A Deeper Dive Into Combat Medic Training Free

ABSTRACT

The recent article by Knisely et al. provides a comprehensive review and summary of recent literature describing simulation techniques, training strategies, and technologies to teach medics combat casualty care skills. Some of the results reported by Knisely et al. align with the findings of our team’s work, and these findings may be helpful to military leadership with their ongoing efforts to maintain medical readiness. Accordingly, we provide some additional contextual understanding to the results of Knisely et al. in this commentary. Our team recently published two papers describing the results of a large survey that examined Army medic pre-deployment training. Combining the findings of Knisely et al. along with some of the contextual information from our work, we provide some recommendations for improving and optimizing the pre-deployment training paradigm for medics.

The recent article by Knisely et al. provides a comprehensive review of contemporary research related to Army medic simulation, training, and performance evaluation.¹ Our research team recently published two papers describing the results of an online survey that inquired about the pre-deployment training paradigm of Army medics.^2,3 By the number of respondents, this was the largest published survey to date that asked these providers to look back and comprehensively evaluate their pre-deployment training before their most recent deployment. Accordingly, several findings from Knisely et al. warrant further elaboration and explanation when considering our team’s recent work examining pre-deployment training, while also acknowledging the limitations associated with survey-based studies.

A brief description of the current state of medic training is provided in the introduction of the manuscript by Knisely et al., as this training includes basic skills directly related to combat within the MOS 68W (Army’s combat medic) and annual continuing education and competency assessments. Importantly, we found that most, but not all, medic respondents assigned to pre-hospital settings had their clinical competency evaluated before their most recent deployment and felt very or fully confident to provide combat casualty care. Accordingly, we recommend having leadership support to ensure that medics have enough time to have their clinical competency formally evaluated before deployment. Without this support, some medics may deploy without the needed skills and abilities to care for combat casualties; potentially worse, their superiors may incorrectly assume that they have the needed skills and abilities, and this could have deleterious consequences with regard to protecting the health of the force.

Knisely et al. reported on a variety of performance instruments and metrics that were used to evaluate competency. One aspect of performance evaluation that we described in our research involves the Dunning–Kruger effect, which describes how individuals with a low level of competence may be more likely to overestimate their knowledge, skills, and abilities when compared to individuals with a high level of competence.⁴ Accordingly, when self-efficacy is used as a performance metric (third most common metric from Knisely et al.), the Dunning–Kruger effect must be considered to ensure that the assessment is accurate. Having senior clinicians serve as evaluators may help mitigate the Dunning–Kruger effect. However, ensuring that these individuals have enough time to teach and evaluate medics is an ongoing challenge because of their numerous responsibilities.⁵

Common procedures reported by Knisely et al. were many of the same procedures that would have benefited from additional pre-deployment training according to the medic respondents in our studies. Equally important, we also found that medics wanted more opportunities for sustaining these skills between deployments. Without sustained practice and opportunities to perform these life-saving skills, medics may not be able to maintain adequate competency to perform these skills during combat operations, and their competence in these procedures will be imperative in the future when they may be expected to provide more and more life-saving care because of limitations in our ability to have surgical assets widely distributed in far-forward locations in the combat theater.⁶

A significant challenge reported by Knisely et al. was the need to accurately simulate the combat casualty care setting and the actual types of patients that will be seen in the combat theater. One desire frequently expressed by the medic respondents in our studies was the need for more pre-deployment training that induces stress, as medics frequently need to care for casualties in hostile environments on the battlefield. Furthermore, an added benefit of introducing stress using a systematic approach, such as stress inoculation training, may help reduce anxiety and improve performance.⁷ In addition, this training would ideally occur with scenarios that resemble what will be encountered when deployed. Training in these scenarios that are unique to the battlefield is important, as future multi-domain operations will consist of highly lethal environments requiring prolonged casualty care with limited resources and varying evacuation capabilities.⁸

Based on the findings of Knisely et al. and our studies, the following recommendations may be helpful for improving the pre-deployment training of medics. These recommendations are given while acknowledging that there are limitations when drawing conclusions from self-reported survey data. Additionally, although both Knisely et al. and our studies focused on Army medics, some of the findings and recommendations may also be applicable to Air Force and Navy pre-hospital enlisted care providers. Medics should feel comfortable performing life-saving interventions not only at the point of injury but also during evacuation, prolonged field care situations, and mass casualty incidents. Accordingly, medics should receive training that realistically simulates the logistical obstacles and psychological stresses that occur when delivering care in these challenging but common battlefield scenarios. This training should be conducted by seasoned instructors that provide constructive teaching and feedback that is timely, specific, and commensurate with the experiences and skill sets of the medics.⁹ A variety of training and simulation strategies should be employed, and leadership should ensure that medics have enough time before deployment to take advantage of these opportunities. Equally important, competency should be evaluated before deployment, and depending on the performance assessment strategy that is utilized, awareness of its limitations, such as the Dunning–Kruger effect with self-efficacy, should be considered. Finally, hands-on experience with actual patients is critical given that more and more life-saving interventions may need to be performed by medics or other pre-hospital personnel in future conflicts.⁶ Efforts are underway within the Defense Health Agency to overcome identified institutional barriers to ensure access to high acuity patient care settings and ensure that medics can maintain the proficiency that they develop in combat casualty care skills during conflict and prevent the skill degradation that occurs during peacetime. Avoiding this cycle between skill optimization and decline, or the “Walker Dip,” will help to overcome the aggressive learning curve that occurs if combat casualty care skills are not maintained before the next conflict.¹⁰ To conclude, we agree with the final sentence by Knisely et al., where they state that ongoing research that advances medic performance evaluation is needed, and this will be critical for ensuring that medics can effectively treat wounded casualties at far-forward locations on the battlefield.

ACKNOWLEDGMENTS

Not applicable.

FUNDING

Not applicable.

CONFLICT OF INTEREST STATEMENT

None declared.

DATA AVAILABILITY

Not applicable.

CLINICAL TRIAL REGISTRATION

Not applicable.

INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS)

Not applicable.

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)

Not applicable.

INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT

All authors contributed to the writing and revising of the manuscript. All authors read and approved the final manuscript.

INSTITUTIONAL CLEARANCE

It is not applicable but submitted out of courtesy and approval received.

REFERENCES

Author notes