Draft program for the training of medical personnel of combat units
Draft program for the training of military doctors of special forces
Introduction
Based on the results of an earlier review of training programs for medical personnel of special forces and tactical evacuation units in the armies of the US, Israel and NATO countries, the following conclusions were made [1]:
1. Training of all categories of military personnel and medical workers in providing assistance to the wounded at the prehospital stage is carried out within the framework of the international concept of "polytrauma assistance". The concept is based on the principles of care used in resuscitation of emergency surgery [2,3].
2. Military medics of the US Special Operations Forces (USSO) perform specialized tasks: assisting the wounded in small groups, assisting with delayed evacuation, tactical and strategic evacuation, pre-hospital work of specialist doctors, and support for the rebel forces [4].
3. The Israel Defense Forces systematically trains medical personnel for the military echelon and special purpose units within the framework of the concept of “polytrauma assistance” [5].
4. In the future, the medical personnel of the Specialized Forces, the tactical evacuation unit and advanced medical units in the prehospital level will be in demand: the widespread use of means and methods of intensive therapy, an increase in the arsenal of surgical and traumatological skills, diagnosis and treatment of infectious diseases [6].
Purpose of the review
Based on the analysis of information sources and the requirements of representatives of the Armed Forces of the Russian Federation (RF Armed Forces), a draft program for the training of medical personnel in the Special Forces on the basis of the basic principles of resuscitation and intensive care was formed. Overcoming one of the problems of special operations medicine in the RF Armed Forces is the discrepancy between the level of training of military doctors and the requirements in the Special Operations Forces of the RF Armed Forces.
Proposals of combat specialists to improve the level of special operations medicine
Below are the transcriptions to improve the effectiveness of special operations medicine in the Russian Federation. The scope of application is special purpose units of various ministries and departments.
According to the ones formed in the XIX-XX centuries. In classical views, a military conflict is a clash of two opposing sides, which are sovereign states. Realities of the XX – XXI centuries. indicate that wars and armed conflicts of the modern era seem to be more complex in their internal organization in comparison with the classical model of the XIX-XX centuries. The dynamics of the development of the military-political situation during the maturing and development of an armed conflict is as follows: "Peace - political conflict - crisis - war" [7].
Opponents often try to resolve contradictions either in the course of the political process, or through operations, actions, and the use of “dirty technologies”.
The actions are mainly of a deeply conspiratorial nature, subversive and sabotage activities are being conducted, sabotage is being organized, all-round training of irregular forces, opposition groups, information and psychological operations, intelligence is being carried out, an internal crisis is being prepared or, conversely, prevented.
Thus, the role, place and significance of special forces in a modern armed conflict becomes clear - none of the tasks solved before "Wars", cannot be solved without the systemic, large-scale involvement of special forces.
Study of conflicts of the XX-XXI centuries (Nicaragua, Sudan, the Second Congolese war in the Democratic Republic of the Congo, Afghanistan, both Iraqi campaigns of the United States and allies, Mexico - the war of drug cartels, Libya, Lebanon, Syria, the conflict in Nagorno-Karabakh, the civil war in Ukraine, and a number of others) makes it possible to understand that the armed forces can be used not only for their intended purpose, but also take part in various kinds of force actions and special operations, both on their own territory and on the territory of other states [8].
One of the features of modern armed conflicts is that irregular formations are becoming an active participant in a modern armed conflict. Irregular formations can be represented by various types of groupings and associations. In addition, a huge number of other structures are present on the modern battlefield: international humanitarian and human rights organizations, media representatives, etc. A separate category of "participants" in an armed conflict is the population of the conflict territory.
The opposing sides are interested in support from the population, therefore, along with military operations, they carry out so-called humanitarian actions aimed at "winning hearts and minds."
Taking into account the listed facts, the tasks of the special forces can be conditionally divided into two groups:
1. Conducting special operations in phases "Peace - political conflict - crisis" :
- Profile tasks, according to the guidelines.
- Support for irregular formations.
- Participation in the preparation and leadership of the underground on the territory of the enemy, preparation and actions as part of or in cooperation with irregular formations.
- Participation in political and humanitarian operations (for example, vaccination of the population), holding information campaigns, interacting with the population, ensuring the safety of employees of related organizations and units controlled by the media.
2. Participation in combined arms operations of large-scale military conflicts in the phase - "war":
- Action in battle formations in the most difficult sectors in defensive and offensive combined arms operations.
- Carrying out specialized special operations in the framework of a large-scale armed conflict.
- Support for irregular formations.
Based on open materials on the use of special purpose units (SPN) - the main unit of the SPN is the group. The number of special forces personnel involved in a particular event can range from a few people to a combined special forces detachment.
