Combat-Relevant Anesthesia Fellowships Help Sustain the Army’s Multidomain Medical Force

ABSTRACT

In the community of Army Nurse Anesthetists, there is an underutilized potential for Combat-Relevant Fellowship training that, if enthusiastically encouraged and taken advantage of, would proffer many benefits to the Military Health System and the beneficiaries of its care. Most importantly, increased access to and encouragement for participation in these fellowships for Nurse Anesthetists would act as a tool for skill sustainment, denying any potential for skill degradation or readiness gaps in preparation for the next-generation war. These fellowships would also augment the already robust breadth, quality, and safety of Army Nurse Anesthetists’ combat and noncombat anesthesia care, potentially increase Return-To-Duty rates, potentially expedite casualty clearance of the battlefield, increase the often-limited access to advanced pain management care for chronic pain patients in Military Treatment Facilities, increase the retention rates of Nurse Anesthetists, augment the military anesthesia community’s knowledge-base, and help to advance the art of anesthesia as a whole. To triumph against the anticipated rigors of the future war’s multidomain operational environment, we are duty bound to continually improve and strive to be the best versions of ourselves as soldiers, as professionals, and as communities. This paper will explore the untapped utility of Combat-Relevant Fellowships for Army Nurse Anesthetists.

INTRODUCTION

Systemic readiness challenges within Army Medicine are contributing to skill-degradation amongst Army Certified Registered Nurse Anesthetists (CRNAs). These challenges include the Walker dip,¹ the time-cycled loss of combat-experienced medical professionals, and the projected capability gaps for prolonged care in an all-domain contested battlefield. These circumstances challenge Army Medicine’s ability to address skill sustainment, readiness, and manpower before the next war^2(pp.3). Army medicine can attenuate these issues, especially the loss of medical professionals with combat experience, if it takes the “disciplined initiative” required to “evolve our force” for success in the future operational environment (OE), as prescribed by General Stephen J. Townsend in a 2018 pamphlet priming the U.S. Army for multidomain operations (MDO).^3(pp.iii)

Army Medicine is taking several steps to maintain and enhance readiness for the war of the future; however, each subspecialty must ensure their communities are continually sharpening their relevant skills. As part of this process, Army CRNAs must self-advocate for access to combat-relevant anesthesia fellowships (CRFs) to sustain the skills they have mastered while growing their force to meet the demands of the next war. This advocacy should focus on policy and culture changes that evolve post-graduate Long-Term Health Education and Training (LTHET) for CRNAs by expanding and streamlining their access to currently active military and civilian CRFs, exploring the utility of unorthodox CRFs, and by maximizing efforts towards creating internal CRFs. These initiatives are needed to meet the challenges of the Large-Scale Combat Operations (LSCO) environment, and can potentially maximize skills sustainment in preparation for MDO, hasten battlefield clearance of casualties^4(pp.9), improve Return-To-Duty (RTD) rates,^5–7 decrease morbidity and mortality on the battlefield, enhance pain management access and overall quality of care in stateside military treatment facilities (MTFs), and improve CRNA manpower strength and retention through education-related service obligations.

THE BREADTH OF CRNA UTILIZATION THROUGH THE ROLES OF CARE

Across the roles of care, certain skills are most susceptible to degradation and most detrimental to warfighter health when lost. The future medical OE will likely involve masses of evacuation-sequestered, high-acuity casualties^2(pp.6) requiring the protracted delivery of high-quality, round-the-clock Advanced Trauma Life Support, Damage Control Resuscitation (DCR), Critical Care Medicine (CCM), and Regional Anesthesia and Advanced Pain Management (RAAPM). The overwhelming influx and delayed efflux of these casualties will be especially profound around the damage control surgery (DCS) centers of Role 2 facilities, hence the recent Force Design Update (FDU) of Prolonged Care Augmentation Detachments (PCAD).⁸ As CRNAs are doctrinally 1 of only 4 types of provider-level⁹ clinicians at these locations, they will likely be called on to perform beyond their traditional roles in DCR, general anesthesia, and limited RAAPM. As experts in the management of ventilators, hemodynamics, fluid balance, acid-base balance, analgesia, and sedation, Role 2 CRNAs will likely be called on to serve as critical care providers and advanced pain providers in the PCAD and other patient holding areas.

