Springtime. Chief year. After enduring 5 (or more) arduous years of training, most general surgery residents are preparing to embark on a career in surgery in their first professional staff position or continue their training in fellowship. A much smaller proportion of us, having sensed a calling to service, will instead be receiving our first official orders and instructions to prepare for our first combat deployment. Although military surgical residency training programs largely follow the same processes and paradigms as any civilian program, the military staff and trainees must always be aware of the one key and stark contrast between the two: when the civilian resident graduates, he or she will either be moving on to fellowship (more years of direct supervision) or to a civilian clinical practice in a well-resourced facility and with senior colleagues/mentors readily available to assist them with any problems of difficult clinical scenarios. In contrast, the military residency graduate has to be prepared to go from trainee status on June 30 to potentially getting on a plane on July 1 to deploy with a forward surgical team to an active combat zone. In this environment, he or she may have no senior colleague or more experienced surgeon located with them and will be called upon to take care of the most severely injured trauma patients that exist.

As I’m sure many can attest, preparing for that first combat deployment can provoke unparalleled anxiety. How close to the “action” will I be and how busy has the area where I’m going been? Will I be the only surgeon or will I have backup? If I have backup, what is their level of experience? How experienced is my support staff? What diagnostic capabilities will I have available? How will I deal with injuries that I’ve never encountered before? Certainly, these questions only strike the surface of the many concerns that will dominate my thoughts, not to mention the endless litany of clinical scenarios I will begin to mentally examine and determine how I’ll handle them when they occur.

Assessing the competency and readiness of surgical trainees to move on from residency as licensed practicing providers is a hot topic in the surgical literature, so how could anyone fresh out of residency possibly be ready to be placed in a situation as a solo provider in an austere environment dealing with devastating injuries, using minimal equipment and a head lamp? On the one hand, I am certainly confident that my surgical training has provided the foundational elements necessary to deal with everything from the most basic to the most complex surgical dilemmas. Knowing normal anatomy, understanding physiology of injury, and trusting the technical skills acquired during the training years will all allow the recent graduate to approach a significantly injured patient in an organized and systematic fashion.

Relying on the experiences and lessons learned from our mentors over the last 15 years of active military engagements, a greater emphasis has been placed on preparing surgical trainees for deployment. In addition to the required trauma rotations mandated by the ACGME core curriculum, the trauma experience of trainees is being increasingly supplemented by emphasizing Advanced Trauma Life Support algorithms, providing courses such as the Combat Casualty Care Course (C4) , and instituting simulation-based training such as Tactical Combat Casualty Care (TCCC) and, more recently, the implementation of the American College of Surgeons-affiliated courses Advanced Trauma Operative Management (ATOM) and Advanced Surgical Skills in the Exposure of Trauma (ASSET) . These programs provide the opportunity to become familiar with the diagnosis and management of traumatic injuries as well as procedures that generally fall outside the realm of traditional civilian general surgical training.

While experiences gained on trauma rotations and the addition of supplemental training programs provided me with some semblance of confidence that I will be able to address an individual patient’s injuries, there are a few issues for which I’m not sure my training has adequately prepared me.

As a resident, I had the opportunity to spend 6 months at major level 1 trauma centers in the Pacific Northwest. While I was exposed to a variety of injuries and injury patterns, I had experienced this in a considerably controlled environment surrounded by the luxuries that accompany high-volume civilian trauma centers, such as specialized trauma teams consisting of multiple experienced providers, well-trained and experienced support staff, rapidly available advanced diagnostic imaging, readily accessible consulting specialists, and ample consumable resources. In addition, it was rare to have to deal with more than one to three acutely injured patients at any given time. Conversely, in the combat casualty environment, it seems that multiple severely injured patients and mass casualty management are common. This is probably my single greatest anxiety related to deployment – with no prior experience and lack of the amenities and resources associated with a civilian trauma center, how will I be able to prepare and effectively deal with my first MASCAL scenario? The cornerstone of effective mass casualty management requires experience with triage and patient prioritization. Trauma rotations did not prepare me for making life or death decisions regarding who I have the best chance of saving, let alone how to deal with the guilt of not being able to save them all.

I have also often thought about the difficulties associated with the transition back to civilian practice following deployment. Much of the operative experience in today’s surgical residencies consists of minimally invasive surgery. In the vast majority of cases in this day and age, residents will perform their first appendectomy or cholecystectomy via laparoscopy. Many advanced procedures such as gastric bypass or fundoplication may only be performed using the laparoscopic approach during a resident’s training. Conversely, surgery in the deployed setting is performed through a large laparotomy incision. After being deployed for 9 months, what will happen to these perishable skills that I only recently acquired? I have had colleagues who on the one hand were fortunate enough to have not had to operate on many soldiers. The flip side of this is that following training, instead of entering a busy practice where they could fine-tune their skills and grow as individual surgeons, they immediately spent close to a year with minimal operative experience. Their greatest anxiety ended up being a lack of confidence to operate once they returned from deployment. Table 46.1 lists a number of recommendations for clinical and educational efforts that you can take as a senior resident to better prepare yourself for potential deployment shortly after you graduate.

