Training Tomorrow’ Military Surgeons: Lessons from the Past and Challenges for the Future

Abstract

The nature of conflict is evolving, with current warfare being associated with an initial "shock and awe" phase followed by protracted periods ofcounter-insurgency and peace support missions. As conflict has changed, so have the munitions deployed and the resulting patterns of injury. Improvised Explosive Devices have become the preferred weapon of the insurgent and the resultant explosive and fragmentation injuries are the hallmark of modern military wounding. These injuries pose a significant challenge to deployed medical forces, requiring a well-defined, seamless approach from injury to rehabilitation. Traditionally, military medical services demonstrate a poor 'institutional memory' in the maintenance of combat surgical skills. Numerous publications detail the re-learning of key tenets of war surgery by generations of surgeons deploying onto the field of battle. While the maintenance of military surgical capability in trained surgeons may be addressed through combat surgical courses, concern exists as to the generic competency of those currently in training and their ability to deal with the burden of injury associated with modern conflict. The training of junior doctors in the United Kingdom and further afield is in a state of flux. New curriculum development, streamlined and run-through training programmes have combined with the legal requirements of the European Working Time Directive to produce a training landscape almost unrecognisable with that of previous years. This article investigates the development of current military wounding patterns and modern surgical training programmes. It describes processes already in place to address the unique training needs of military surgeons and proposes a framework for enabling appropriate training opportunities in the future.

The French Advanced Course for Deployment Surgery (ACDS) calledCours Avancé de Chirurgie en Mission Extérieure (CACHIRMEX): history of its development and future prospects

“…To date, after seven full cycles of five modules, this course seems to meet the challenge of how to provide appropriate training for military surgeons, which is considered as a key point by many nations 12 13…”

Maintaining surgical skills for military general surgery: the potential role for multivisceral organ retrieval in military general surgery training and practice: Table 1

“…Overseas fellowships may provide an excellent opportunity to experience high-volume trauma training but these are extremely expensive for the Service and therefore limited in number. Training courses based on animal models (Exercise Surgical Training Denmark) and cadavers (the Military Operational Surgical Training course)2 12 have been used extensively to prepare surgeons for deployment in recent conflicts. However, they are expensive and provide a one-off opportunity to practice advanced techniques in models that are either anatomically incorrect (pigs) or have altered tissue characteristics with no vascular perfusion (cadavers).…”

Military surgery in the new curriculum: whither general surgery training in uniform?

“…High quality trauma experience outside deployments may require a period of time outside the UK, a prospect that has financial implications for the individual and DMS. The current fiscal constraints placed upon the DMS means justification for these fellowships must be robust and based on a sound business case 6. An extra training year(s) may even need to be bolstered onto the final stages of the CST programme for military trainees wishing to pursue a career in general surgery.…”

“…In addition, only 30% of consultant general surgeons felt they had the adequate skill set to manage acute cardiothoracic injuries 4. To compound matters, the introduction of the European Working Time Directive and later European Working Time Regulation have reduced the available time for surgical training opportunities, prolonging the years taken to achieve competency in independent operating 5 6…”