Hello everyone and welcome to the Quorum podcast.
This is where academic medicine meets remote, austere and
resource limited areas. Welcome back to the podcast,
This is Avacol Kelly. This week we are with Doctor
John Quinn, who is on our teaching faculty.
He started out as a paramedic and now he has his MD and his
PhD. John, welcome back to the
podcast. We could be back.
Thank you for the opportunity. So tell us a bit about yourself
and what's keeping you busy. Yes.
So I've been fortunate enough to be able to be working between
the United Kingdom and volunteering in Ukraine and
occasionally working elsewhere throughout the the United
Kingdom, NHS sort of trusts everywhere.
But I've been fortunate enough to be able to do some
volunteering training missions throughout Ukraine over the last
few months. And I've been also been able to
to try to push things forward on the research side for damage
control, resuscitation and damage control procedures really
for the last two years or so. And that's something you've done
with the college and and Doctor Tom Allison, you've done ADCP
course in Ukraine. So how about we start from the
very beginning, John, tell us what is damage control
procedures? What precisely is DCP?
Sure. Yeah.
So it was great to be able to engage with Doctor Tom for the
damage control resuscitation and the damage control procedures
workshop. Basically the long and short of
it is this. In the remote, the remote
medicine and really the the far forward and austere medicine
paradigm, we need access to certain things.
So tactical combat casualty care gives us excellent access to
point of injury care and it really sets us up for success
for any sort of prolonged casualty care or prolonged field
care environment, which is great.
However really what has to happen at some point is that
patient may require damage control resuscitation, which is
a really fancy way of saying they're going to have to have
access to blood as well as all of the other aspects around it.
However that's only part of the story.
The other part of the story is that we need to stop the
bleeding actually definitively. So not just determined it and
not just sort of pressure and not just these these adjuncts
which are very helpful and excellent for the patient, but
really damage control procedures takes it to the the next level.
And at the way far end of that damage control resuscitation and
also damage control surgery paradigm that sort of that that
trajectory for that patient, that damage control surgery is
really only available for surgeons.
So there's these great courses out there.
There's the asset, the Asset plus the COTS, the COTS and the
COTS plus course, as well as the Hess course, which is a
humanitarian focus. All of these abbreviated courses
for damage control surgery are brilliant for surgeons, and some
instances they're brilliant also for anesthesiologist or
anaesthetist. However, there's a gap.
There's this gap between damage control, resuscitation, the
stuff that a lot of paramedics and a lot of parkour doctors
will be doing, and what those surgeons will be doing, and the
gap is kind of twofold. 1 is in a paradigm, an academic paradigm
of what you're allowed to do, so a governance thing, but it's
also geographic what where the surgeon may actually be sitting
and waiting for a patient to come and where you may be for
forward with a patient. There's actually that gap.
We say how can we close that gap?
So the concept of damage control procedures, which has really
been, you know, it's kicked off that significantly, not only
with the college remote and optional medicine, but also with
the Disaster Health Institute and kind of bringing together
loads of partners, different universities, different
specialist, different subject matter experts and saying,
listen, we need to get our heads around this and we need to to
push this forward. So the concept of damage control
procedures is really trying to address that gap of saying we
may have a delayed medical evacuation environment.
We may not have access to surgeons, even though a lot of
surgeons have a lot of guts and they're willing to to push far
forward and they're willing to do a whole lot of stuff far
forward. But still, even Even so, you may
have that geographic gap and that that tyranny of distance.
And you may also have have that gap of staying actually we need
to do something, we don't have access to a surgeon and we need
to be able to do some of these damage control procedures so
that we can help reduce preventable morbidity and
mortality. So in a nutshell, that's sort of
what the concept of damage control procedures is and does.
So this is about surgical skills for a nurse, a paramedic or or
even a combat medic corpsman and having them do doctor level.
No, not even doctor level stuff. Surgeon level skills.
Yes, absolutely. And it's, it's absolutely.
And it's really out of necessity.
So yes, you're right. You know, nurses, combat medic,
corpsman, combat medics, paramedics, EMTs, doctors and
other other healthcare professionals that really want
to upskill. The concept is to be able to
give them training so that they can save a life when it's
required. Now, having said all of that,
there's also governance consideration.
So a lot of countries will say no way, Jose, this is
impossible. There's no way we're going to
allow this to happen. There's other governance issues
for paramedics and for doctors, for example, an emergency
medicine doctor or a nurse or a paramedic saying actually we're
not allowed to do that. So there's a whole lot of
governance issues to overcome. However, we really need to just
push far forward, do what needs to get done for the patient in
this paradigm, this concept of damage control procedures under
the auspices of clinical governance saying, yes, you are
allowed to do this. But first and foremost comes the
training comes the, the, the capability of being able to
recognise the patients that require advance an escalation
level of care and then being able to have the skills to
actually competently execute those, those those
interventions. So it's, it's quite a complex
web of considerations. But yes, you're right, it's not
just for surgeons anymore in in limited capacity.
