Austere Medicine and the Ukraine War with Dr. Brian Strickland

In this episode, we interview Dr. Brian Strickland, a current EM physician at Massachusetts General Hospital and an expert in wilderness medicine, about his experiences in austere environments such as Ukraine. 

Transcript

Unknown: 1:01

Brian, hello, I'm Captain Turner, and welcome to another episode of the GSA SEP podcast. In this episode, we're interviewing Dr. Brian Strickland. Dr. Strickland is an EM physician and clinical fellow in space medicine at Massachusetts General Hospital. After graduating from EM residency at the University of Chicago, he completed a wilderness medicine fellowship at MGH, and has worked clinically in remote and high altitude locations, such as the Himalayas of Nepal, Northern Mariana Islands, and the Alaskan Arctic. When not working, he spends as much time on skis or mountain bike as possible. So, Brian, why don't we start off with you telling me a little bit about your career? Yeah, so right now my official position is a I am a clinical fellow in space medicine at Massachusetts General Hospital, or Mass General Brigham. This is a fellowship oriented, it's a two-year fellowship that is emergency medicine based, in which we spend time working almost like an internship at Commercial Space Flight Company, either right now it's like Fast or SpaceX, while also spending some additional time on scholarly projects like research and other authorship, and then working in a more typical academic emergency medicine environment. My background is I did my residency in emergency medicine, the University of Chicago graduated in 2019 and went on to do a fellowship in wilderness medicine, 2019 to 2020 at Mass General. After that, I was really interested in continuing some work in some more remote and austere environments, a small Pacific island called Saipan, which I think some of your listeners would be familiar with, and then also had some projects in Nepal and the Himalayas near Ever Space Camp, and then also have worked in the Alaskan Arctic as well. My focus is currently mostly on space medicine, but more broadly is in resource-constrained and remote environments. How do we deliver healthcare successfully in those environments? How do we teach other people how to be successful in those care environments? So, yeah, all part of the same continuum. So, how did you end up working in Ukraine? So, I've been following this conflict quite a bit before the full scale invasion in 2022 but I think, like, a lot of us are really starting to understand the global implications of the war as it intensified, and as Ukraine managed to hold off that initial push on Kyiv, despite facing a much larger and well-resourced invading force, the Ukrainians are really showing like remarkable resilience and innovation, and I was, and continue to be, really amazed by their ability to innovate, create solutions, and survive in an environment with relatively few resources and a significant manpower disadvantage. I kind of just talked about my background, that's taken me to some really remote locations to practice, places where we did not have much of the same resources that we do in a typical ED setting, working in those places, those have really helped me to improve the quality of care in some challenging environments, but also at the same time it's refined my own skills and made me a better physician once I'm back in the emergency department. So I've seen this always as a two-way street, I'm always looking for additional ways in which I can both help others who are in these resource-constrained environments, but also learn more about how to practice medicine, or at least what are the challenges of working in these environments, so that I can take that back home and myself become a better physician, and also teach others back stateside, so with the conflict in Ukraine, as I watched all this innovation, and as just the entire nature of the conflict changed, I really wanted to see whether my experience in these remote in Austria environments and practicing early teaching those environments, how could that translate into like a new setting? So I was really lucky to connect with a nonprofit called GSMSG, which is an organization that provides medical care as well as education for healthcare providers in conflict zones, and they gave me an opportunity to travel to Ukraine last summer to teach a course for a couple weeks on prolonged field care. What sort of work were you doing in Ukraine? Our work was focused on education. Specifically, we're made up of a team that consisted of a trauma surgeon, actually two EM physicians, and two paramedics. Our goal is to train a team of combat medics and skills for prolonged field care. This is an in-person course, and we had a pretty diverse instructor team, so each of us could bring knowledge specific to our own specialties. The course itself was focused on prolonged field care. I think a lot of your listeners will be familiar with the concept. It's gotten more attention because of the war in Ukraine, but for anyone who's like less familiar with this, I think the key word is just right there in the name, prolonged. The more traditional T triple C, or tactical combat casualty care, is built around what's essentially a time-bounded problem. Prolonged field care, sometimes called prolonged casualty care, is designed for what happens when that time-bound breaks. So, T triple C assumes like that we have capability for evacuation in minutes to hours. Think of the whole like golden hour framing, and it's designed to address the leading causes of preventable battlefield deaths, so things like massive hemorrhage, tension pneumothorax, airway compromise. You stabilize the patient and hand them off. The whole model depends on effective logistics, or at least geographic proximity to definitive care, or at least Kazevac, but your TCCC algorithm, it ends with that quick handoff in cases where you can't make that quick handoff because of distance, whether something like a mass casualty event, contested airspace, or really like the case of Ukraine drones like FPV or drop drones that are actively targeting medic teams and vehicles, you need a completely different paradigm to keep your patient alive until they are able to reach the definitive care. Sometimes that could be up to like days away. So, instead of like treat and transfer, becomes treat, reassess, continue to treat, anticipate, and recognize deterioration and manage complications when they occur, and they will occur in this newer style of conflict. Medic teams are seeing exfo times of multiple days, which is up from, you know, significantly from the global war on terror, where we saw towards the end of that conflict mean time to definitive care to like roll two, being about like 45 to 60 minutes on average. Anybody who's a combat medic in this environment, they need