The tasks performed by the special forces groups require comprehensive support. This is intelligence, communications, material and technical, engineering, cynological, topographic, including medical support. For a certain range of tasks, minimal medical support is sufficient - an individual first aid kit and the skills of military personnel to provide self- and mutual assistance.
For a group performing a task in isolation from the operating base, it becomes necessary to have a qualified doctor trained for independent actions to provide first aid and medical aid from several hours to several days, with an appropriate set of medical equipment [9].
In a number of cases, apart from hospitals, a team of doctors is required to organize and conduct evacuation, to provide assistance to armed formations of friendly forces, during humanitarian operations among the population. For example, when deploying a field hospital (medical company / forward point of assistance / evacuation point) [6, 10].
The involvement of doctors to work in special forces units "from the outside" is ineffective, since a medical worker, being directly in the combat formations of a unit, must have sufficient military training, a minimum and sufficient linguistic level, know the specifics of the application and tactics of the unit, the procedure for performing the task and its scope ... The advance stage of preparation, conspiracy, and legend of the tasks performed implies the presence of a doctor on the staff of the special forces unit.
The need for a doctor directly in the special forces unit is often due to the inability to quickly evacuate the victim to a medical institution due to the remoteness of medical facilities, air superiority / effectiveness of the enemy's air defense, blocking / isolation of the group's area of action, intense fire from the enemy, lack of a road network [11 ].
For example, in the experience of current operations in the Syrian Arab Republic (government and allied forces), in 2015-2020, the time of arrival of the victim at the hospital in the absence of opposition in some cases reached 3 hours.
Trained non-staff sanitary instructors are able to provide first aid, but they are not ready either technically or tactically to further monitor the condition of the wounded, respond to changes in it and conduct intensive therapy in the “field” due to lack of necessary knowledge and skills. A number of resuscitation and surgical skills and a significant list of medical equipment, in accordance with the current legislation, have the right to use only medical workers with the appropriate qualifications [12].
Based on the existing experience in the use of special purpose units, the range of tasks solved by medical workers and their skills can be designated as follows:
- providing first aid on the battlefield;
- assessment and monitoring of the condition, if necessary, the use of a complex of resuscitation measures: on the battlefield, during preparation and during evacuation;
- evacuation of the wounded to the hospital link, using resuscitation equipment in auto and air transport, training of evacuation teams;
- qualified transfer of the wounded, control and escort of the wounded when providing him with assistance in the hospital link;
- treatment of the sick and wounded, the evacuation of which is impractical or impossible;
- medical support for the life of the unit and the attached forces in the conditions of the operating base, the deployment and effective functioning of the medical center;
- participation in search and rescue work, including as part of a helicopter search group;
- prevention and counteraction to the spread of infectious diseases, sampling and analysis of the quality of water and food;
- participation in humanitarian actions (providing friendly forces with essential medicines, pediatrics, vaccination, fighting outbreaks of diseases in friendly territory, collecting and processing biomaterial for analysis, providing emergency assistance);
- medical support for special activities;
- performing the duties of a special physiologist;
- knowledge and application of the fundamentals of applied psychology and psychiatry in relation to the tasks of the unit;
- development and adjustment of nutrition programs for various tasks of the Special Purpose Department;
- development and maintenance of programs for pharmacological support of the performance of the military personnel of the group;
- participation in the development and adjustment of physical training programs for various tasks;
- instructor work in the specialty in the subdivision, training of servicemen of the group to the level of "emergency sanitary instructor";
- training of non-staff specialists of friendly forces;
- medical support for irregular friendly forces, consultations in the equipment and deployment of medical facilities, selection and assessment of the qualifications of doctors from among the local population, additional training of this medical staff;
- participation in the development and implementation of promising algorithms for the provision of medical care, new samples of medical technology and equipment, exchange of experience with medical structures of other departments and organizations.
Considering all of the above, the presence of two doctors (officers) in the special purpose unit with basic training in the specialty “resuscitator-anesthesiologist” in a military medical educational institution and additional training in the specialization “doctor of the special purpose unit” will be minimal and sufficient.
Taking into account the request, it is possible to formulate the requirements for the training of a specialist in the specialty.
A specialist in emergency medicine must have knowledge and skills in providing emergency care, master the basic program of resuscitation and intensive care, and therapy of emergency conditions. At the basic level, take a course of infectious diseases, master a number of surgical procedures, take a course of actual military hygiene, have an idea of the physiology and special physiology of activity in relation to special needs, take a course of actual psychology and psychiatry, have an idea of sports medicine and programs of actual physical training.
The most important of the above (in terms of the volume and importance of disciplines) are anesthesiology and resuscitation [13].
As part of the specialization "doctor of a special purpose unit", a basic course of combat training and an advanced course of actual combat training are required [4].
