At 0300 our Forward Surgical Team (FST) received a warning of ten incoming “urgent surgical” patients from a suicide bomb attack on a US convoy. Our unit sprang into action and set up our six-bed receiving area, including assigning responsibilities. We had only three physicians, and so each took two of the beds, knowing we would have to hop back and forth. If one or more of us had to go immediately to the OR, then the remaining docs would have to cover even more. But then, the nurse practitioner and her team from the base Navy Provincial Reconstruction Team arrived and covered the last two beds and any “walking wounded.” The MASCAL ran incredibly smoothly, and when we got out of the OR, the remaining patients were already evaluated and ready for disposition.

A 15-patient MASCAL event occurred just outside of the base where our split FST was located. Fortunately, our small unit was colocated with a Role 1 aid station commanded by an incredible physician assistant. All of the incoming patients were evaluated initially by her team, including a search for weapons or explosives, and then triaged to either our FST beds or to the aid station beds. Ten of the 15 less severely injured patients never even came into our FST, and the dreaded “over-triage” that can degrade any MASCAL response was avoided.

The role, numbers, and use of ACPs vary widely across the country from state to state and even more so within various medical systems and practices. Thus, physicians and surgeons may spend their entire training or portions of their career with little to no interaction with nurse practitioners (NP) or physician assistants (PA) . Many providers are likely unaware of the military’s unique and important part in the development, education, and use of ACPs. Moreover, many young surgeons without significant military experience prior to residency may not have an appreciation for the capabilities, backgrounds, and potential of ACPs in the world of operational medicine.

Physicians in North Carolina and Washington State identified a shortage of doctors following the Vietnam War, particularly in primary care. Former military corpsmen and medics were recruited into the first physician assistant training programs after recognizing the potential role of medical providers with significant experience, practical education, and hands-on training, without the formal background and time commitment required of medical school and residency training. The success of these programs and the ACPs they produced gave rise to training programs across the nation and within all branches of the military. Today, ACPs play a crucial role in the military medical system worldwide, across the spectrum of education and training programs, routine clinical and specialty care, and operational medicine.

ACPs, particularly physician assistants, compose a large part of the military medical manpower . The majority of military advanced practitioners have a background in general or primary care , but subspecialists in surgery, critical care, and emergency medicine exist. Many PAs have former backgrounds and careers in an enlisted field as corpsmen, medics, or other health-care specialty personnel and often with extensive operational and deployment experience. ACPs are routinely assigned to battalion-level units as primary care providers and may command units such as Forward Surgical Teams , Ambulance and Treatment Platoons, and Forward Support Medical Companies. Since these providers often serve a number of rotations in field units, they are well versed in the day-to-day management of military units and command and staff duties.

In the deployed setting, ACPs are heavily utilized in the Role I echelon of care with field units. ACPs can be found staffing sick call, aid stations, and forward medical treatment sites, on the ground with combat arms units, or assisting in Role 2 and Role 3 facilities. The background, experience, and training of these providers can be of substantial help to the deployed surgeon, particularly if you have little operational experience. Most importantly, these providers and their teams can be key assets to augment your Role 2 (or even Role 3) facility’s ability to provide care for multiple simultaneous patients, or for any MASCAL incident. You should always identify any of these available assets that are colocated at your base of operations and integrate them into your team’s activities and training as much as possible. They should always be included in your MASCAL plan and any MASCAL rehearsal drills. Beyond clinical duties, ACPs can be of significant assistance with the development and exercising of medical readiness training, executing mass casualty drills and events, preparing for CBRNE contingencies, understanding the frustrating system of medical logistics, assisting in patient evacuation and movement, and understanding the complexities of combat operations.

For the first-time deployed surgeon, the NP/PA can be a resource for the mundane details of deployed life, as follows: How do I adjust my body armor? What do I need to take with me on a convoy or flight? How can I order more of something? What should I do with this weapon they gave me? When the battalion commander asks me about something, what should I say? This is not to suggest that physicians and surgeons are inept in daily deployed life, but most spend the majority of their early career in the bubble of medical center life. The NP/PA is an important ally and colleague to the deployed physician and surgeon; develop this relationship early as it can make your deployment experiences far more successful and rewarding.

A unique subset of PAs within the military has extensive backgrounds in combat arms fields , serving as prior medics or nonmedical roles in the special operations community or other combat arms branches. These individuals often represent a fountain of knowledge and experience for medical operations planning owing to their mix of tactical and operational experience and medical background. Frequently, these individuals can help “translate” between the clinical providers and the nonmedical military leadership. When faced with difficulty communicating with chains of command or nonmedical leadership, these ACPs can be of great assistance. Regardless of the background of the advanced practitioner, the deployed surgeon is well advised to seek out and partner with these professionals to ensure a successful mission.

The attack started at approximately 2300 h as the infantryman and MPs rotated guard shifts on our small FOB. About 30 soldiers had just finished an outdoor movie and were beginning to head back to their tents for the night when the rounds began to impact. The first few mortars that impacted were white phosphorous and fortunately impacted just outside the perimeter. However, because of the dark and sudden flash, several of those on guard duty had to be led to the Battalion Aid Station (BAS) as they were temporarily blinded. The enemy switched to high explosive (HE) at this point. Three of the GP large sleeping tents were impacted, and by sheer providence, these were the tents that housed the platoons that were on patrol that night. The rounds that impacted near those leaving the movie were another story. Multiple patients wandered/walked in the dark to the BAS, and a few were brought in by their buddies. Despite multiple extremity wounds and ongoing hemorrhage, most were ambulatory. We had practiced our mass casualty (MASCAL) plan and implemented pulling all of the casualties into the hardened old bombed out Iraqi building that housed our supply section. Tourniquets were applied, and rapid assessment showed that we had 13 casualties. Four had night blindness but intact visual acuity with ambient light, two had chest and abdominal penetrating wounds but were stable without peritoneal signs or shortness of breath, and the rest had varying degrees of penetrating extremity trauma. One soldier in particular was walking when the mortar impacted right next to a light post he was passing. Every exposed extremity had wounds in it, but his trunk was fortunately spared by the pole. He literally ran out of his shoes getting to the aid station. After the casualties were stabilized and other interventions secured, we converted applied tourniquets to pressure dressings. A 9-line MEDEVAC request was sent, but due to the enemy activity in our area, our request was denied. Because we were 15 km by ground from the nearest Role 3, we discussed the current threat situation with the battalion commander and QRF leader . We decided together to evacuate those that had the truncal injuries and eyesight changes immediately, and the others would be evacuated in the morning when the units on patrol would return and additional assets would be available. Antibiotics and pain management were given to those that remained at the BAS.

Military physician assistants are licensed providers that function with a high degree of autonomy, often located in remote and austere locations with the units that they are attached to.

The physician assistant (PA) career and training program began with Dr. Eugene Stead at Duke University with four former Navy Corpsman in 1965. The Army, Navy, and Air Force all followed shortly thereafter in 1971 initiating their own programs, and the Coast Guard sent their candidates to the Duke program. The schools were combined in 1996. The program was modeled after the shortened physician training during the World War 2. The role of the military physician assistant was implemented to augment and supplement the physician shortages across the military.

The majority of physician assistant programs require an undergraduate degree and a substantial number of clinical hours and consist of 24–30 months of training that is divided nearly equally by didactic education and clinical rotations. After training, PAs must pass the Physician Assistant National Certification Exam (PANCE) and are required to pass the Physician Assistant National Recertification Exam (PANRE) every 10 years, along with ongoing continuing medical education.