Fixing the Wounded or Keeping Lead in the Air Tactical Officers Views of Emergency Care on the Battlefield

MILITARY MEDICINE, 180, 2:224, 2015 Fixing the Wounded or Keeping Lead in the Air Tactical Officers Views of Emergency Care on the Battlefield CAPT Sten-Ove Andersson, NC SwMC* ; LT Col Lars Lundberg, SwAF MC* ; MAJ Anders Jonsson, NC SwA* ; Pia Tingstro m, RN, RT, PhD ; Madeleine Abrandt Dahlgren, PhD ABSTRACT The aim of this study was to identify tactical officers views of prehospital emergency care in the field before an international mission. A qualitative study with a phenomenographic approach based on interviews was used. The result of this study is a set of descriptive categories on a collective level, showing the variation in how the tactical officers perceived the phenomenon of emergency care in the battlefield. The result can be viewed as (1) noncombat-oriented including being able to do one s specialist task, being able to talk with local people, and being able to give first aid, and (2) combat-oriented including soldiers skills and roles in the unit, being able to act in the unit, and being able to lead the care of injured. These findings are important for officers preparation for international missions. The interaction between military and medical knowledge on-site care should be developed between the tactical officer and the medical personnel in order to minimize suffering and to enhance the possibility for survival of the casualty. INTRODUCTION The aim of this study was to identify tactical officers views of prehospital emergency care in the field before engaging in an international mission. This article is part of a comprehensive research study within a Swedish context, aiming to identify the field and relevance of educational training relating to prehospital care in a military environment. Taking care of wounded unit members on the battlefield is complicated because of the threat of hostile fire, the difficulties of working in the dark, the number of casualties, possible limitations regarding medical equipment, and prolonged evacuation times. 1 The battlefield environment differs from civilian prehospital care environments and, therefore, military prehospital care guidelines have been specifically formulated to meet the requirements for appropriate care in a military environment through the Tactical Combat Casualty Care curriculum (TCCC). 2 TCCC is a system of prehospital trauma care designed for the combat environment to reduce the number of preventable combat deaths. Major preventable combat deaths are extremity hemorrhage exsanguination, tension pneumothorax, and airway obstruction. 3 TCCC training emphasizes tourniquet application for exsanguinating extremity injuries, needle decompression of tension pneumothorax, and insertion of nasopharyngeal airways or cricothyroidotomy for airway obstruction. 4 The medical treatment must be adapted to the tactical situation. Combat casualty care has been divided into three phases: Care Under Fire, Tactical Field Care, and Tactical Evacuation. 5 Holcomb et al 4 predict that consistent use of TCCC guidelines will reduce preventable combat deaths in the future. *Swedish Armed Forces, Centre for Defence Medicine, Box 5155, SE-426 05 V Frölunda, Göteborg, Sweden. Borås University, School of Health Sciences, SE-501 90 Borås, Sweden. Department of Medical and Health Sciences, Centre for Educational Development and Research, Faculty of Health Sciences, Linköping University, Campus US, SE-581 83 Linköping, Sweden. doi: 10.7205/MILMED-D-13-00558 Different versions of TCCC have been implemented by military medical organizations in the British Army, 6 the Canadian Forces, 7 the Israeli Defense Force, 8 and the U.S. military. 5 The Swedish Armed Forces model of combat casualty care is inspired by the TCCC model and has three different levels of providers in their combat units. At the first level, all soldiers are trained in combat first aid, accident first aid, and cardiopulmonary resuscitation. At the second level, one out of eight soldiers is trained to be a combat lifesaver. At the third level, a specialist nurse gives treatment and care on-site, and then transports the casualty in an armored ambulance to a Forward Surgical Team or to a Military Hospital. 9 Research into combat trauma training for nonmedical and medical personnel has hitherto predominantly focused on three areas. The first describes different types of training programs, which emphasizes the importance of clinical evidence and clinical experiences in the design of this training program. 10 13 The second part evaluates the effect of different training models. The design of various training models is affecting the participants knowledge, skills, and confidence. 14 17 The third evaluates the impact of TCCC guidelines in the battlefield. The uses of TCCC guidelines indicate a reduction in the rates of combat deaths. 4,18 Previous research on the outcomes of combat trauma training has been limited to quantitative studies, while there is still a lack of knowledge about the learning process from an officers perspective when it comes to the way learning is experienced, regarding content and form, i.e., what is learned and how. A recent qualitative study by Andersson et al 19 suggests that describing learners views on the relevance of prehospital combat training can be a viable way to identify the learning outcomes of such training. The study shows that combat medical training should contain components of interaction, action, and reflection. This result may provide a basis for developing training content and form. The aims and scope of battlefield trauma education are of great interest to obtain efficient TCCC training and have 224 MILITARY MEDICINE, Vol. 180, February 2015