Sections of combat training: fire training, tactical and special training, engineering training, military topography, mountain training, high-altitude training, driving vehicles, parachute-free airborne assault, air navigation, special training, linguistic training, etc. The level of combat and physical training of a special forces doctor, project combat training programs are outside the scope of this article and will be indicated in the appendix.
The complexity of the task of staffing the SP with anesthesiologists-resuscitators
The most prepared to perform these tasks (in the realities of modern medical education in Russia) are anesthesiologists-resuscitators (A&R) [14]. They have the skills to use the means used in intensive care (IT), methods (IT), emergency care skills.
Previously, internship graduates in the specialty of A&R physician were the most suitable candidates for a specialty physician. The specialist training period of 7 years made it possible to quickly prepare a doctor for the unit. Currently, the training of interns in the specialty A&R has been discontinued in the entire system of higher medical education in the Russian Federation.
The training program for A&R residents continues to become more complex due to the basic program and narrow areas (anesthesia during operations in special conditions, cardio and neuroreanimatology, efferent IT methods, nutritiology, A&R in obstetrics and pediatrics) [15].
Service of a doctor in the departments of the Specialized Forces after training in residency is a controversial issue. The skills of specialist doctors are quickly lost, and it is extremely difficult to maintain them in the process of service. Dequalification of a doctor in such conditions is inevitable. Training a doctor for a period of 8 years, which in 4-6 will require serious retraining, is a controversial decision. It should be noted that a modern IT specialist must have the skills to work with a fairly wide range of medical equipment, which is now available in portable versions.
It is also worth mentioning the total shortage of A&R doctors, which was only exacerbated by the COVID-19 pandemic.
The example of paramedics in the US and NATO should not be misleading. The training period for paramedics in the A&R specialty abroad is 6-7 years. Abroad, the use of the means and methods of A&R in the pre-hospital level and tactical evacuation has been decided, among other things, by involving the medical staff [16, 17, 18].
In the RF Armed Forces, the categories of paramedic and sanitary instructor have low staff mobility, which reduces motivation to improve skills and leads to specialists leaving for other positions. The recruitment of paramedics is extremely difficult and is compensated by the redistribution of responsibilities to doctors and medical instructors. A doctor-officer of all categories of medical workers is the most motivated in growth as a specialist, since he has great prospects.
In the realities of the Russian Federation, the doctor's awareness of the fact that in a combat unit his medical activity can be secondary, the need to undergo serious combat training, the rapid dequalification of a doctor of narrow specialization, getting into an aggressive service environment with an increased risk to life, limit the number of candidates.
At the same time, there is a growing deficit of knowledge, skills and competencies among SPN doctors. The small number of people willing to serve in combat units and the low motivation of candidates, multiplied by the widespread shortage of personnel, seemed to make the task of eliminating the shortage of specialists impossible.
Implementation of the training program for SPN doctors in the Russian Federation
The way out of the situation mentioned above is postgraduate training of SPN doctors on the basis of the basic A&R program. The actual delegation of the basic skills and powers of A&R doctors to SPN doctors, since A&R doctors in practice are engaged in maintaining the vital functions of patients.
Formation of a basic postgraduate program in the form of training and additional training of the medical staff of the Specialized Forces. Creation of a program on a modular basis: medical training, combat training, special disciplines. Overcoming departmental disunity through the use of basic international algorithms and federal standards for the provision of emergency care and A&R care at the prehospital stage. Formation of program options for paramedics and sanitary instructors based on the medical program.
The application of this program will lead to a common denominator for all categories of doctors in the SPN in the specified personnel niches.
The main personnel niches of the prehospital level for doctors in the SPN:
1. Unit doctor: in fact, a medical officer, a specialist - an instructor of military medical training - a special forces fighter is located directly in the combat formations of the unit [19].
2. The doctor of the primary medical center at the prehospital stage [20].
3. Physician of the tactical evacuation link: actually a doctor-operator of the resuscitation and evacuation module based on a car / armored vehicle / helicopter [21].
4. Doctor of the admission / anti-shock department of the primary field hospital, in fact, a doctor with the skills and qualifications of an A&R intern [22].
5. The doctor of the search and rescue group is actually a doctor with the skills and qualifications of an A&R intern, as well as the skills of a rescuer [23].
When staffing combat subunits with medical personnel, there are several sources of personnel: 1 - graduates of civil and military medical schools without independent work experience, 2 - military level doctors, 3 - hospital level doctors. Comparative characteristics of these groups are outside the scope of this article. For example, graduates of civil and military medical universities are the most numerous, most problematic and demotivated category of candidates at the moment.
Review of the draft program for the training of medical personnel in the specialty
The objective of this training program is to transfer the means and methods of resuscitation and intensive care to the prehospital link, to increase the level of care in the special forces and, as a consequence, to increase the survival rate of the wounded.