It's also the idea of being able to give these skills and give
them into the hands of competent paramedics, nurses, other
doctors, other healthcare professionals, as you said,
combat medic corpsmen, combat medics, EM, TS, etcetera.
So John, there's a lot of publications on damage control
surgery for non surgeons on pub Med, but they're referring to
given to giving surgical skills to non surgeons, meaning other
doctors and not to non doctor. So how angry, how, how cross
will the surgeons be when they hear about this programme?
Yeah, I think it's really important to to put it in a
framework, I think. I don't speak for surgeons.
I know that surgeons wake up every morning and they wake up
at 3:00 in the morning when they're on call to go in and
save lives. That's why they are willing to
do their residency for several years and decades, in fact, so
that they can save lives. And they are they, as I said,
they have guts. They're, they're willing, a lot
of surgeons, especially in Ukraine, willing to push far
forward and they're willing to do surgery in basements very
close to the line of contact. However, the line is huge and
sometimes the resource that surgeons have cannot spread
across the line to all the areas that it needed.
So it is possible that the concept of damage control
procedures will really rattle a lot of cages inside the surgical
community. However, I think it's an
opportunity to be an adjunct, A surgical extender.
You can extend some of these aspects under the offices, under
the direct care and supervision by a surgeon saying, hey,
listen, I've trained you on how to do this.
I feel comfortable with your skill on how to do this.
You may even have the ability to discuss the case over Starlink
or other protected Internet by a telemedicine, maybe even
something as simple as a WhatsApp or a Signal video call
or sending different photos back and forth or just having
messaging back and forth over secure communications saying,
OK, based on all the information you said we've got, you know,
three days for an evacuation. This patient is likely to perish
unless we try some of these interventions.
And I feel comfortable and confident with your with your
approach. So let's let's continue that.
So really an extension of that surgical, that surgical
expertise, of course, that won't happen in all environments.
And, and it's, it's yet to be, you know, consistently tested.
But that's, that's really I think the the best pairing
opportunity for surgical extension and really having
close surgical oversight saying, listen, we can do this.
We have the skills, we have the training, we have the equipment,
but we need, we need, you know, the go ahead essentially.
And I think I think surgeons, you don't need to assess that
and they need to give their own feedback as well and say what
whether or not they're happy with it, You know, in across all
NATO and, and, and NATO partner nation.
And just to go back to some of the partners that started with
this within the College of remote officer medicine, we have
surgeons that have that have looked at this curriculum.
They're still reviewing a lot of discrete in the concepts with a
really a lot of thumbs up. We also have a disaster health
institute, a lot of surgical expertise and subject matter
experts also reviewing and supporting the curriculum
development. In fact, there's other partners
such as a precisely these Medical University that have
given massive support. And really some of the the early
considerations of the curriculum really came out of discussions
with with surgical expertise, trauma surgical expertise, not
only from Europe, but also from their experience in in North
Africa and elsewhere in Asia. So there's a lot of surgical
roots and surgical DNA inside this curriculum and inside this
concept, and it just needs to be explored, that needs to be
considered and really needs to be pushed forward.
John, you've designed this and you've run this in Ukraine.
Walk us through how the DCP programme is.
What does it look like? How long is it?
What skills are you teaching what?
What surgical skills are you giving to the medic on the
ground? Sure, sure.
Well, and just to go back a little bit, we, we have done a
damage control procedures workshop, so a limited workshop
really focusing on gathering a whole lot of information
specifically related to damage control procedures.
We've also done a lot of these isolated skills and you know,
college or more than ultra medicine and the Disaster Health
Institute are not the only groups that have that have been
trying to explore some of this. There's also been organically
inside Ukraine out of just sheer necessity, really trying to
better understand some of these skills.
Not on a mannequin, not on, not in a, in a very quiet training
environment, but in the far in the field, in far forward
environments with cadavers, etcetera.
And, and you know, a lot of their qualitative and anecdotal
feedback is also fed into these concept and systems.
So just to go in kind of in the three phases, it's basically 3
phases. And some instances we refer to
them as tiers. In some instances we refer to
them as echelons of care. But the first one is kind of a
review. And it's really a review of the
combat medic form. And so the idea is that if you
are not a good competent combat medic form and within
procedures, but you have, you know, you have the interest and
you want to upskill yourself that idea.
Tier 1 is really a combat medic form and skill course, a
slightly expanded skill course. So, so there's a surgical
airway, there's the chest drain, so a finger of thoracostomy and
a tube thoracostomy. There's intra osseous.
And there's also a very specific look at how to use tourniquets.
And I know it sounds kind of basic, kind of rudimentary for a
lot of a lot of folks out there saying a lot tourniquets.
We've been doing that from since day one, but being able to
really approach, Hey, let's, how do we really convert that
tourniquet? How do we, how can we downgrade
that tourniquet? How can we replace that
tourniquet? How can we do it safely in a
farm court environment where we don't entirely take something
off, but we just sort of we, we, we try to minimise the amount of
morbidity associated with that turn kit, but also maximise the
medical outcome. So we look at that as well
within tier one and then also the the idea about having access
to really assessing a, a traumatic amputation.