Following Role 2 care, these patients will require robust follow-on CCM and RAAPM at a Role 3 staffed by an Anesthesiologist and several CRNAs. CRNAs in these roles will likely be called on to support less-experienced and/or noncritical care providers by providing direct-care CCM or consultatory support, necessitating the sustainment of their CCM skills. Beyond CCM, many reports have demonstrated need for advanced RAAPM providers at these locations for continuity through the Roles of Care and to maximize RTD for eligible patients.^5–7 After Role 3 care, many of the injured soldiers that return stateside may become part of a chronic pain population that often has challenges with access to care, which can be ameliorated by the participation of qualified and trained CRNAs in nonsurgical pain management.¹⁰ Through the use of CRFs as skill-sustainment tools, CRNAs will contribute to minimizing morbidity and mortality on and beyond the battlefield at every point on this spectrum of care.

OUR EVER-FLEETING PROFICIENCIES AND THE EXIGENCIES OF WAR

While the capabilities of Army CRNAs are well-defined and robust in these realms of care, their current day-to-day on-the-job activities put these proficiencies at risk for degradation, because of limited exposure to trauma or complex, high-acuity cases at most MTFs¹¹ and peacetime skill degradation.¹² This concern for the sustainment of a ready medical force has been the impetus for various readiness initiatives, including the Army Military-Civilian Trauma Team Training (AMCT3) program¹² and the widespread utilization of individual Military Training Agreements (MTAs) with civilian medical centers nationwide.¹³ Although CRNAs are embedded into the AMCT3 locations, these opportunities are limited to less than a dozen slots that are typically time-cycled to 3-year minimum tours. Additionally, Army CRNAs have historically not engaged in the individual MTAs with local trauma centers that would help sustain their combat-relevant skills. Although these military-civilian partnerships for skill sustainment are still being optimized, Army Medicine needs to exploit additional training opportunities such as active participation in CRFs.

Beyond the skills that encompass the delivery of anesthesia, Army CRNAs have a robust and versatile set of knowledge, skills, and abilities (KSAs) involving pain management, regional anesthesia, and acute CCM. CRNAs demonstrated these skills during the recent coronavirus pandemic when many of them acted as Critical Care Providers in Intensive Care Units across the nation.¹⁴ However, the resource-deprived, prolonged critical care that will be required in the next war’s Role 2, Role 3, and PCAD environment will require CRNAs to use CCM and Trauma Anesthesia proficiencies that are vulnerable to degradation in the current low-volume and low-acuity levels of care in MTFs.¹¹ Barring those serving at Level 1 Trauma Centers in AMCT3 and San Antonio Military Medical Center, Army CRNAs’ exposure to trauma surgery is scarce.¹¹ The ability to provide effective CCM in Role 2 and PCAD may be heavily reliant on the CRNA present. Whether through a formalized CRF, internal or external to the military, or through informal, occasional rounds with their local MTF’s CCM-provider team, Army CRNAs need to exercise the skills to manage critically-ill patients in postoperative and/or nonsurgical settings.

After World War II (WWII) began, American Physician Anesthesiologists reflexively developed a healthy appreciation of the need to expediently grow and sustain their skills. In response to the prolonged care during WWII^15,16 and significant combat trauma seen during the GWOT,^17,18 military Physician Anesthesiologists organized to maximize their clinical readiness through additional training and education. Guided by these historical insights, Army CRNAs should pre-empt their readiness for the next war by advocating for liberal and unencumbered post-graduate training opportunities to fortify, refine, and sustain their proficiencies to provide care in MDO in the realms of CCM, trauma anesthesia, as well as RAAPM.

BENEFITS OF COMBAT REGIONAL ANESTHESIA AND SKILL SUSTAINMENT

With some studies suggesting that military anesthesiologists may have combat-readiness gaps in their advanced RAAPM proficiencies,^19,20 one can reasonably project and transfer these readiness gap studies onto military CRNAs since they train and operate in the same manner, in the same MTFs, and on the same patient populations. These potential RAAPM gaps are worrisome as the anesthesia and analgesia-related Joint Trauma System’s Clinical Practice Guidelines, many major combat-related literatures, and a plethora of combat anesthesia-related peer-reviewed articles emphasize the utility and paramount importance of RAAPM.^17–31 These resources emphasize the benefits of RAAPM techniques in austere settings, especially the placement of continuous peripheral nerve block (CPNB) catheters that can be utilized as the patient progresses through the Roles of Care from the Point-of-Injury to a Role 4 MTF in the continental United States. RAAPM techniques, particularly CPNBs, may facilitate a more rapid clearance of casualties from the battlefield since the equipment, knowledge, and space burden required for Medical Evacuation personnel will be minimized compared to a patient who may require more medical support after a general anesthetic. A contributor to this skill degradation is that the Army Medicine completely omits RAAPM techniques from CRNAs’ Individual Critical Task List of combat readiness requirements, which is incongruent with the demands of the future OE.³² Army CRNAs’ proficiency, confidence, mastery, and skill sustainment in RAAPM and other combat-related realms of care can be improved through the use of CRFs and other training methods.