Increasing the educational level of SPN doctors will allow the use of such tools, methods and IT skills as: artificial ventilation of the lungs, maintenance of airway patency, tracheal intubation, conic and tracheostomy, transfusion therapy of hemorrhagic shock, central venous catheterization, differential analgesia, "FAST" ultrasound protocol , balloon aortic occlusion, monitoring of vital functions, etc. [24, 25].
The program is divided into 3 parts: 1 - medical training based on the basic course of the A&R doctor with the study of the protocols for the provision of emergency care "ABCDE" and "MARCH", 2 - a course on combat training, 3 - a course of additional and special disciplines [26].
The total duration of the training course is from 4 to 8 months, depending on the basic training of the trained doctors [27]. The medical module is the same for departments of various departments. The combat training program may vary. Section 3 - special disciplines, includes subjects that are not studied or studied insufficiently deeply within the framework of a 6-year medical education, while they are not included in sections 1 and 2. A number of special disciplines are not indicated within the framework of the article.
Medical training based on the basic course in anesthesiology and resuscitation:
1. Lecture course.
2. Simulation course on A&R. Study of the protocols for the provision of emergency care "ABCDE" and "MARCH". Ultrasound imaging course.
3. Basic course in anesthesiology, including sections: anesthesia for thoracic operations, anesthesia for polytrauma and other urgent operations.
4. Basic course in resuscitation, with the most relevant sections of IT.
5. A course of some urgent and outpatient surgical procedures. A short course in relevant dental skills.
6. Cycle of work in a multidisciplinary hospital as a doctor on duty in the departments of anesthesiology and resuscitation.
7. Completion of educational programs and courses in emergency medicine based on the concept of "polytrauma care": BLS, ALS, ATLS, PHTLS / ITLS, ЕМS SAFETY, CCEMTP / TPATC / TNATC, TCCC.
Elements of this concept have been partially implemented in the Russian Federation: the system of trauma centers and aviation disaster medicine. At the legislative level, these structures are assigned the priority of providing emergency care for polytrauma in the Russian Federation.
8. Cycle for work in the crews of resuscitation vehicles and ambulance helicopters.
9. An up-to-date course on military medical training, taking into account personnel niches in combat units and at the level of tactical evacuation.
Combat training course:
1. Primary course in combat training.
2. Advanced combat training course.
The course of additional and special disciplines: topical infectious diseases, topical psychology course, sports medicine, special physiology, veterinary medicine, etc.
Conclusion
The ideology of the training program is to increase the educational and professional level of the medical staff in the specialty and create opportunities for a wider use of IT tools and methods at the pre-hospital stage. The application of the program is necessary in the following areas: additional training of active doctors of the Specialized Forces, training of graduates leaving for service in the Specialized Forces
Providing an advanced combat training course for doctors before starting service in the Special Forces is necessary for a number of reasons. A high level of combat training is the main condition for the use of medical skills in a combat situation [28]. The rotation of the specialty specialist in the specified personnel niches in the prehospital level and work together with specialists of the hospital level will increase the level of care.
In the future, the saturation of special forces with doctors is possible due to the creation of separate groups in military medical universities. The departure of some of the graduates to the SPN will create a standard personnel gap between graduation and getting into residency in 3–6 years.
Physicians with experience in SPN are a motivated category for training in clinical residency, with experience in independent work and decision-making.
Service in the Special Forces should be a stage in the service of a military doctor, and not the final place of stay before retirement. The age factor, health, the ability to further study, teach and work in the specialty of a doctor - are the criteria that limit the time of service in the SPN.
The short-term goal is to cover the personnel needs of the prehospital link in the medicine of combat units. The long-term perspective is the formation of a personnel and mobilization reserve and, in general, an increase in the level of military medicine.
At the moment, a number of problems have been resolved: adequate programs have been developed for military medical training and assistance on the battlefield, similar to the leadership of "TCCS"; considerable experience has been accumulated in the participation of military doctors in armed conflicts of low and high intensity, the use of advanced surgical and resuscitation teams is being practiced to strengthen the pre-hospital level. The use of the program based on IT and A&R will increase the possibility and efficiency of the use of advanced surgical teams, create an opportunity for the work of special forces doctors in the hospital link and increase the level of instructor work of military doctors.
Graduates leaving for service in combat units need the knowledge and skills indicated above, it is difficult to obtain them already in the process of service. The SPN military doctor is a category of military doctors that has emerged relatively recently. In the future, it is possible to predict an increase in the number of this category of doctors. It should be emphasized once again that this is a special cohort of specialists who require knowledge and skills that are significantly ahead of the level of training of doctors at the military level.
All information for this article is obtained from open sources.
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