And then in Tier 2, we have a really expands quite a bit and
we have a limited laparotomy and we have a so that's really a
laparotomy where you open up the abdomen, you pack for quadrants
of the abdomen, you really pack that liver in the event that
it's bleeding, obviously with really it's indication.
And then and then you have a damage closure as well as the
concept of the lower limb, external fixation of the lower
limb. And the reason it's the lower
limb only is that, you know, you can really get some excellent
immobilisation of the upper limb, even with partial
traumatic amputation and being able to secure that that upper
limb, especially for, you know, working age men and women, you
really want to maximise the outcome.
So when it, whether it comes to, you know, a surgical speciality
for the upper limb, the hand, the wrist, the forearm and the
upper limb in, in, as a whole, you really want to do that well.
And so in the, in the lower limb, it's a little bit easier
to train and it's a little bit easier to be able to get a lot
of the, the, the, the, the, the tips of the trade and the tricks
of the trade to be able to do the lower limb well with
external fixation, which is when you actually drill screws into
the bone and then you have an external rod to give, give
support for, for lower limb, either parts amputation or
significant trauma, trauma. And so that that's kind of the
focus of up Tier 2. We also kind of expand a little
bit and go into a little bit more detail on some of the
aspects of of surgical amputation and then also
expanding a little bit more about burns, exterotomy and
fasciotomy. And really, you know, kind of
going into a deep dive into advanced burn care.
So that's, that's more or less. And some of these, some of these
are interchangeable. So as we're kind of walking
through different tiers and we deal with different groups, they
say, well, actually, hold on, we don't want, we want it as a
menu. We want to actually, we want
that, that, that item from tier one, we want that put in Tier 2,
we want that item from Tier 1 and put in tier 3, etcetera.
Tier 3 is a bit more extreme and we look at the the use of bur
holes. We also look at the use of
advanced technologies and the use of partial retrograde
endovascular balloon occlusion of the aorta or partial boa,
which is something that is very controversial and controversial
with surgeons, controversial with pre hospital providers,
controversial with hospital providers.
It's when you use a central line in the artery and you you
actually put a catheter with a balloon all the way up to zone 1
inside the chest for a traumatic and obtundant patient who is
really doing poorly. And and then you can partially
occlude the aorta and really better understand what is going
on. What do you need to do to stop
the bleeding? Hopefully you can get some blood
on board as well as do a whole lot of intervention.
And so that's sort of the, the walkthrough.
There's also an advanced technologies, essentially the
concept of what will become phase three likely in the next
few years. But right now it's more or less
a phase four, which is really quite slick stuff.
So that's looking at brain wave activity, looking at doing HEMA
filtration, which there's a lot of great evidence in the
literature right now, especially with the trauma.
And Ukraine is leading the way. They have this this excellence
in, in medical care for the modern battle field and they're
doing quite a bit with hemifiltration.
So you know, you have a patient that may have waited 12 or 18
hours with significant trauma and they may have just just
absolute massive muscle injury, internal organ injury.
They're really dealing with a lot of metabolic and respiratory
acidosis and other and other really challenging issues for
kidneys. And so the idea is that if you
have a very cheap, very easy, relatively relatively easy tip
to use for chemo filtration, you can actually filtrate out the
blood and filtrate out a lot of those metabolic components that
are that may be actually causing harm.
And so if you can philtre those out well and still put the blood
back and perhaps even transfuse more blood, you'll be able to
actually have much better outcomes in the long run.
Now, the data is still forthcoming.
It's not readily available. It's not super cheap just yet
and it's not terribly easy to use yet.
However, as those technologies are coming a line, we're dealing
with a lot of those innovative technology technology providers
to be able to better understand, hey, how can we actually, how
can we plug this into to the system also with the idea of
Burr holes. So for intrapranial pressure,
there's a few systems that actually are a little bit easier
for the purposes of ICP measuring as well as being able
to offload some of that pressure.
So there's a whole lot of moving pieces.
It's obviously not just for a specialist of an emergency
medicine alone. This is, you know, this is
transdisciplinary, requires neurosurgeon input, requires
faster surgical input, traumatic surgical input and several other
specialties to be able to really link it in and just in time
medicine and saying, listen, this is exactly what's needed.
We're going to wait. We have a highly contested
environment. We need to be able to up skill a
lot of these a lot of these providers, we need to be able to
put these pools into their hands.
It can't be terribly expensive. It can't be huge and burdensome
and heavy. We need to be able to go into a
building of opportunity or vehicle of opportunity and and
be able to execute a lot of these very specific
interventions exactly when they're needed to be able to
reduce preventable morbidity, mortality.