NOVEL AREAS FOR COMBAT-RELEVANT EXPANSION OF CRNA PRACTICE

Both stateside and downrange, existent and prospective chronic pain patients may have limited access to care because of a lack of credentialed chronic pain providers.^10,33 The utility of CRNAs as nonsurgical pain management (NSPM) providers is well-established in the civilian sector,³⁴ suggesting that properly prepared Army CRNAs can help fill this gap. There are several extant Pain Fellowships that prepare CRNAs to work as primary pain providers or interventional pain medicine providers (IPMPs) in outpatient, chronic-pain clinic settings. The skills gained in these CRFs could also translate to enhanced care delivered downrange. In support of the major efforts and significant strides in pain management made by the Defense & Veterans Center for Integrative Pain Management and the Army’s Pain Management Task Force,⁵ along with the advent of Interdisciplinary Pain Management Clinics,³⁵ Army CRNAs trained in NSPM could generate significant improvement in acute and chronic pain patients’ access to care in MTFs and downrange. Several reports exist in favor of increasing the availability of IPMPs at Role 3 MTFs in forward-deployed locations.^6,7 Many of these reports indicate that some of the most common nondisease battle injuries are pathologies that would benefit from immediate access to interventional pain procedures (epidural steroid injections, facet blocks, plantar fascia injections, etc.).⁷ Additionally, reports show that when IPMPs are present at a Role 3 hospital, the RTD rates are significantly higher than when these providers are not available. One study reports a RTD rate of 94.7% and strongly advocates for these specialty providers to exist in deployed areas.⁶ Taking advantage of currently available Pain Fellowships would allow Army CRNAs to contribute to NSPM and advanced pain management for chronic and complex pain syndromes.

CURRENT STATE OF ARMY CRF OPPORTUNITIES

While there are several accredited civilian-based CRFs for CRNAs,^36–39 the only active ones are the RAAPM Fellowships. In the recent past, there has been a Trauma and Critical Care CRNA Fellowship, but it was one-of-a-kind and is currently unavailable. Additionally, there are several Nurse Practitioner (NP) and Physician Assistant (PA) CCM Fellowships that indicated interest in allowing Army CRNAs to attend their programs. Although not a fellowship, one hopeful and commendable effort for internal CRNA training is the up-and-coming Combat Anesthesia Readiness Training Course (CART-C).⁴⁰ The benefits of creating internal Army CRNA CRF are self-apparent. Even though several CRFs exist, the Army has not granted access to nor funding for these types of programs as it has for many other medical specialties including, but not limited to, PAs, NPs, and Physical Therapists through various LTHET opportunities.^41–44

THE WAY FORWARD

Aligning with the recently retired Surgeon General’s intent of remaining relevant,⁴⁵ Army CRNAs should have access to funding for RAAPM fellowships, post-graduate critical care and trauma education, Point-of-Care Ultrasound fellowships, etc. The demand and value of these CRFs was reinforced in a 2018 statement by the Committee on Armed Forces to the House of Representatives in which it “encourages the … Secretaries of the military departments to consider … fellowship programs for CRNAs as part of their respective [LTHET] programs.”⁴⁶ Additionally, these sentiments are merely echoes of the Army’s Medical Capability Development Integration Directorate recommendation to broaden the battlefield employment of “Advanced Practice Nurses.”⁴⁷

While preparing to fight the next war, the Army should improve CRNA skill sustainment models.⁴⁸ Increasing the number of Army CRNAs with advanced training would be a force-multiplier with several benefits. These benefits include enhancing Army CRNA satisfaction with practice, enhancing the care delivered down-range and at-home, and creating a network of CRNA faculty and staff with advanced training at academic MTFs. The service obligations attached to these CRFs would increase retention directly while advancing people further into their time-in-service, increasing the likelihood that they will remain until retirement. Simultaneously sustaining the Army CRNA’s skills and their drive to stay in the military through education is a win-win scenario. The future OE will demand a robust force of highly proficient, well-rounded, and seasoned CRNAs. For the sake of the future sons and daughters of our country, we are duty-bound to seize this initiative to become the best version of ourselves.

ACKNOWLEDGMENTS

None declared.

FUNDING

None declared.

CONFLICT OF INTEREST STATEMENT

None declared.

DATA AVAILABILITY

The data that support the findings of this study are available on request from the corresponding author. Some references/resources require military Common Access Card for review.

INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS)

Not applicable.

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)

Not applicable.

INSTITUTIONAL CLEARANCE

Institutional clearance approved.

INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT

The author collected and analyzed the data and drafted the original manuscript. The author read and approved the final manuscript.

REFERENCES

Author notes