In February 2008, JEMS published an article by William Brown titled"A Missing Link,"about the Advanced Practice Paramedic. Brown_s concept that paramedics can be an extension of the medical director, allowing those who excel to have the ability to perform at a level beyond traditional paramedics, is an interesting one. Some of his ideas mirror an existing military program called the Advanced Tactical Practitioner (ATP).
The ATP was developed and implemented by the United States Special Operations Command (USSOCOM) Curriculum and Examination Board (CEB), a group of civilian and military professionals who have spent the past five years working to address some of the same issues that Brown mentions but in the military special operations environment. The genesis of their work is a federal medical provider certification for special operations medics (SOMs).
Although the military version of the certified ATP may not be 100% compatible with the needs and desires of the civilian sector, the concept is similar and the work that has been done could provide a head start in the development of either the Advanced Practice Paramedic or the sorely needed development of an EMT-Tactical Medic certification level.
What Does an ATP Do?
The following story is a typical night for the ATP engaged in the Global War on Terrorism (GWOT).
At just past midnight, a Special Operations Assault Force sets off in Blackhawk helicopters from an undisclosed location in Iraq. Because this mission has been deemed extremely dangerous due to the likelihood of encountering enemy forces and difficult terrain, two ATPs accompany the assault force tonight.
The assault force slides down ropes from the hovering helicopters to the target and begin their assault. They_re immediately met with AK-47 fire and sustain casualties. Both medics move with their respective elements toward the location of their wounded comrades. The medics encounter the following patients:
Casualty 1sustained a gunshot wound (GSW) that entered under the left armpit at the mid-axillary line that appeared to have severed the axillary vasculature. The entrance wound was approximately 1-2 cm wide with a large racquetball size cavity behind it. ATP 1 managed to clamp one of the bleeding vessels by palpation with a set of large hemostats. He continued to work on obtaining control of the axillary wound while ATP 2 started exposing the chest. A third soldier exposed the left arm and found a GSW to the left bicep. Because there was significant bleeding from the arm wound, ATP 1 directed the soldier to put a tourniquet on the arm, stopping the bleeding.
At this point, ATP 1 had sustained a GSW to the right forearm, which had tracked up the entire length of the arm. He applied a tourniquet to his own arm and continued to treat casualties. He would require evacuation due to the blood loss he had sustained.
Just prior to taking over for the injured ATP 1, ATP 2 performed a surgical cricothyroidotomy on Casualty 1 to gain control of the airway. Taking over for the wounded medic, ATP 2 moved over to Casualty 1_s right side and started trying to palpate the chest wound, attempting to gain control of the bleeding. After finding a large cavity in which the flow of blood could be palpated, ATP 2 decided it was necessary to open up the wound into the cavity to visualize the bleeding. After making a three-point star pattern incision centered on the initial bullet hole, access to the large chest and lung cavity was obtained. Although there were no large bleeding vessels visible, a large area of severely injured tissue along the chest wall and upper axillary area was bleeding profusely.
With the help of another soldier, the blood was wiped away and hemostatic dressings were torn in half and used to line the chest wall and axillary area. The cavity was then packed with Kerlex, trying to build a "ball" that would put pressure on the chest wall and upper axillary area. The arm was rotated downward against the casualty's body, using the humerus to put pressure on the ball of Kerlex. The arm was secured with a cravat looped around the casualty's wrist and tied around his thigh to keep the humerus over the ball to maintain pressure.
ATP 2 then rolled Casualty 1 to check the posterior side and found an exit wound 1-2 cm in diameter in the mid thoracic area of the left chest just lateral of the spine. A chest seal dressing was applied, which was effective. Another soldier opened the litter, and Casualty 1 was placed on the litter and strapped in.
After moving to the landing zone (LZ), ATP 1, Casualty 1 and ATP 2 were loaded onto a helicopter, which immediately departed for the Combat Support Hospital. After loading, ATP 2 began to ventilate Casualty 1 with a bag-valve mask (BVM) and oxygen. While ATP 2 continued to bag Casualty 1, the flight ATP performed a needle decompression to the left chest. The packing in the axillary was holding, and there was no hemorrhaging. When reassessing the vital sign monitor in the aircraft, Casualty 1 was noted to have thready to absent pulses. Chest compressions were started. Following the successful resuscitation, monitoring continued for the remainder of the flight to the hospital.
Casualty 2 received a non-debilitating ricochet to the left forearm. The intact bullet was buried within the dermis and later removed with secondary closure after returning to base. Post-procedure wound prophylaxis included Gatifloxacin 400 mg QID for seven days.
Casualty 3 received minor shrapnel injury to the face when his weapon was hit while returning fire. The shrapnel was removed, and the area was irrigated and debrided accordingly. He was followed up daily for signs and symptoms of infection.
AlthoughCasualty 1 did not survive through surgery, the ATPs provided heroic prehospital care to seriously injured multi-system trauma patients, at night in the middle of winter with little to no light. The care required byCasualty 2 andCasualty 3 was initially provided by ATPs, and because of the advanced training that an ATP receives, the procedures, follow-up care, antibiotic and medication prescribing (done under a physician's license), and determination of the return to duty status were all done by ATPs as well. The ATPs in this scenario provide routine and preventive medical care to all the Special Operations Soldiers with whom they serve. In addition, medical planning and coordination for all the operations within their element is done by the SOF team_s medic -- an ATP.