additional skills in order to do their job well. So, instead of just doing something like a needle decompression, your medic needs to know how to subsequently place a chest tube. It's not enough to put on a tourniquet. Your medic needs to be able to take that tourniquet down after a few hours, once they're in a safer place, and perform potentially a vessel ligation to prevent any unnecessary limb loss, potentially they need to place IVs or even potentially central lines to give blood. Casualty who has been in the field for days, your medic needs to recognize the early signs of sepsis, potentially start fluids or antibiotics, things we do in the emergency department, but much more difficult to do in a field setting. Also, in wintertime, patients become hypothermic and coagulopathic, so medics have to recognize hypothermia, learn about coagulopathy, the importance of keeping their patients warm, and then also learn about rewarming strategies where their patients aren't going to survive. Like I said, this type of instruction does predate the war in Ukraine, but until recently, there hasn't been a large scale interest, or really like, like a mass need for that, but with the conflict in Ukraine, and looking forward to what conflict might look like around the globe, this is not really like a niche concept. So our class was really aimed at addressing that gap, which was glaring, and you know, there was a big need and a big demand for this sort of curriculum. Actually, in Ukraine, it sounds like a great thing that you're doing. Definitely, over here on our side, there's being a lot more emphasis on that, but I think there's still like a lot of people don't realize how like essential this is going to be in the future. So, when it came to training these medics, did you encounter any particular challenges or cases that were more difficult to teach than others. A broad answer to that question is that all of us that were on this trip were just so impressed by the medics, their abilities. Many of them don't speak English as their native language, but to work through some of just kind of some basic communication difficulties that you would expect, all of them did so well, and I, we were just amazed by their ability to learn this curriculum quite quickly, and sort of extrapolate it to care for patients that are in an environment that ourselves, like that, we're not inherently familiar with in the United States. In my experience, and with like international relief work in general, whether that's direct medical care or formal or even informal teaching, we always try to do some sort of needs assessment, like something like that is important to do as early as possible. So, as far as challenges go, we try to like figure out what those are going to be really upfront. We had some information about the medic team ahead of time, but it was a little limited. So, on our first day, we sat down with them to get a sense of, like, what their experience level was. You know, as you expect, their knowledge, skills, abilities are all over the place. Some of them had some significant formal TCCC training and years of combat experience, while others were quite new to the role, or had some skills gaps that we needed to address early, so yeah, I think it was actually like a pretty big challenge to figure out how to bring the less experienced medics up to speed, so that they could get a lot out of the class, we. While simultaneously keeping your more advanced medics engaged, that way a big challenge, but one I think that we did a good job in doing. We also were had an excellent team that was there with plenty of instructors, so that we're able to break off and provide more individualized and almost a case-specific type education. How long was the entire course? Course was just a little over two weeks. Gotcha. Did this course incorporate the effect of drones at all? I mean, obviously drones are a huge reason why we have prolonged field care in the first place. Absolutely, one of the things that I think we were all aware at the time of the course was how drones have really like shaped this conflict in the last couple of years. I think even with that being said, we did not fully understand that, like, how much at the time, so it was a challenge, not for the students, but was more a challenge for ourselves as instructors was figuring out how to design this curriculum so that all the students could get as much as possible out of it, and an example of that was actually when we arrived in doing that needs assessment that I talked about, we had a session where we went through with the whole group, and had just a big conversation of like, what type of injuries are the casualties actually experiencing out there. What are the truly the big challenges to expo? Like, is it just being hit by drones? Are there other things? What times of day are we able to, like, move patients? What's the access to different equipment, whether it's supplies for medical care or ability, anything like, like a Skedko to, like, move your patients, and we saw that based on our conversations with them, drones have impeded essentially everything, they have posed a challenge to nearly every aspect of operating in the field, medically or non-medically, and we'd actually brought a mannequin along with us that had some simulated, like, gunshots to, like, the torso and extremities, and we hold this very heavy mannequin all the way to Kyiv, and we got there, we were talking with them, and they're like, "That's great, but we don't really see gunshots anymore. It's all blast injury from drones or from artillery. So, drones are the main mechanism in which casualties are actually injured in the fields. This is 10 months ago. So, what that's like now is they probably have an even greater effect. I can only imagine it's incredible to me to think about a war where most of the casualties aren't even coming in with bullet holes. 