And I, I should also say really as like an overarching on onset
because I know a lot of people may be saying this stuff
absolutely crazy. We do have a, a few Seminole
papers that I've already commented on this a little bit
and quite a few conference presentations kind of unfolding
it in the event that we did in, in November and keep really kind
of set the tone for a lot of the feedback and, and, and really
helping us Polish off the concept of the curriculum for
damage control procedures. But what we have, you know, a
lot of paperwork, a lot of papers coming out academically,
trying to unpack this and put this within a framework and
really make it a little bit easier to, to describe and, and
under for others to understand. Hey, this is kind of where our
thought process is. This is where we were going with
this and this is what the curriculum is looking like.
And so that's really the the whole concept of damage control
procedures, more or less in a nutshell.
Is there anything in in in motion to have a telemedicine
requirement, requirement for like virtual oversight with a
surgeon or having having just a WhatsApp video of you're doing a
Burr hole? Are they going to be discussing
this with a surgeon before they do it?
The idea is that you should be able to work autonomous and
offline. So the idea is that you may not
have access to telemedicine, you may not have access to clinical
oversight, you may not have access to medical control or
medical direction. And so if you have excellent
skills, if you have excellent indications for execution and
you have clear triggers, it'll be a lot easier for the provider
to be able to say, listen, I need to pull the trigger on
this. We need to do this.
Now having said that, that's a really challenging environment
to put a paramedic or or someone who does not do these types of
procedures to scale or to the volume that to give them
confidence and so. Having access to that
telemedicine online or offline medical control will be
significantly helpful. Obviously, online medical
control and telemedicine support is really the standard that that
everyone is pushing for what everyone wants.
There are a lot of units that are far forward that have access
to telemedicine, they have access to networks and they do
have access to medical support where you can give a picture,
you can send vital signs, you can send mechanism of injury
time since injury and interventions done thus far as
well as hey, we're totally delayed.
We are literally behind enemy lines and we do not have access
likely for the next two to three, possibly 5 days.
And it'll make telemedicine decision making a lot easier to
have all of that information. You may only get part of that
information. It may not be alive and online.
You may have to send a packet of data and that data may may take
several minutes or even hours for it to be actually reached
the, the, the the surgeon. So obviously having
contingencies with that offline medical control will be, will be
fundamental. There's also the, the, the
potential of just the sheer volume of patients being dealt
with. You may not have access to a
surgeon that is actually available to be able to sit and
listen and comprehend and digest the clinical information being
offered in the event of a large scale combat operation that
involves, you know, all, all elements of power.
So it is very, I think it's very important to, to have both that
online telemedicine component saying, hey, listen, I really
want to discuss this case before I start doing something.
But at the same time appreciating and understanding
you have to have that offline telemedicine and medical
control, medical direction. And this is where governance
really takes a role. You know, you have to have
surgeons willing to say this. And I'm not willing to have this
take place on my watch, so to speak.
But I am willing to have this and this and this take place as
long as I oversee and approve of the curriculum and oversee the
training. And I, I approve, you know,
different providers be able to do this.
If you think back to, you know, in pre hospital days in the, in
North America, there were, there were several instances where,
you know, in order to be able to provide intubation in the pre
hospital space, you had to undergo several numbers of
intubations only in, in surgery and in theatres, surgical
theatres, but you also had to do them in the pre hospital space.
Then you get signed off and then the medical director would say,
OK, you've done XM number of intubations not only in the
hospital, but also the pre hospital space under some levels
of revision. You now are like can do this,
this skill, you know, autonomously.
And so there there there's it's a it's a much larger spectrum
when you deal with damage control procedures.
If you think about a limited laparotomy fully cow, that's a
that's a very involved intervention.
If you think about any of the interventions mentioned,
including those from tier one, which are really an expansion of
sort of combat metformin skills, those are also those are intense
intervention. And if you don't manage those
properly, if you don't address those properly, if you do not
intervene at the right time, you can definitely cause harm.
All of these intervention 100% can cause harm, 100% can lead to
absolute unfortunate morbidity and mortality.
One in 100% that can happen. As with anything in medicine,
everything that we do can definitely help and it can also
cause harm. So being able to to give those
these skills is going to be able to hopefully reduce preventable
morbidity, mortality. But we have to do it smartly,
wisely. That can't be done 9 years from
now. I think 9 years from now will be
too long. I think we have to be able to do
a lot of these things now. I think we have to crawl, walk,
run. I think we started the crawl.
I think we're starting to walk in and at some point probably in
Q1 and Q22027, I think we're going to be running and we
really need to be able to get these skills into the hands of
of these providers. And additionally with this, this
is not just the procedures, we have to also think this doesn't
replace anything. This only adds, so we have to
also think about the damage control resuscitation clinical
practise guideline from the DHA from deployed medicine and
there's actually a few that's wonderful prolonged field care
that the overarching damage control resuscitation document.
Those are the same skills and concepts that have to be
followed, right? We still have to get blood and
blood products on board as soon as possible.
We still have to have appropriate and responsible
resuscitation. We still have to provide all of
these other adjuncts with resuscitation such as TXA and
calcium. And we, we, we have to be able
to provide these basic interventions as, as all, you
know, as you and I both know from all of our training, you'll
never get to that those, those cool, sexy advanced skills
without excellence in the basic life support.