The Evolution of the ATP
As described, the ATP represents a highly trained SOM who is further trained to deliver a selected level of medical care normally reserved only for mid-level practitioners, such as physician assistants and nurse practitioners, and physicians. Through advanced training and certification processes, the ATP learns to address specific complex traumatic and medical problems encountered on the modern battlefield and to provide advanced medical care for troops in austere conditions where no other advanced medical provider is available.
The need for an ATP certification arose from the recognition that the current certification process, although effective in the civilian sector, was not answering the requirements of the military. In the 1990s, Congress recognized the need to accredit military health-care providers. In fulfilling this mandate, the National Registry of Emergency Medical Technicians (NREMT) was utilized as the licensing and oversight agency for medical training of military medics. However, because the training and certification were based on the civilian paradigm, where definitive care was readily available and the clinical time of responsibility was limited, this model was not ideal for the SOF environment.
This dichotomy between training and need was emphasized by the military actions in Somalia, Bosnia and Desert Storm during that time. Medics in these environments were required to perform increasingly sophisticated invasive medical procedures. Because the survival rate of injured soldiers depends on the close proximity to definitive care, but moving a critically combat-injured patient or bringing substantial number of physicians to the front-lines are both impractical, enlisted medics had to assume greater responsibility for prolonged patient care.
As a result, the SOF medics were receiving the same certification (EMT-P) as civilians, but were required to have additional knowledge and skill sets in order to provide the care needed in their environment. Some medical procedures performed by the SOF medic were not recognized as being within the skill set of the EMT-P, and therefore, were not technically certified or authorized by the NREMT certification. Minor surgery, prolonged nursing care, suturing techniques and medical decision-making were out of the question in the civilian world under the NREMT-P certification but were routinely required of SOF medics in different areas of the world.
It became clear that the dynamics of warfare and the non-linear battlefield required a new approach outside the existing EMT training and certification parameters. Thus, the Special Operations Combat Medic (SOCM) Advanced Tactical Practitioner (ATP) occupational model was developed. This model was based on interoperable SOF mission activities and the patient populace within those mission parameters, rather than the overall country's general patient populace. The SOF medics were now required to meet the requirements for EMT-P and then receive additional advanced training that was not required on the civilian side.
This occupational model was a novel concept, and the SOF medic received no recognition through any type of formal certification or licensing process. The NREMT certification did not address or certify the SOF medics to operate with the higher skill sets that were becoming increasingly necessary in the GWOT. Unfortunately, no nationally or internationally recognized prehospital curriculum or certification process encompassed the knowledge base or psychomotor skills needed to successfully conduct medical operations within all of the USSOCOM operational missions.
Because there was no certification process that authorized the procedures or degree of independent medical activity being performed, it became necessary to develop a new level of medical certification. After conversations with the National Registry did not yield a definitive solution, the USSOCOM commander directed the USSOCOM surgeon to develop a method of training and certifying SOF medics to requirements that would ensure mission success.
Thus, a multi-disciplinary board -- composed of military and civilian physicians, allied health personnel, and SOF medics -- was established to develop a curriculum, certification process and certification exams for all SOF medics. This board, termed the USSOCOM Curriculum and Examination Board (CEB), established a certification process that had a number of goals:
- Withstand outside scrutiny of inspecting or accrediting educational agencies.
- Certify the SOF medics for their unusually high degree of medical techniques and advanced nursing care that must be administered prior to evacuation.
- Develop a curriculum that would allow for the certification process.
- Develop the legal basis and framework under which the new certification process could be developed and implemented.
Although development of a new level of certification seems relatively straightforward, the implementation was slow and complex. Before developing the ATP certification, it was necessary to:
- Develop a departmental structure composed of pre-existing personnel within the USSOCOM Headquarters/Component Commands and volunteer health-care providers and educators from the conventional military and civilian medical communities.
- Mirror business practices and medical credentialing processes to that of state and provincial governments' bureaus of emergency medical services.
- Establish a Requirements Board (RB), composed of operational-level enlisted medical operators and physicians, to develop an educational needs assessment, including identification of the fundamental tasks (a Critical Task List) that the SOF medic should be capable of successfully performing, while providing sound medical care. Essentially, the Critical Task List would form the basis for the scope of practice for the new ATP certification.
- Develop a medical curriculum and certification process through the employment of a specialized Curriculum and Examination Board (CEB), composed of professional health-care providers and educators from various backgrounds and communities. Specifically, the CEB included subject matter experts selected from the conventional side of military medicine, the SOF side of military medicine and the civilian world of medicine -- military physicians, civilian physicians, civilian educators, military educators, and military medical operators. This balance allowed a number of different perspectives to be introduced throughout the development process.
- Seek accreditation by the Committee on Accrediting Emergency Medical Services Programs (CoAEMSP) for the medical training centers of USSOCOM.
