Note: This guest post was written by DK, an Air National Guard pararescueman and doctor of physical therapy.

BK recently wrote an article in which he cautioned against overreacting to the controversy surrounding military contractor and retired Army physician John Hagmann. Like BK, I interacted extensively with Dr. Hagmann during my career as an Air Force pararescueman, having taken his Operational Emergency Medical Skills course four times. At no point during those courses did Dr. Hagmann conduct himself in what I perceived to be an unprofessional manner, although he did teach and supervise numerous procedures that could be construed as somewhat risky without proper context.

I hope to provide that context to elucidate why training civilian trauma practitioners and SOF medics must necessarily differ. The non-medical accusations made against Dr. Hagmann are a different matter altogether and beyond the scope of this article. The personal aspects of this case should not, however, obscure the medical validity, the necessity, in fact, of the training espoused by Dr. Hagmann.

Despite graduating with a clinical doctorate from an Ivy League university, I can say without hesitation that the quality and clinical relevance of my training as a SOF medic far exceeded anything I encountered in formal academia, in a fraction of the time. Between the pararescue pipeline and continuing education courses like Dr. Hagmann’s, I learned to confidently and independently conduct procedures that a civilian with a comparable scope of practice (chest tubes, surgical airways, blood transfusions, narcotic administration) might not learn for 8-10 years.

In fact, courses like Dr. Hagmann’s highlight how antiquated medical education is in this country. Any honest medical practitioner will tell you that the skills he actually uses in clinical practice were cultivated during residency and fellowships, which, in the case of an aspiring physician, begin eight years after he graduates high school.

Most academic medical programs are rights of passages in which students are required to memorize such an excessive volume of information that important concepts can be missed in an effort to retain esoteric details. Courses like Dr. Hagmann’s are principle-based and provide a sufficient theoretical background to guide clinical decision-making without overwhelming the student with facts that can be looked up in seconds with a pocket guide or smartphone.

The SOF medic simply does not have eight years to learn a surgical airway or chest tube, especially considering that the tactical and mobility aspects of the job require equally extensive training. SOF medical instructors are educators who, out of necessity, must demystify advanced skills.

The same people who regard SOF medical practices as unnecessarily extreme probably do not skydive, SCUBA dive, or fast-rope out of a helicopter to get to work. The nature of SOF medical training must reflect the reality of the job. There can be no false confidence. SOF medics bear an incredible degree of autonomy and responsibility. Even an attending physician in the emergency room has access to a team of residents, specialists, nurses, and medics when treating a critical patient.

During my first mission as a pararescueman, I had to perform a surgical airway on a pilot in Alaska who had sustained substantial facial trauma after crashing his private plane into a forest. The crash site was only accessible by helicopter, the rotors of which forced snow into the dark, damaged cockpit as we tried to extricate and stabilize the patient at night. I had just completed Dr. Hagmann’s course, where I practiced that very procedure on a live patient model.

I don’t think I could have confidently executed that procedure under such conditions had I learned it on a simulator or mannequin. My teammate, the team leader, was generally unable to assist with the patient’s medical treatment because he was on the radio, helping the flight engineer guide the hoist cable (our only way out) through the densely packed trees.

During my most recent mission as a pararescueman, I was tasked with running a casualty collection point for a mass-casualty incident incited by an improvised explosive device and follow-on ambush, involving a total of 12 partner force soldiers hours from definitive medical care. When we weren’t conducting operations in this theater, I provided sick-call medicine for coalition and partner forces at our forward operating base, once again, hours from specialized care. The training methods that those outside the SOF community might consider deplorable prepared me well for the complex situations I encountered.

Now that the “context” of SOF medicine has been established, the seemingly controversial aspects of Dr. Hagmann’s course must be identified and justified.