So we still have to remember that this is not a replacement.
We're not saying, OK, well, this is damage control procedures.
Now we don't have to wear, but all this other stuff, no at all
that the basic life support still remains the mainstay
before we jumped into these really cool advanced procedures.
And this is, you know, something that I think all of us
appreciate in the teaching community and in the, in the
execution operational environment.
You know, basic skills are really what saves lives.
And all the advanced stuff is brilliant and excellent.
It's it's high speed and we want to do it.
We want to do it well, but really we'll never get there
without having just absolute excellence in our own
operational environment of the basic skills as well.
You mentioned in the history of paramedics.
I remember watching the TV show Emergency back in 1974 about the
first paramedics and they needed to call permission.
They had to get medical oversight for giving an IV or
even oxygen. And then it, you know, small
steps we built from that. So we can't, we, we had to start
from somewhere. Are you seeing this being
something similar to what we had to start as as paramedics until
now we're up to doing a lot of stuff on our own.
Absolutely. And it's a, it's an excellent
reference point. My, my paramedic, my paramedic
instructor, instructor Patrick, he would always talk about
Rampart, Rampart, Rampart, the, the name of the hospital to call
the, the, for medical direction when you have access to one of
these fancy radio phones, etcetera.
Yes, I do see this is the way that, that, that, that things
are going. I, I would just, I point out two
skills that come to mind anecdotally from my experience
in Ukraine, intra osteus and chest tubes.
Intra osteus access was just a challenge, as was needle
decompression, a massive challenge.
And as, as things expanded, as things grew forward, as a, it
became a little bit cheaper. So cheaper to train on, cheaper
to get your hands on, cheaper to use.
Yes, there were, there were inappropriate intra osteus
place. Yes, I can, I can verify that
yes, that took place. However, as as you train it to
scale, especially for patients that are appropriate to receive
intra osteus, especially for damage control, resuscitation
and transfusion medicine, it expanded massively and it wasn't
necessarily legal. And you do have to get
permission. And even with permission, people
would still kind of bicker over the governance aspect.
And now you see a large expansion of that component of
that intervention of that modality to help patients
massively across the line inside Ukraine.
The same thing for finger thoracostomy and and two
thoracostomy. I think the, I think the, the
it's a little bit more limited certainly.
However, you have definitely seen an expansion of the level
of training of chess tubes. I was doing chess tube training
in 2014 with about 6 to 8000 people in 2014 to 2015 by 20 and
other things taking place between them.
Obviously by 2022 we were kind of back to baseline where not a
lot of people had access. It was not an intervention that
was taking place in the pre hospital space in Eastern your
brain and very rapidly, not only surgeons technically within the
governance structure, surgeons are supposed to be doing this
and rapidly. You had any doctor that was
receiving patients by 2023 that had training with chest with
finger glorcostomy and tube glorcostomy of patients that
required that you'd have much larger access.
Again, it's qualitative. I'm not going to tell you the
number of of of of role ones or role twos.
I'll cross the line that had access to this, but it was
larger than what it was in 20/22.
It was largely what it was in 2014 and 2015.
So that slow expansion of being able to provide best practises a
really life saving intervention. So we know that attention
pneumothorax or pneumothorax will kill a patient and being
able to get that finger to acostomy as soon as possible,
being able to get that to acostomy as soon as possible
will be life saving. So that has expanded.
I don't have a number for you, but it has expanded and the
scope has expanded. And that's just a one small
example of what, what, what are certainly advanced skills, but
in the grants team of, of, of of damage control, surgical
interventions, those are only a few and then it kind of goes up
from there, right? So I would say that those are
those are some basic examples of, of where, where you could
actually see that going, you know, in reference to being able
to have medical control reaching back, Hey, I've done the
training, can I do this now? And after you do that a few
times, then the surgeon saying, yes, you know, you have a
standing order, you're allowed to do a finger glorcostomy or
you're allowed to do an intraositus access or you're
allowed to do a needle, a needle decompression in the at the
axilla, not no longer an anterior approach.
And being able to do that in for nurses, for combat medics or EMT
equivalents, 60 whiskeys, etcetera.
So what's next for the DCP pathway?
What? What needs to happen now?
Yeah. So the DCP is is exploding the
damage control procedure is course we've already executed a
few elements of them. Right now we're really working
hard to get governance online. Doing cadavers in Europe is a
challenge. There's obviously a whole lot of
technology that exists to do these types of courses and I
think the Hess course has an excellent model and the Asset
Plus course normally uses cadavers.
There's actually a few that are coming up that are available in
Europe and encourage our surgical colleagues to reach
out. Unfortunately, if you're not a
surgeon, you cannot do the Asset Plus course.