20 years ago, that would have been unthinkable. They told us we had an opportunity just to like to see their ambulance and go through some of their supplies and get really a good idea of how they function, and not only was the ambulance camouflage vehicle, but they told us that they're not able to get their ambulance within, you know, within 15 kilometers of their, of their casualty, just because a ambulance is the probably the number one target for an FPV drone, because it's usually unarmored, is slow moving, and will draw additional rescue forces to the area if you get a successful hit. Healthcare workers are one of the top targets for drones. I've been reading recently that Ukraine's been placing more of an emphasis on, like, underground rule two hospitals. Did you see any of that? Unfortunately, we did not see that I have also heard about that, and read about it, but yeah, we did have some opportunities, I think, to potentially see these kind of things while we were there. One of the challenges of teaching this type of course is just trying to find the ability to cram all of that knowledge in in two weeks. I think we were finding that this is a broad field, and we're learning more every day about how to effectively provide care. However, we just didn't quite have enough time, I think, to go see these kind of places. So I'm able to go back. I would very much want to see one of those facilities. They do look really cool, like they're like prefabricated, some of them, like there's companies that are producing them now. I highly encourage any of our listeners to take a look at some of the World Two combat hospitals that Ukraine is building. They're pretty impressive. How did your time in Ukraine change your perspective on medicine? My perspective has been gradually changing over the last few years as I spend more time in like remote settings, so as far as a big shift, I think maybe the best way to think about it is whether it's budget constrictions or constraints like escalating military conflicts around the globe, AI, climate change. I think we can all agree, like, there's some really intimidating threats on the horizon. Would it come. Comes to effectively providing care and keeping our knowledge strategy strategies and skills up with like all the chaos in the world, so yeah, I wouldn't say my experience like fundamentally changed my perspective so much as reinforced something I already believe, maybe it's a little bit in the background that all of us will never really truly master our areas of study or practice, and then we have to continually refine our knowledge and skills. That's always been true, but in this current landscape it's more important than ever. You know, I mentioned that when we were doing our initial, like, needs assessment with the students about learning that, like, around 90% of their capitalities were due to blasts, and we had a lot of equipment that we had brought directed at teaching management of gunshot wounds, and that was no longer relevant. We also had to sit down and significantly adjust our curriculum, and that was such a positive experience that each day we actually sat down with students again to review what we would potentially be talking with them the following day, so that we could then go back and further adjust our curriculum to make sure that all of our education would be as effective as possible, and so this was a really cool experience in which we were not only teaching something that's very important but also ourselves spent almost equal time learning from our students, and this is something that is just so different from the way that medicine is taught traditionally, especially in the United States, especially at my own institution. Take a good takeaway is that if even if you feel like you're an expert on something, things are moving just so quickly that if you want to maintain that expertise, like you have to sit down and learn from the people who are experiencing that change up close and personal, and in this case really means spending time learning about the conditions that your patients are in, if you're teaching a course, learning about the conditions that your students are trying to learn in and trying to work in, I think this was always there. I've always tried to continue to learn and adjust my own practice style, but it really reinforced this idea that for every bit of knowledge I try to teach or every way through clinical practice that I try to benefit or impact the community in which I'm working. I need to try to acquire an equivalent amount of knowledge to improve my own practice, so I can maintain that ability to be effective. Nice. I really like that. I'll be honest, I had another question, but that actually seems like a really good one to end on. That was really good. Cool. Anything you want to talk about just to close up the podcast? Are you good? Yeah, I think you know one of the last things that really in talking about this podcast with some other folks, and then also talking with some people who are not in medicine about, like, why do we care about this? This is a conflict that's like far off. Yeah, what's the relevance this war that's happening in Eastern Europe? How is this going to impact us in the United States when we have so many other things that are that we care about, and so many threats to our healthcare system and our society. I see what's happening there as a similar force to any, it's a force similar to like many other environmental conditions. It's not a coincidence, I think, that like we talked about, like climate change, that that the military has classified that as one of the most important security threats. And now I'm not going to go ahead and discuss climate change at length, but it is a good comparison, because maybe a few years ago, most of us saw this is a problem that was far away, and now we've learned that we're all affected, and every corner of the globe is being touched by this. And now, if we switch over to Ukraine, I think it's really easy for the public to see this, like at least initially this war was like covered in the news quite a bit, but now you don't see too much, because we've moved on to other topics, but the impact of that war is soon going to be, and already is being felt worldwide, and so inexpensive drones hit civilian infrastructure kill 1000s of people who are hundreds of miles, like nowhere near a conflict zone, and many of those attacks have targeted healthcare facilities and emergency workers, as other armed groups around the world learn these lessons and begin to adopt this technology with minimal requirements for funding or large organizational structure need to operate a $500 FPV drone, and with the prevalence of global conflict rising, a lot of the civilian population around the world may not be seeing this as such a far away threat. It's hard to say how we all will be affected, but I do think that a significant number of civilians around the world, but also here in the United States, may be seeing the effects of this quite soon. So I do think that it's important for. For all of us to recognize that I think it's really important for all of us as physicians or healthcare providers to recognize the potential impact that this force has on our ability to care for patients and the impact that this has on the lives of our patients, whether it's being directly in the line of fire or being displaced or just how we design healthcare systems or EMS systems to be resilient. We'll have to understand how this force is evolving and will continue to affect our ability to provide healthcare. Definitely, something that is not, I think, really important for people to know, even if they don't have an interest in military or austere medicine. Oh, I could not agree more. And thank you so much for taking the time to come on. Yeah, thanks, Matt. This is, this is cool. Bye.