partly been debated by Butler and Blackbourne, 20 who argued that the leadership between tactical officers and medical officers is vital to implementation and training TCCC. Increased knowledge of the learning processes relating to the development of leadership between the tactical and medical officer can be viewed as a key component to improve combat trauma training. The tactical officers are trained to participate in and lead armed combat at a tactical level and are responsible for the emergency care in the battlefield. The officers are also trained instructors in combat first aid, accident first aid, and cardiopulmonary resuscitation. It is therefore of interest to know the tactical officers views of emergency care in this specific context. Correct decisions made by the tactical officers can reduce the number of injuries and preventable combat deaths within the unit. TABLE I. Interview Guide 1. Can you tell the most important thing you have learned during the training mission? 2. What is the most important thing to learn in first aid? 3. What knowledge is needed to take care of a wounded soldier in the field? 4. What impact does the leadership have on the care of an injured soldier in the field? METHODS A qualitative empirical study with a phenomenographic approach was used. Phenomenography is a well established methodology in the fields of education and health care research, particularly in relation to research questions that are relevant to learning and understanding in an educational environment. 21,22 Phenomenography is used to obtain knowledge of the world from a nondualistic perspective, focusing on the variation in how people experience phenomena in the surrounding world. The result of a phenomenographic study is a set of descriptive categories, showing the variation in the way a certain phenomenon is perceived within a group of individuals. The most common method of collecting empirical data in phenomenography is through interviews. Phenomenography applies a second-order perspective in taking the view and standpoint of the interviewees, as compared to a first-order perspective where the researcher defines the phenomenon under study. 23,24 In this study, the phenomenon is defined by the researcher as pre-hospital emergency care in the field. The analysis is conducted from a second-order perspective, i.e., focusing on the officer s ways of experiencing the phenomenon. The empirical data in this study were based on interviews and were conducted by one of the authors (SOA). The interviews lasted between 22 and 50 minutes (m = 34.75 minutes). The interviews were audio-recorded and subsequently transcribed verbatim. The collection of data was made using a semistructured interview, which means that the same questions were put to all participants, and they could then speak freely in their own words about the topic. The questions were focused on emergency care in the battlefield, with follow-up questions referring to their answers (Table I). The interviews were conducted during the participants predeployment training. In qualitative research, and particularly in phenomenography, a strategic (purposive) sampling is commonly used to maximize the variation of critical aspects from the participants. The sample for this study, however, was limited in time and space, and therefore, we used convenience sampling. 25 The analysis contains a number of distinctive stages, which have been described by Sjöström anddahlgren. 26 The first step Familiarization was to read the text and listen to the audio recording and correcting in the transcript. Some adjustments and additions to the transcript were carried out. The second step Compilation was to compile all answers to the main questions and identify the most significant elements given by each informant. Each element is named in the interviewees own words and the amount of interpretation by the researcher is kept to a minimum. The third step Condensation was to condense and reduce in order to find the essential parts of longer answers. There may be a risk of important information being lost by condensation of the participant s answer, so this step was performed carefully. The fourth step Grouping was to perform a preliminary grouping or classification of similar answers. Five preliminary groups were based on the participants statements. The fifth step Comparison was to perform a preliminary comparison of categories, and to establish borders between the categories, which resulted in an additional grouping. The sixth step Naming was to name the categories to emphasize their essence. Two categories were created, each one containing three aspects. The final and seventh step Contrastive comparison represents a comparison of similarities and differences and between the categories obtained. Significant excerpts from the interviews were used to illustrate the categories. During the analysis, the software program NVivo 10 was used to help to organize and structure the data. At the beginning and end of the analysis phase, the categories were discussed with other researchers to increase the trustworthiness of the study. The result of this study is a set of descriptive categories on a collective level, showing the variation in how the tactical officers perceived the phenomenon of emergency care in the battlefield. ETHICAL CONSIDERATIONS This research was approved by the Regional Ethical Review Board in Gothenburg (Dnr 142/06), and by the Swedish military authorities. Each participant was informed about the design of the project and his/her rights as a participant. All participants were asked whether they were willing to participate, and they were informed both by writing and verbally about the aim and design of the project. All participants in the study signed a consent form. 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RESULTS The participants of this study were 20 officers designated for service in Afghanistan and Liberia, 19 men and one woman, with ranks ranging from Second Lieutenant to Major. Seventeen officers belonged to the Army and three officers belonged to the Navy. The participants were aged between 24 and 51 years (m = 35), and seven had previous experience with international missions. On the basis of the officers answers to interview questions, two categories portraying different views on emergency care in the battlefield emerged: a noncombat-oriented view and a combat-oriented view. Table II shows the categories with their associated aspects and the distribution of the answers from the tactical officers. The descriptions of the categories include significant excerpts from the interviews and are integrated in the text in italics. Noncombat Oriented The noncombat-oriented view focuses on the officers own training and the environment without regard to the impact of combat. The first aspect pertaining to this category, called being able to do one s specialist task, contains statements about the training and how they will cope with