It has been touted a million times “War is the only proper school for surgeons.” Hippocrates was correct circa 400 BC. But this raises the question: how is a surgeon properly schooled for war? There is no doubt that military surgeons have improved their capabilities during wars in Afghanistan and Iraq over the last 14 years. Parallel with our skill improvement were advances in patient transport, battlefield vehicles, body armor, prehospital care, the development of the Joint Trauma System Clinical Practice Guidelines, and resuscitation strategies. This begs the question: how do we really know if military surgeons became better surgeons after multiple busy combat deployments, or was it just an improved system of care? The answer: ask one. If one were to ask any military surgeon who had one or more busy combat deployments if that experience made them a better surgeon, the answer would uniformly be yes. The old adage practice makes perfect does not sound so virtuous when discussing the craft of surgery, but can instead be translated into experience saves lives. The statement is adjudicated every day around the world when the experienced surgeon gets called into the operating room to help with a complex case or for an opinion regarding an unexpected finding. This brings us back to the question: how is a surgeon properly schooled for war?

Surgeons may be the most ready for deployment in the months to a year following residency training . In residency we are broadly exposed to surgical disease, including trauma. The ACGME has recently increased the trauma requirements, and most military training programs are staffed with surgeons who have been deployed to at least one combat zone and incorporate combat trauma-relevant pearls into daily residency training and teaching. While many would argue that it is not ideal to deploy a junior surgeon who has just completed training, I would argue that it is less ideal to deploy a surgeon who has spent the last 2 or more years doing mostly laparoscopy and had zero exposure to trauma; at least the new grad would presumably have had exposure to major trauma cases within a year. But we have to realize that we are continually walking a fine line between being a junior surgeon who has recently done significant training in trauma care but who lacks experience and the older surgeon who may be in the exact opposite situation. Where that line is drawn, and how far to one side or the other we steer, is an area of continuing ongoing discussion and debate.

After graduating residency, a proportion of military surgeons get stationed at Military Treatment Facilities (MTFs) with slow clinical practices and minimal to no trauma exposure; in my opinion, this is an unfortunate and potentially perilous reality. The immediate years following residency training are crucial for continued growth and skill development as one embarks on operating with complete autonomy and surgeons with latent practices during the early post-residency years are at risk for struggling on their first deployment. A survey that was done in 2015 as part of a performance improvement (PI) project with the military Office of the Surgeon General Consultants demonstrated that Army surgeons just out of residency were more comfortable with their deployment readiness trauma skills than those who were farther from training. These results either support the earlier statement that military residency training (and presumed recent exposure to complex trauma patients) prepares a surgeon for deployment or it incites the Dunning-Kruger effect where the inexperienced lack awareness of potential incompetence. As a surgeon who deployed 4 months after graduating residency, I hope it is the former; however, the survey results were interesting in demonstrating that surgeons who never deployed (including those remote from residency training) had more confidence in their deployment-relevant trauma skills than those who had deployed previously. The survey is still undergoing analysis and results will be published in the future. What is very clear from the survey is that most respondents deployed within 1 year of completing residency training, and many had not even completed their board certification process at the time of the first deployment (Fig. 46.1).

For the practicing surgeon at an MTF, it is important to participate in structured surgery (and ideally trauma related), PI, and trauma-relevant education on a regular basis. Surgeons at big medical centers or at civilian centers can easily attend these forums as they are usually established and reoccurring meetings; however, this is not always the case for smaller MTFs. As residents, we fear the morbidity and mortality conferences because we are usually the ones presenting the complications and may feel like we are facing a firing squad – at least that was my experience as a resident. As attending surgeons we realize the true value of these conferences and projects. A structured performance improvement system and attendance at conferences enables system-based learning and keeps us engaged in managing complex patients and complications.

While active involvement in continuous educational efforts and PI improves surgical awareness and helps maintain currency, these opportunities are unfortunately not always readily available at some of the smaller MTFs. In these situations, military surgeons should seek out or initiate PI and educational endeavors at their MTF. Military surgeons who are stationed at small MTFs can participate in PI and CME outside their institutions through the American College of Surgeons and the military’s Joint Trauma System or by attending meetings and seeking out conferences that address individual and system challenges in caring for complex trauma patient, such as the AAST and EAST meetings. The Joint Trauma System has a weekly performance improvement and educational conference every Thursday. During this conference, which is over 10 years in the running, combat casualties are presented from point of injury through the continuum of care. Patient management and the system of care are discussed, problems are troubleshot, advances in battlefield medicine are highlighted, and system- and provider-relevant issues are addressed with the intent to afford the providers along the care continuum follow-up as well as to continuously analyze and improve patient care. When casualty volumes are low, a continuing education lecture occurs that addresses relevant issues pertaining to combat casualty care.