From a practical viewpoint, the Requirements Board developed the Critical Task List necessary for the ATP portion of the course. It was then given to the CEB, which was assigned to:
- Develop the recommended Terminal Learning Objectives and Enabling Learning Objectives that would satisfy the requirements for testing of the knowledge required by the Critical Task List. (Teaching would remain the responsibility of the Joint Special Operations Medical Training Center and the Pararescue School at Kirtland Air Force Base.)
- Develop the test bank of questions that would become the basis for the ATP certification exam.
- Develop the review process for determining question validity.
- Develop the testing process for this exam.
- Develop the administrative oversight process for the testing process.
- Develop a study guide for ATP students preparing for this certification exam.
- Develop the Tactical Medical Emergency Protocols for a set of medical conditions that would further define independent medical care by the ATP. This also led to the establishment of medical protocols for use in the special operations environment when direct medical control and oversight was either operationally impractical or impossible.
As the Special Operations environment is an ever-evolving one, the question development process and subject matter process are also ongoing, as medical technology and treatment approaches change. And as "Lessons Learned" studies become available, the ATP certification process will be adapted to reflect the updated knowledge and procedural changes.
Once certified, the ATP certificate is valid for two years and is then renewed after attending the SOCM Skills Sustainment Course and obtaining the required additional CME.
The Committee on Accrediting Emergency Medical Services Programs (CoAEMSP) has recently reviewed the curriculum at the Joint Special Operations Medical Training Center (JSOMTC) and has certified that the JSOMTC is CoAEMSP compliant.
What the USSOCOM CEB has to offer to our civilian counterparts are the developmental experiences and countless hours spent devising a workable concept of an advanced tactical prehospital practitioner. The current process has allowed for the successful development of a certification process to ensure that medical training supports mission requirements while simultaneously ensuring quality that will meet external scrutiny. This, in turn, has resulted in the successful development of a certification process that recognizes the advanced clinical skills and knowledge required by the Special Operations Combat Medic and allows for uniform education in the special operations environment in all services (Army, Navy, Air Force, and Marine).
In developing the Tactical Medical Emergency Protocols, the CEB attempted to mirror civilian paramedic guidelines when they were applicable and established others where gaps were identified. This required extensive out-of-the-box thinking, particularly when dealing with situations where resource constraints and prolonged evacuation times dominated the decision-making process (e.g., determining weight and space requirements for the medical backpack, supplies and medications). However, focusing on the end state and the fulfillment of the mission requirements allowed solutions to be developed, which initially seemed unachievable.
Following this, sustainment training was developed with a two-year certificate to ensure practicing ATPs are kept abreast of new advances and changes in protocols and medical knowledge. Constant feedback from the field and the ever changing special operations environment continue to drive these protocols forward. This was fundamentally achieved by what Brown coined as the "cognitive leaders," who were field-level experts. The result of the entire process is the certified Advanced Tactical Practitioner and an educational program that has been in operation for several years with tremendous success, as evidenced by the high quality of battlefield care in Iraq, Afghanistan and other regions where SOFs are deployed.
With the concept of an Advanced Practice Paramedic (APP) being considered in the U.S., the USSOCOM CEB would welcome the opportunity to share our experiences in the development and implementation of an ATP with the civilian community. Proposals for an APP have been developed and successfully implemented in the past five years at the JSOMTC training center in North Carolina and Kirtland AFB in New Mexico. Given the difficulty in developing a new certification program, it seems logical to integrate the experiences of the USSOCOM CEB and the desire to develop a new civilian certification for the APP.
Further information on this program may be obtained via e-mail email@example.com.
Rick Hammesfahr, MD, is the chairman of theUnited States Special Operations Command Curriculum and Examination Board. He's themedical director of theTactical Emergency Medical Support Team, Marietta (Ga.) Police Department and adepartment physician andspecial deputy sheriff for Cobb County, Ga. He's also the author of "Tactical Emergency Medical Support - A Field Manual."
Troy Johnson, MD, is the assistant chief for academics in theDepartment of Emergency Medicine at the Brooke Army Medical Center in San Antonio, Texas. He's also an assistant professor in Military and Emergency Medicine at the Uniformed Services University of the Health Sciences. He serves as the secretary of the USSOCOM Certification and Examination Board and has an extensive background in Military Special Operations.
Bob Hesse, RN, NREMT-P,has 22 years ofexperience and background in multiple areas of medicine, including EMS, military medicine and critical care transport. He's a certified flight nurse and certified flight paramedic. He is the prehospital clinical specialist for the United States Special Operations Command Curriculum and Examination board and has published multiple articles on SOF medicine. He's also on the editorial review board of the Journal of Special Operations Medicine.
Bryan E. Bledsoe, DO, FACEP, EMT-P, is a clinical professor of emergency medicine and an attending physician at the University of Nevada School of Medicine and University Medical Center in Las Vegas. A former EMT, paramedicand paramedic instructor, Dr. Bledsoe has written numerous EMS textbooks, including Brady_s paramedic textbook series. He_s a frequent contributor to JEMS and JEMS.com and regular speaker at EMS conferences worldwide.