their situation and their own role in the mission area. It emerged that there were differences between combat training and their own specialist training. Specialist training was highlighted as a key training component in order to be able to do one s task on the spot in the mission area. Combat training was not considered as important as specialist training and was something that lay to the side of real service although the combat training was, nevertheless mandatory. The second aspect included in this category, being able to talk with local people, contains statements about the understanding of their role in the mission area, why they were there, how to behave, and what to think about. It was also important to understand how local people think and what their situation was like. It was perceived that they were needed and that local people wanted help. This was implemented by communication and not by using arms or force: (It) is not a situation where people are shooting at you, but you re talking to people. The third aspect, being able to give first aid, reveals statements relating to delivering self-care and first aid at the accident scene. Learning first aid on the basis of the environment that you are in,...we can, of course, run into other things that are related to the environment. This can mean self-care, such as preventing chafed feet, maintaining good hygiene, preventing stomach flu, and knowing how to act, for example, in the event of snakebite. Furthermore, statements are based on being able to provide first aid in case of an accident. This means that it is important to prioritize primary actions, such as stopping bleeding, securing airways, and initiating the prevention of shock. Making use of first aid mnemonics is a way to remember measures in stressful situations. The importance of taking care of the wounded during combat was toned down,...as gunshot wounds do not happen very often, meaning that being able to respond to TABLE II. Categories With Aspects and Distribution of Answers From Tactical Officers Tactical Officers Aspect 1: to Do One s Specialist Task Category A: Noncombat Oriented Aspect 2: to Talk With Local People Aspect 3: to Give First Aid Aspect 1: Soldiers Skills and Roles in the Unit Category B: Combat Oriented Aspect 2: to Act in the Unit Aspect 3: to Lead the Care of Injured 1 X X 2 X X X 3 X X 4 X X X X 5 X X X 6 X X X 7 X X 8 X X X 9 X X 10 X X 11 X X 12 X X 13 X X 14 X X X 15 X X X 16 X X X 17 X X X 18 X X 19 X X 20 X X X Total 5 4 15 6 12 9 226 MILITARY MEDICINE, Vol. 180, February 2015

traffic accidents and cardiac arrests is considered to be more useful knowledge. Combat Oriented Within the combat-oriented category, the commander role appeared clearer, as well as the importance of unit members being able to act in different situations. In the first aspect of this category, soldiers skills and roles in the unit, statements emerged about ensuring that all soldiers end up at a basic readiness level for action and that the training mission is adapted to the deployment area. Furthermore, this area of investigation was to discover what skills the soldier had and to see the soldier as a key resource within the group. This was illustrated by an ambulance nurse discussing his experiences from emergency care: It bears fruit; it s like real things he has when he comes with something. It was also important to clarify the roles of the group that the medic primarily is a combat soldier because of the importance of maintaining firepower: (He) need not release his warrior role then, just because someone gets hurt; we can take care of each other. For the group, it means being able to take care of each other, that you can trust the soldier next to you, making demands of themselves and their surroundings to manage their task as soldiers. The second aspect found, being able to act in the unit, is part of the group s ability to act in different situations. To increase the ability to act, one has to practice and then analyze how to act in different situations. One has to know how to act when something extraordinary occurs. Being able to collaborate within the group. Being prepared and having confidence in each other creates a sense of security within the group. Reflecting on the tactical behavior in combat contact, We get into a fight, and pull out as quickly as possible; we are not there to win the war, we are there to go out and meet people. If someone was injured in a combat situation, it was important that you should try to keep the lead in the air, before taking care of the injured. To handle such situations, the soldiers must have trained for this in as realistic a situation as possible. Simplicity will work, as well as being able to do things at the right time. The group does not expect an ambulance to be waiting for the casualty: Now we are here and we have to survive; we re going to get back home. The third aspect pertaining to this category is being able to lead the care of injured. To lead the care of the injured onsite means taking the initiative, showing the way, taking a step aside, allocating and delegating the work, and deciding if medical evacuation of the injured is required. As a commander, one does not need to be an expert on health care because none of the decisions you have to make are medical. However, you need someone who can prioritize the injured. To lead on-site care, it is important to have a boss who really is a boss, and not emotionally involved or feeling responsible for the injured. Medics...may think they are the boss just because they feel the responsibility... the chief is still the chief; the medic is the chief (only) for the wounded. Physicians should not take command and lead care, but their knowledge will be used to take note of if a patient is dead or not. The medic s actions are concentrated on the injured soldier. It can be easy for a medic to take initiative, which could affect the military situation: His task is to fix the injured. It is my job as a commander, then, to ensure that no more are injured; if he goes forward then and the situation might not (safely) allow it, there emerges a conflict. As a commander, you need to be sensitive and listen to the medic to minimize conflict between military and medical considerations. Should the medical personnel have a military background, this could reduce the conflict between the