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