But I think really what the idea of the full package and the idea
of being able to offer it in its entirety, specifically right now
to those who need it most, which is in Ukraine and being able to
provide a full package to a several of a large cohort of
trainers of learners and being able to have a training training
system where, you know, I just to take a bit of a side a side
detour. Ukraine and Ukrainian military
medics are fighting in Modern Warfare and they have a lot of
learning and a lot of observations and a lot of
lessons that a lot of them are being shared with NATO and NATO
partners. It's true.
However, a lot of them are being lost.
They're being missed because there's just the engagement that
needs to be increased. You need to increase our
engagement and support for our opinion colleagues.
We have to be able to kind of shut up and listen to them and
listen to what they have to say and listen to their experience,
their observations and instead of necessarily teaching or
training them, Although obviously medicine is a, is a,
is a, a science and it's a vocation that we do exchange
from one person to another. It's like it's a two way St of
exchange. We need to, we need to listen,
we need to really hear what what their experiences as well.
So the damage control procedures will be procedures offered in
Ukraine. Obviously there's going to be
two echelons offered in 26. And then we want to do the full
package start to finish in 2027. And I think it's a great
opportunity. This is not just for the special
operations, you know, community. This is not just for the far
forward, high speed, low drag military medical community.
This is really for all of those in the pre hospital space.
So within Ukraine, obviously there's disaster response,
there's the Ministry of Health, there's the Ministry of Internal
Affairs and of course the Armed Forces of Ukraine.
And we want to be able to offer this to as many people as
possible. And I shouldn't comment as well.
I mean, there's a lot of other softer skills such as the
surgical, basic surgical skills. So the, the, the idea about what
it is like to to work in theatre and then try to be as sterile as
possible in that far forward environment.
There's also a few more comments about resuscitation, not only
with blood, blood products and also adjuncts.
Unfortunately there's not enough blood, there's not enough
universal donor blood in the country to be able to provide
for all the patients that that we have.
There's also not a lot of blood components necessarily.
So being able to look at alternatives as well is also
part of the part of the curriculum.
John, you mentioned Disaster Health Institute.
Tell us about DHI. Yeah, DHI.
So I'm double hacked. I've been a faculty for college
remote optional medicine. It's been an excellent
experience. I also helped support the
starting of a non for profit with the Disaster Health
Institute. And they they are really a
collection of subject matter experts mostly from the disaster
health epidemiology, far forward operational medicine and
disaster response. North America, Europe, Central
Asia, elements from Africa and South America.
And really trying to bring bring forward the concepts of best
practise at a very high level. So a very operational strategic
level and trying to bring trying to bring best practises to the
places that need it most. There's been a whole lot of
engagement and coordination with several different institutions,
including the European Union and other response disaster
institutions that do a whole lot of stuff operationally.
But it's kind of trying to be a bit more focused on the
strategic level. And there's been a lot of
workshops that have been put forward trying to bring subject
matter experts doing some red teaming and some really
challenging exercises in, in what are we going to do if X
happens? So disease X, obviously event X,
not just conflict, but also disaster in, in, in general.
And really trying to bring bring forward not only subject matter
expertise from within the Disaster Health Institute, but
also from around and really bring together and be a
collaborative of saying, Hey, we need to link up all these
things. We need to let data drive our
decision making. And if we don't have that dad,
that, that data, we need to run out and, and, and get that data,
we need to run out and capture that data.
And so that's, you know, that's one of the things, you know,
that I think DHI really on the on the, on the front of it,
they, they look at strategic policy stuff, but a lot of their
subject matter experts also also engage with operational things
as well. So trying to bridge those two
things as, as you know from working college runoff for
medicine, it is challenging when you engage with little big
decision makers doing a whole lot of stuff at a high and
strategic level. And then you're dealing with and
really operational guys and gals that that kick indoors that put
tourniquets on. That is being able to, to
communicate and engage with both groups of folks is, it's a, it's
a bit of a skill, bit of a skill set to be able to get the data
that's needed and to be able to convert that and analyse that
and speak to those that are, that are having, you know, the
final decisions on a lot of things, hopefully to make
everyone's lives better. Are you going to be speaking
about DCP at the the Soft CMC conference in Paris?
I, I, I think I'm missing the CMC this year, although there
may be a late entry, but I really, those guys are doing
great work. You know, being it went there, I
think I was able to bring forward the concept of taking
really advanced skills and pushing them down into echelons
closer to to point of injury. So this was in the CMC in
Germany. And those are just it's a great
community of folks, the the organisers there to ABS they
move mountains when they put these things together, that flip
flopping between having it in Germany and having it in Paris.
It's an excellent mixture of subject matter expertise, not
only is in the special operations medical community,
but also, you know, across the board in, in everyone that is
preparing for hopefully preventing the next large
conflict. I mean, we need to be ready for
it. And I think they're doing a
great job of information sharing, very ad hoc, very
practical information sharing so that everyone understands, hey,
what, what do we need to do? What our best practises?
What is the data thing we need to do?
Most of the data is true. It's coming out of Ukraine for
the last 4 1/2 years, for last arguably to, you know, 12 years,
it's been coming out of Ukraine. And we need to, you know,
capture that data, analyse that data.
