Exceptional Readiness

Dive medicine training at the Uniformed Services University of the Health Sciences


During the two-week course held in Key West, Florida, military medical officers learn the necessary skills to treat wounds and life-threatening injuries in and around the water while in remote and challenging locales.


Sean DeBevoise stood at the front of the classroom filled with military medical officers from the Uniformed Services University of the Health Sciences (USU). The former Marine Corps scout sniper wore a brace on his left leg and had scars on his head, shoulders, legs and arms — visible reminders of the life-threatening injuries he sustained in an ambush during the Battle of Fallujah in Iraq in 2006. A bullet remains lodged in his brain, and grenade fragments still occasionally make their way up through the surface of his skin. He carries one in his wallet.

Standing with him was a member of his medical treatment team: Dr. Matthew Welder, a retired Army colonel and an assistant professor at USU. "This is why you're here, ladies and gentlemen," Welder told the group. "This is who you're doing it for," he said, referring to DeBevoise.
The Course
These opening statements marked the beginning of Welder's two-week course in Key West, Florida, for USU military medical and graduate nursing students to receive training for underwater emergency response. This course — the first of its kind — is one of three in a series focusing on ensuring that USU students are prepared to care for military service members, like DeBevoise, in the austere, remote and challenging conditions they often face while deployed. The dive medicine course, which comprises both classroom and in-water training, includes open-water, advanced open-water and water-rescue certifications. The only dive-specific prerequisite was the ability to swim.

Students arrived the first day wearing blue rash guards and carrying dive bags full of unusual gear and fins around their wrist and awaited their instructions. During the first week of the course, students familiarized themselves with their equipment and learned to scuba dive. The second week added pressure, exposing students to stressful conditions and teaching them to perform water rescues.

Over the course of the program, students worked as a team to accomplish 12 open-ocean boat dives, practiced maintaining calm while diving in demanding conditions and learned firsthand the challenges inherent to the marine environment. Training culminated in a high-angle rescue on board a U.S. Coast Guard cutter involving a man-overboard scenario with an unconscious victim.

This isn't Welder's first course in emergency medical response. "The courses that we run — dive medicine, wilderness medicine and mountain medicine — are about readiness," Welder said. "I break it into four areas: physical readiness, clinical readiness, operational readiness and emotional readiness. Participants in the courses, which are electives for USU medical and nursing students, are certified in wilderness, mountain, avalanche and water rescue for six years. This is the absolute best combination of diving, dive medicine and resiliency training of any dive course I know. It will absolutely improve the care of military members who experience dive injuries."


The training includes classroom instruction and pool sessions on rescue techniques and dive skills.


Readiness
Because readiness can be hard to define, Welder's four categories help students distinguish between tips that are "nice to know" and those that are "need to know."

Clinical readiness refers to building the medical expertise to identify, assess and respond to medical incidents. In Welder's Key West course, students receive 40 hours of medical instruction targeting the demands of military medicine. It is one thing to develop skills to treat patients in hospitals, but translating those skill sets to remote environments — in tents with field equipment that fits in a backpack, at night and with enemies near — is a different matter. USU professors have military experience; they've learned the tricks of the trade and now dedicate their lives to passing along these lessons.

Physical readiness includes overall fitness, nutritional or energy reserves, the capacity to perform under dire physical conditions and the availability of all necessary equipment. From the first day of the two-week course, students were required to swim, perform other physical exercise and practice using dive, medical and combat gear. Welder summed it up in three questions: "Do you know what tools you need and how to use them? Do you have the equipment to perform damage-control resuscitation and surgery? Can you trek several kilometers with 35 pounds of gear on your back, including a defensive weapon and enough water and food to sustain you through the night?"

Operational readiness prepares practitioners to recognize the impact of terrain, weather, communications limitations and other environmental factors on the administration of medical care; in addition, it involves preparation for work during deployment — away from familiar and comfortable environments and readily available tools. The austere or operational environment could be anywhere. Medical providers in the military need to be able to perform whether they find themselves in a combat zone, on a small island in hurricane conditions, working with an unfamiliar team or, in the case of this course, involved in activities related to the underwater environment.

"Too often a physician is trained in dive medicine without a complete understanding of the operational components required to conduct a safe and efficient diving program," said Dr. Robert W. Sanders, a dive medicine instructor and assistant professor at the University of Texas Medical Branch in Galveston. "This course melds together these aspects into one cohesive program. It gives the physician a glimpse into the operational aspects of diving, training them to be a complete asset to the operation, able to comment on prevention and not just treatment."


Students learn underwater navigation in open-water sessions.
Emotional readiness, which is often overlooked but equally critical, is different for everyone and constantly in flux. Emotional readiness is what ensures survival. It requires people to know their strengths, recognize their triggers and admit their weaknesses. While there is no magic pill or training exercise that can ensure emotional readiness, the pressure that medical professionals feel to hide their emotions and to appear strong is a clear and dangerous impediment to emotional readiness. To address this situation, Welder's course trained students to perform required tasks in uncomfortable environments, such as removing a mask underwater and sharing air at 30 feet while rescuing downed divers in strong currents, to help them learn to make decisions under stress. Students were also reminded that teams save lives, while individuals are only spokes in the wheel of medicine.

"One cannot simply read about the skill in a book and then be successful in the austere environment," said Navy Capt. Justice Parrott, a nurse anesthetist and former student in the course. "This experience with dive medicine and water rescue helps bridge the gap between when providers think they are ready to go into harm's way to render care and when they are actually prepared."

"The dive medicine course really provided me with a rare opportunity to gain insight into diving and the risks that operational forces are exposed to when performing missions," added Air Force Capt. Rachael Meaders, a nurse anesthesia student in USU's Graduate School of Nursing.
Outcomes

Training culminated in a high-angle rescue on board a U.S. Coast Guard cutter.
Military medical professionals must be ready to perform their skills anytime, anywhere. Their skills must be applicable when working in hospitals, responding to natural disasters, lending support to humanitarian missions or rescues and performing in operational or deployment environments, including underwater environments. Welder's two-week course in diving and emergency preparedness for military medical professionals was immersive in both senses of the word.

While the course focused on diving and underwater emergencies, its benefits have a scope above and beyond the ocean. "If you can do a neurocognitive exam on the back of a boat or quickly develop a life-saving differential diagnosis while pulling a 250-pound diver through the ocean, you know you can do it in a hospital," explained Dr. Eric Meyer, a USU assistant professor and Air Force major who took Welder's course. "Learning the fundamentals of dive medicine pushes all providers to a higher level of clinical care, which translates to improved care in any setting."

On the last day of the course after the final exam and the after-action review, faculty and participants reflected upon their training experience. DeBevoise, whose presence provided inspiration and motivation for the students throughout the training, quietly stood by, listening as faculty and participants shared their after-action comments.

"When it comes to readiness, this course did more than just get your feet wet," Welder told the group. "It is a reminder of what you're preparing for: to stand ready to protect our women and men, like Sean, who risk their lives for our nation."

© Alert Diver — Q4 Fall 2018