comes with Nanotech for example taking a buckyball and putting some oxygen in it or putting whatever drug in it and delivering it directly to the tissue that's injured. You know, I'd love to see that evolve on the battlefield, like more directed care that's tissue and organ specific.

Brian: Now it is different, obviously, then wars in the past. How does military medicine changing for the treatment of these psychological issues? Because we're seeing a lot more of our service members coming home that have sustained injuries, some of them not sustaining injuries, just what they have seen. Like you were referring to, even people that in the future may not be feet on the ground, but from what they see with the drones or pilots like that and those psychological injuries, what is the military doing in that landscape right now? Because the healthcare may really change when it comes to that and how they treat that.

Dr. Givens: Well I think the most important thing is protecting people from being vulnerable to it in the first place. So, establishing programs that give service members resiliency and prepares them for these types of experiences that they have a tool kit that they can reach into to deal with these experiences. That's incredibly important and it's where a lot of energy is being focused. It's on a holistic perspective. When you build somebody that's physically resilient and psychologically resilient and they have a social support structure that can fill in where they have their own gaps and also teach them that it's okay to reach out for help and assistance. Then you've built somebody that can withstand the assaults on the psyche and the assaults on the body, and be much less likely to have these sequelae from the things going forward in the future.

So I think we're doing a good job of focusing our efforts on those kinds of things. When we look at the population at large, such a small percentage serves in the military, but we're starting to see events across the country, we're seeing mass shootings, we're seeing these catastrophic things that happen, and being able to share those resiliency tools with our entire community so we have a much more resilient population to deal with all the stresses of today's world is another thing where I think we can do a much better job of sharing those types of things that just make stronger humans in general.

Brian: Absolutely. As we get ready to wrap up here, Dr. Givens, if there is someone listening today that is thinking about going into medicine in the civilian world instead of going into the military to do that, what advice would you give to those people?

Dr. Givens: I will always be the person to say that the military is not for everybody, but for those that are interested in it, there's a way they can meet their personal and professional goals through the military in such a diverse manner. Within the military healthcare community there are research positions, there's academic positions, there's more, you know how you typically think of the military, go get on a helicopter and jump out of airplanes and do what we call “Hoo-ah” things, there's those opportunities. There's leadership opportunity to be the equivalent of a CEO of a hospital. So the opportunities for career progression are endless within the military.

However, I do remind people that you serve the military, you are supporting and defending the Constitution of the United States and with that comes some responsibilities that are different than that of working in a civilian community. Starting to understand what that means is a good first step. I'm very grateful for what the military has provided for me in terms of education,  that would have been opportunities that I'm not sure I would have realized otherwise. In those terms of financial, of being able to afford school, but also in being given leadership and responsibility that were probably ahead of what I would have been afforded in a civilian setting, there's really a lot of room to challenge yourself and move forward. So I encourage anybody that's interested in it to just reach out, reach out to somebody in the military and ask questions and see it as a land of opportunity where there really are a lot of potential options for somebody who's interested.

Brian: There obviously could be a tremendous amount of benefit to doing that on a lot of levels, just as you mentioned. So I would encourage those people that might be interested in that to reach out to a recruitment office or someone to get in contact with them to at least pursue those opportunities. Dr. Givens, I can't tell you enough, thank you for your service to our country, to our service members that you treat and I really appreciate you taking time out of your busy schedule to have a few moments with us today to talk about that.

Dr. Givens: Thank you so much, and like I said it's my privilege and honor to serve and I cannot end any talk about anything without saying thank you to the combat medics that I serve with. They're the non-traditional providers who go far forward into the worst of places, and I will thank them every time you put a microphone in front of my face because they're my favorite part of my job. So, I'm going to close out with saying thank you to those I work with, and thank you for this opportunity to be able to speak about it.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host Brian Fortenberry. Listen to more episodes, subscribe to the podcast and find show notes at SVMIC.com/podcast.

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