And they're doing a good job of doing that.
And there's also a lot of data coming out of the Indo Pacific
theatre. There's a lot of events that are
coming out of the Middle East. We need to, we need to capture
that as well. And we really need to be able to
put our put our heads around it so that we can better understand
what works in one theatre may not work in another.
It's absolutely true. What works in one military or in
one unit may not be transferable, although elements
of it may be. And I think the CMC is a great,
a great venue to be able to engage with everyone in a very
peer-to-peer Manor. And it's a, it's a great
environment, it's a great group of folks, but I, I think I may
be missing it this year. Unfortunately so also you and I
are hosting another webinar for the Royal Call to Certains of
Edinboro at the end of June and you wanted this as your topic,
isn't it? Yes, that's right.
Yes, damage control procedures and really unpacking it in a bit
more academic rigour, bringing a little bit more data from some
of the events. One event that I shouldn't
comment on that Doctor Tom and I were able to do is a workshop of
trying to unpack and sort of pull information out of the
Ukrainian experience to be able to better Polish off the the
curriculum of the DCP really specifically for Ukraine.
So essentially it was we, we ended up in, in late November
after doing a damage control resuscitation training, which
was, which is absolutely brilliant with our partner
tactical medicine N, who are just an absolute brilliant
provider and service provider for Free Hospital care within
the Armed Forces of Ukraine. But they also do a lot of
training and they, they really, they, they, they pack a punch
well above their weight class. They do, they do some, some
great stuff. And in that, in that damage
control procedure workshop, we, we used a nominal group
technique, which is really a fancy way of saying we let
everyone's voices be heard without getting any attribution.
So we got a lot of, a lot of fields folks in the room and we
from across the board and we, we, we had, you know, Chatham
House rules and we were, we're, we're pulling information out or
what's working, what's not working.
How do you define Rule 1 and Rule 2 and what do you want and
Rule 1 and Rule 2 and how do you define those, those skills
specifically? And we kind of teased out a lot
of information. It was quite combative at times.
Academically, it was extraordinarily challenging and,
and, and you know, by the end, we were able to clearly define
what they wanted, what they defined as role one, which is
actually what we one of the papers that'll be coming out.
They really wanted to classify that as role 0, which was very
interesting. It's been a bit of a paradigm
shift to the military medical paradigm from NATO and the
concept from the Department of Defence, department of War, the,
the concept of role zero and really what they want to have
available there, what they're willing to have available there.
These are folks that are that are are, you know, functioning
underground rocket fire and under drones in basements and
they scurry from point A to point B in small groups so that
their footprint is smaller. I mean, these are these are
really far forward folks. I said this is what we want to
do. This is what we consider the
role one to beat is what we consider role zero to beat.
That's what we consider role two to be.
And this is what these are the exact skill sets that we would
like in each of those actual lines of care.
And more importantly, these are the types of medical providers
that we just did, we described. So we defined the.
Competency and the skill sets of the different types of of
providers inside Ukraine and where we want them to be at rule
zero, row one, row 2. So it was a mapping, a lexicon
mapping exercise. It was a descriptive exercise.
The most importantly, it was the Ukrainian voice of what they
wanted. What they saw was the need.
And then we were able to Polish the curriculum so we can we can
face and we could we can meet the challenge of those need that
each of those echelon. Now, it won't be perfect
obviously. And I think even since November
the threat level has changed. The number of fibre optic
drones, the number of drones that attack medical personnel
by, you know, the Russian forces, the number of buildings
that are attacked with really heavy weapon systems.
And the, the, the level of grey zone and hybrid warfare that is
taking place across Ukraine is extreme.
And it's, it's more extreme now than what it was in November.
And despite the, the excellent, the positive news that we're
hearing coming out of Ukraine about the, the, the increased
use of land drones, air drones, and really being able to
leverage that with the use of AI systems to capture land.
I mean, this is all excellent and great and positive.
There's still people dying every single day and there's still
significant challenges in dealing with a, a huge adversary
with a lot of people, a lot of technology.
And the, the, you know, no qualms about completely
obliterated the concept of genetic convention, No issue
whatsoever about attacking civilian, civilian
infrastructure. And also no, no, no issues
whatsoever about going after healthcare facilities, medical
evacuation facilities and vehicles, and doctors
specifically and medics specifically.
So really still a massive challenge and a massive threat.
So when we, when we were back in, in February and March doing
some training near some Borderlands, that was great to
get additional data capture again, qualitative data capture
of what we see is going on and what, what the feedback we're
getting back from them. But overwhelmingly all of them
said, yes, we need the DCP, we need, we need access to at a
minimum Tier 1 and Tier 2 concepts of the damage control
procedures because we are, we are getting patients we cannot
deal with. We do not have the skill set to
deal with and we're getting patients that need far more than
what we can do. We can't get them to where they
need to be in time. And so that's that challenge.
Despite the threat level getting worse, despite the change in
the, the, the battlefield, still we need, we still have this gap,
this damage control procedures gap that we need to address.