1. Live-tissue models do offer a training advantage over patient simulators. Simulators are great for certain things, like running through algorithms for cardiac arrest cases (i.e. when somebody needs CPR). In cardiac arrest, the patient is essentially dead anyway! The number one cause of preventable death in the tactical environment is uncontrolled bleeding. A live patient model “bleeds” much differently than a mannequin out of which an evaluator hand pumps red Kool-Aid through plastic skin. Live-tissue training accelerates the learning curve for SOF medics exponentially. One might argue that for ethical reasons, the ends (superior training) of live patient models do not justify the means (harm to a living creature), but the end state itself is not debatable.
2. Performing penile blocks and Foley catheters on one another is not just an exercise in sadomasochism. Penetrating and blast trauma are far more prevalent in the tactical environment than even the most violent U.S. cities. The genital region may not be spared in a blast injury or gunshot wound. Pain control is probably the most humane thing a medical practitioner can do for a patient. In the SOF world, centrally acting (working at the level of the brain) pain medications may be contraindicated in instances of genital trauma because the patient may still need to operate a firearm and perform other cognitively demanding skills. A locally acting procedure like a penile block (an injection that numbs the area) provides pain control without affecting a patient’s decision-making ability. In a hospital room, potent, centrally acting pain control for genital trauma is much easier to justify. As for Foley catheters, SOF medics typically do not have the time to rotate through intensive care units to gain experience with this procedure. If a SOF medic has to catheterize someone in the field, it’s probably because he must monitor urine output in a patient that is days from evacuation in a non-permissive environment. The procedure itself is theoretically simple but the execution is all about the details, which are not reinforced by notionalizing the steps.
3. “Shock labs” and buddy transfusions are not too dangerous to perform in training. Outside the military, no medic level providers are permitted to administer blood products, let alone independent of medical control. Then again, in the civilian world people rarely lose multiple limbs and close to half their blood volume instantaneously from blast trauma. Most SOF medics have treated this kind of injury, many numerous times. Especially when transport times are extensive, these patients will die without a blood transfusion. Practicing buddy transfusions (using the trainee’s own blood) in a controlled environment during which a physiologically insignificant amount of blood is drawn from the trainees resonates much more than simulating the procedure with Kool-Aid in a mannequin. Again, the procedure is theoretically simple but missing a single step can confound the practitioner under duress. The powerpoint generation of educators often forgets that the emotional/contextual aspect of learning ultimately ensures retention. Partaking in an actual procedure as the subject and/or the practitioner is much more impactful than checking the boxes some other way. In the SOF environment, there can be no false confidence because nobody will be there to correct you when you mess up.
4. Drugs like Ketamine can safely be administered to trainees. Ketamine has emerged as the centrally acting drug of choice for pain control in the SOF community. It is relatively safe drug, but like any medication it is not without side effects. Witnessing those side effects in a controlled environment in healthy subjects administered minimal doses of the medication is substantially more salient than reading about them in a textbook. This seemingly subtle distinction matters because the SOF medic needs to recognize the difference between a routine side effect and a deterioration of the patient’s condition. Without having observed how people respond to Ketamine, one might perform an unnecessary invasive procedure on a patient or invest resources into evacuating somebody that isn’t actually sick. Recreational alcohol consumption is more dangerous than the “experimental drug use” that occurs in Dr. Hagmann’s course. Nevertheless, students should provide consent prior to receiving medications like Ketamine in training.

Now that these practices have been exposed in the mainstream media, there will almost certainly be political pressure to reform the manner in which military medics, including those from SOF, will be trained. The lazy solution would be to dismiss Dr. Hagmann’s effectiveness as an educator in light of the questions about his character. They are two separate issues, and at this point, Dr. Hagmann’s motives for these seemingly extreme training methods are speculative.

Hopefully, when evaluating military medical training going forward, civilian leadership will solicit the input of the people for whom this training was designed and not capitulate to those whose occupational reality is drastically different. Per capita, more man-hours in the military are lost to ultimate frisbee and jogging than to medical training like that championed by Dr. Hagmann.