military and medical decisions. DISCUSSION The aim of this study was to identify tactical officers views of prehospital emergency care in the field before engaging in an international mission. The findings of this study have revealed a (1) noncombat-oriented view, including three aspects: being able to do one s specialist task, being able to talk with local people, and being able to give first aid and (2) a combat-oriented view, including three aspects: soldiers skills and roles in the unit, being able to act in the unit, and being able to lead the care of injured. These six aspects separately are important for officers preparation for international missions. The findings could be used in future training programs for officers to create a better understanding of the whole knowledge field of military prehospital trauma care. By including aspects from both the noncombat-oriented view and the combat-oriented view, the officer is given the possibility of integrating the different aspects into a coherent whole. Understanding of prehospital trauma care as a whole entity thereby facilitates the learning of the different aspects included. 21 Within the noncombat-oriented category, it was found that officers were not motivated for either the combat training or the combat casualty care training because they do not end up in combat situations. If a soldier wears a uniform and carries a weapon in any type of mission, there is always a risk of being involved in situations that make use of TCCC. Of course, it is also important to learn to act in a traffic accident, but there are no civilian accidents in a military environment because in most cases special consideration has to be given to the tactical situation. 27 Therefore, training must be changed to motivate and alter the attitude of the tactical officers since every Swedish officer is trained to cope with armed combat. Within the combat-oriented category, the commander role appeared clearer, as well as the unit members importance of being able to act in different situations. This means that a strong team spirit in the group has to be fostered so that the individual actors are encouraged and empowered to help each other. 28 It was clear that military tactical thinking was MILITARY MEDICINE, Vol. 180, February 2015 227

relevant to how the group would act in the case of an injured soldier, for instance, the importance of maintaining firepower to minimize the risk for additional injuries. 29 Decisions about moving an injured person were linked to how to act as a commander and not to medical knowledge; it is a matter of moving a person from point A to point B, a logistical problem to be solved. What, then, is the officer s view of qualified medical personnel, such as doctors and nurses? It appears as if their knowledge is important to them, and that it is necessary in some situations. Medical personnel have more or less a consultant s role and are not an integrated part of the military environment. Therefore, nurses and doctors need to have an adequate knowledge of the military environment, and officers need to have a deeper understanding of the medical field; in other words, both groups should have an understanding of each other s knowledge, since they have different goals to be carried out through their actions. 8 Leading emergency care on the battlefield means emphasizing the relationship and importance of cooperation between military and medical judgment. Therefore, it is important to be aware that tactical decisions based on medical judgment can be detrimental to military success, and vice versa. 8 Hence, military judgment is what has to ultimately be the valid and respected authority; however, it is of utmost importance that, if the situation allows, there is a dialog between the medics and the tactical officer to be able to take medical judgments into account and make the bestinformed decisions. Medics are in charge of the individual medical judgments and interventions, but these decisions are subordinate to the tactical military decisions that are conducted by the tactical officers. The military judgment of the situation focuses on the importance of keeping the number of injured down, and not leaving anyone behind. This judgment is what directs and sets the conditions for all medical interventions. 30 The officers views of their own knowledge and understanding of how to lead the care of the injured can be seen as a simplified view of what may affect the injured person s condition before he receives qualified care. Moreover, nurses and doctors own civilian medical knowledge and experience needs to be transformed into military tactical knowledge in order to make the right decisions at the right time under difficult circumstances. 31 METHODOLOGICAL LIMITATIONS The objective of this study was to focus on the variation in how tactical officers perceive the phenomenon of prehospital emergency care in the battlefield. Normally, a strategic sampling of participants is used to obtain maximum variation. The group of possible participants is limited in numbers. To make it possible to collect adequate data, convenience sampling was used. Nevertheless, the study group showed a demographic variation (age, gender, ranks, troops belonging, international experience), producing a variation of different critical aspects revealed by the participants. Concerning the results of this study, there is no claim regarding the relative frequencies of categories described. It cannot be excluded that additional categories can be found, provided that a different selection of informants is addressed. CONCLUSIONS In the category noncombat oriented, the battle was neglected as a part of relevant activities, and awareness of the battle consequences was lacking. In the category combat oriented, battle was emphasized as an important part of the activities and indicates awareness of how to tactically handle the situation if someone in the group gets injured. By enhancing training/interaction in the key areas identified could result in positive military and medical outcomes. These skills need to be well integrated for mission success. The Soldiers morale improves when they become aware that they will be well cared for when they are injured on the battlefield. This will improve casualty care and effective use of resources. 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