So hopefully we'll be able to address this gap in late June
and and July when we go out again and and do some additional
far forward training specifically with tier one sort
of stuff and Tier 2 damage control procedures and also
establish a little bit better network for cadaver training and
a handful of other logistical things that we need to get
online. And so that's really, that's
really the need. So as as creative as it is that
we're, we're getting us out there, I still feel like we're
late. We're not too late, but I think
we're still very late. And we need to get, we need to
get the Ukrainian involvement much, much more get their input
and their feedback. And I would, you know, anyone
listening to this, I would encourage all of you to engage
more with Ukrainian colleagues, not just trying to talk them for
information. Obviously very busy.
They're dealing with patients on a daily and hourly basis.
But more importantly, what we can do for them and how we can
support them. And I think that's something
that is across the board, whether you're, whether you're
doing disaster helps stuff, whether you're doing
humanitarian health stuff that we need to be able to provide a
lot more, a lot more support material as well as personnel if
you are willing to go and volunteer and spend some of your
time and expertise in countries. So I encourage everyone to to
mobilise and provide more support, absolutely.
For the listener who is interested in learning more
about damage control procedures, are you planning on running a
DCP workshop at our Medicine and Mediterranean conference at the
end of January in Malta? Yes, absolutely.
We were able to get elements of the damage control procedures
really damage to resuscitation in Ukraine, which we we had
concepts of the DCP, we had some some very specific skill sets
there, blood warming techniques, partial verbal, etcetera.
Yes, the answer is yes. If you have interest in damage
control procedures, we will be running a detailed damage
control procedures workshop with a whole lot of new information,
new data sets and a lot of hands on stuff to do in January in
Malta 2027. We're very much looking forward
to that. It's going to have a completely
revamped approach. We're going to have a whole lot
of information from the missions in Ukraine and we're also going
to have access to a lot more procedures themselves.
And I would definitely encourage anyone that has interest to be
able to take a look at that and see, see what you know, see if
you're available, if you're available to come out in late
January, we'd love to have you. John, my final question for you
is this. What advice do you have for the
remote medic, the nurse, the Doctor Who is just starting out
in their career in austere medicine?
See as many patients as you can. So I, I definitely, I think it
is challenging working in the pre hospital environment, it's
challenging working in austere environments, it's challenging
working in this type of environment.
And the confidence I get personally is by seeing
patients, certainly by doing training.
I just completed my my 9th or 7th or 8th, maybe my 9th
advanced trauma life support training, instructor training.
I still do my advanced burn life support, my advanced cardiac
life support, all of these types of training that you do every
two years, every four years. It does help with confidence.
It helps give give you builds your confidence expensive.
It's difficult, it's challenging to plan it, but when I see
patients, I am encouraged and I am reinvigorated.
So if you're out there and you're like, I really want to
get into this, I want to learn about this more, etcetera.
I think you need to increase your your patient volume.
And when you do have patience, do your exam and, and document
your exam. Do your exam well, 'cause no
harm first, do no harm and really, really focus on these
basic skills that they become a second nature.
One of the opportunities I had in, in 2004 to 2006 or 7 or so,
running a, a small clinic, multiple small clinics
throughout Iraq, patients came in all the time and they wanted
tablets for headaches and tablets for this and, and
different things with their, their big toe, etcetera.
Use it as an opportunity, use it as an opportunity to do a
physical exam, take a clinical history, a detailed clinical
history and, and really, really sharpen your clinical skills so
that you have confidence, you have confidence to deal with the
emergency and you don't become complacent and you don't say,
oh, this is cool. I get to sit in the desk and and
do this and that No, you know, get off to get off the desk, go
around, see the, the, the, the area that you're at, look at the
public health, think about the epidemiology that you can
provide support with. You know, the far forward medic
is not just ready for the heart attack, not just ready for the
trauma, but you know, it's a, you're a, you're a provider of
health. And so being able to really
encourage and, and run out there, do a whole lot of
different things, capture a whole lot of information, gather
a whole lot of information, try to analyse that and try to speak
with mentors and engage with mentors so that you can, you
can, you know, make a, the, the healthcare of the patient in
front of you better. But also the environment, the,
the community that you're dealing with, whether it's four
guys on an oil rig or whether it's, you know, 123 local
nationals at A, at a copper mine and everything in between.
Be able to really sit down, sit down with your patient, sit down
with your community and capture a lot of, of information so that
you can hopefully, you know, make the make the community
better. You know, not to sound like a
broken record, but reduce available morbidity and
mortality and really and really look at what you can do to do
that actively and practically. Doctor John Quinn, it's
fantastic to have you on our faculty.
You were you're making a difference in this world.
And I think a little beam of light follows you around hitting
England top of your head as you walk through life.
And thank you for all that you do in the community.
Thank you so much for the opportunity.
I appreciate it. And that light is probably the
police chasing me. This has been a presentation
from the College of Remote and Offshore Medicine.
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