By Stephen Spotswood
JOINT BASE LEWIS-MCCHORD, WA — Maj. Jonathan Monti, DSc, PA-C, says he does not believe in haphazardly adding new technology to the already-overwhelming amount of gear carried by those providing medical care on the battlefield. He spent several years downrange in Iraq as one of three physician assistants (PA) to join the 82nd Airborne Division in the initial hours of Operation Iraqi Freedom.
“Having cared for soldiers on the battlefield, I’ve been reluctant to adopt new technology for use on the battlefield,” Monti explained. “Those providing care on the battlefield are often constrained. When they’re saddled with a clunky device—that can become cumbersome.”
So, if he recommends a piece of technology be incorporated into battlefield care, it is not done lightly. In fact, it’s backed up by mountains of data and years of research.
Nearly 14 years after his first deployment to Iraq, Monti serves as director of Madigan Army Medical Center’s Emergency Medicine Physician Assistant (EMPA) residency program—one of the few residency programs that incorporates prospective clinical research into EMPA training. The focus of that research has been on battlefield medicine procedures and how new technology and improved training can improve outcomes for injured servicemembers.
“We’re specifically focused on technology that can have a profound impact on the care and disposition of patients, but also keeping in mind the constraints those providing care on the battlefield are facing,” he explained. “And, as Pas, we’re acutely aware that we as medical officers can’t be everywhere on the battlefield. For that reason, we’ve focused on technology that can be used by [whoever] is providing the care at the point of injury—PAs or combat medics.”
Ultrasound is one technology that Monti and his fellow researchers suggest could have great potential to change battlefield outcomes. Monti’s doctoral research examined the use of ultrasound to detect hemothorax. He had recognized the benefits of ultrasound years prior in Afghanistan where he taught himself how to use one of the machines.
“Using it, I’m able to detect a life-threatening condition on somebody that I might otherwise have missed,” he said. “It spoke to me about the value of ultrasound, about the ease of its utility and how it can be used without a significant amount of training.”
His initial research has grown and expanded since coming to the EMPA residency program. Results indicate that medics can successfully use ultrasound to improve the diagnosis of infections, and can help locate foreign objects in the body of a patient. Having demonstrated that ultrasound is usable and valuable to PAs and medics, the goal now is to work to implement it Army-wide and to create ultrasound training for nonphysicians, which isn’t currently offered.
The program’s research also focuses on improving existing PA and medic training. One of the more recent studies examines why medics other than those in special operations do poorly when it comes to performing a cricothyrotomy (an incision made into the throat to establish an airway).
“Is there a way we can train them better? Can we improve resources so, when the time comes, they can do better in terms of success rate,” Monti asked.
This focus on research has only increased the reputation that EMPAs enjoy among line units. As for Monti himself, he won the inaugural Emergency Medicine PA of the Year award last year from the Society of Emergency Medicine Physicians Assistants.
“Commanders have long-recognized the value that EMPAs bring. Oftentimes, when they need to request a PA, they’re requesting an EMPA specifically because of their high degree of training,” Monti said. “That resulted three or four years ago in the creation of positions for an EMPA in every brigade combat team. The challenge for us has been to try and grow our programs within the currently highly-competitive learning environment at a time when a lot of those programs are being eliminated or cut due to resource constraints.
One of the ways Monti is doing that is by making sure the value of the program is even more widely recognized. Since becoming program director two years ago, one of his goals has been to raise the program’s profile. He and his team have increased scholarly activity by 400%, including speaking at national and international conferences and seeking publication in journals. “With things being cut, it’s important that we demonstrate our worth. The research we’re producing is very combat-focused.”
Looking into the future, Monti said he hopes to see the work his team is doing eventually make its way through Army bureaucracy to become standard procedures on the battlefield—a process that he recognizes could take up to a decade.
“We’re getting better and evaluating and valuing the skills of nonphysicians who provide that frontline care,” he declared. “The data we’re gathering demonstrates that those providing care—particularly nonphysicians—can do more.”
The process for tracking the DoD’s most serious adverse medical events is “fragmented, impeding the Defense Health Agency’s (DHA) ability to ensure that it has received complete information,” according to a new review.
With a long history of point of care testing at both of its predecessor organizations, the Walter Reed National Military Medical Center (WRNMMC) laboratory services staff were keenly aware of the advantages of using portable testing devices to obtain rapid patient assessments.