Individual Critical Task Lists

Clarifying the Conditions and Standards

By CPT Kieran Martin

Article published on: November 21, 2024 in the November 2024 Issue of the Pulse of Army Medicine Journal

Read Time: 8 mins

Army medicine lacks the necessary skill development and sustainment to support large-scale combat operations. From 2001-2023, the United States military engaged in counterinsurgency (COIN) operations across the Middle East. The U.S dominated the skies, maintaining air superiority and enabling medical treatment teams to focus on the concept of the Golden Hour with rapid and routine rotary wing air MEDEVAC. The Army was able to push surgical teams beyond their doctrinal capabilities and support networks. American forces experienced the lowest death rates from wounds in the history of warfare.¹ Today, Western allies are on the precipice of Large-Scale Combat Operations (LSCO). Ukrainian forces fighting Russia sustain approximately 1,000 casualties per day.² In comparison, the United States military suffered approximately 60,000 casualties over 23 years of conflict.³ It is estimated that the US will lack air superiority and have casualty rates in the thousands, eliminating the Golden Hour.⁴,⁵ Medical assets at all roles of care will see increased casualty rates and decreased evacuation capabilities once engaged in LSCO with near-peer adversaries. Military medical teams must be masters of point of injury (POI), tactical combat casualty care (TCCC), and management of prolonged care (PC). Medical preparation for LSCO must focus on skill development, skill sustainment, and skill evaluation.

Skill Development

Provider-level medical support to operational forces is around 80% Physician Assistants (PAs), with the remainder provided by physicians in the Medical Corps (MC). Two MC officers are assigned directly to the Brigade Combat Team (BCT): a board-certified Brigade Surgeon and a General Medical Officer. The remaining MC officers are MTOE Assigned Personnel (MAP), meaning they are geographically separated and infrequently involved in the unit. PAs provide the bridge between medical knowledge and military experience.

The origin of the PA is rooted in enlisted military experience with advanced trauma training. Currently, the Interservice Physician Assistant Program (IPAP) recruits across all branches, military occupational specialties (MOS), and areas of concentration (AOC). As a result, approximately half of IPAP graduates have prior tactical medicine experience in either deployed or garrison environments. The Army PA motto, “from the line, for the line,” has been undermined as the emphasis on clinical medicine has overshadowed the importance of operational experience. IPAP is a 26-month program without a focused military medical curriculum. IPAP focuses on the National Commission on Certification of Physician Assistants certification and has not updated its curriculum to reflect the change in recruiting. Conventional forces are left to clarify conditions and standards historically managed through experienced recruiting.

Before reporting to their first unit, enlisted IPAP graduates must attend the AMEDD Basic Officer Leaders Course unless awarded constructive credit. The focus of BOLC is generalized AMEDD leadership that lacks focus on tactical medical care in austere, resource-limited environments. Proponents of current leadership models focus on breadth of experience over expertise. The Tactical Combat Medical Care Course (TCMC) and the 40-hour BOLC Area of Concentration (AOC) specific track phase have been implemented as measures to address this shortcoming. The TCMC is a 40-hour course designed for Role 1 and Point of Injury (POI) medical care, while the BOLC AOC specific track phase offers specialized training for medical personnel. IPAP graduates who were officers before attending IPAP do not receive this training before reporting to their unit. Attending TCMC is mandatory before deployment. However, the enforcement of attendance of these courses is variable as it is contingent upon the unit’s capacity to fund attendance.

TCMC is ungraded, experience-focused, and does not provide a validated product at its conclusion. The Defense Medical Readiness Training Institute offers the Combat Casualty Care Course (C4), certifying Physicians and PAs in Advanced Trauma Life Support. However, they almost exclusively reserve their seats for medical students and physicians in residency.⁷ Before assuming a FORSCOM PA position, it is critical that providers attend a Tier 4 TCCC course. One potential solution to solve the funding and attendance issues is to institute mandatory attendance of the BOLC track phase for all PAs before assignment to FORSCOM units and expand upon TCMC.

Skill Sustainment

In September of 2024, the Surgeon General distributed a memo across the force, calling for providers to return to the Military Treatment Facility (MTF) for “skill sustainment.”A published study by Carius et al. in 2020 demonstrates a failure to maintain competency ICTL at MTFs.⁸ In 2024, Tripler Army Medical Center treated zero penetrating trauma.

In 2023, the Army Military Civilian Trauma Team Training (AMCT3) program placed two PAs at New Jersey and Chicago civilian trauma centers. The goal of the program is to increase force capability. While this program is in its infancy, the two PAs rotating at a busy civilian institution will have excellent clinical experiences. However, this program will have a negligible impact on the remainder of PAs in army medicine.⁹ AMCT3 program does not impact degraded or nonexistent trauma and tactical medicine proficiency across the force. There is a perception that the program does decrease access to care at MTFs by decreasing the availability of military providers for primary care. DHA needs to provide support for primary care of FORSCOM units to free PAs, and FORSCOM physicians increased opportunities for skill development and maintenance.

Skill Evaluation

ADP 6-0 promotes the concept of Mission Command. Technically and tactically competent medical providers and teams are essential for the implementation of this concept within Army medicine. “Training and education that occurs in schools and units provides commanders and subordinates the experiences that allow them to achieve professional competence. Repetitive, realistic, and challenging training creates common experiences that develop the teamwork, trust, and shared understanding that commanders need to exercise mission command and forces need to achieve unity of effort.”¹⁰ Current training models within IPAP fail to provide Commanders with medical staff proficient in tactical medicine.

The Individual Critical Task List (ICTL) was created to codify basic knowledge and skills required for military PAs. The Department of Defense revised the ICTLs in March of 2022.¹¹ Per the ICTL, Army PAs must attend eight courses to maintain proficiency. Courses include TCMC, Advanced Trauma Life Support (ATLS), Brigade Medical Provider Course, Army Trauma Training Center, and Advanced Burn Life Support. Currently, no system exists to fund or track compliance. ICTLs cover a broad scope of topics, including “treat a traumatic pelvic injury.”¹² Current ICTLs fail to provide step-by-step guidance on expected treatments. The expectation is that all PAs are already competent in trauma management skills. Therefore, ICTLs need to be codified and tasks, conditions, and standards established to meet the requirements of LSCO and prolonged care.

Conclusion

Military forces are on the precipice of the most extensive war since WWII. Casualty projections will exceed those seen in the past 70 years of war and conflict in the Middle East. Military medicine must adapt and prepare for increased casualty rates and decreased evacuation capabilities. Prolonged care supported by PAs with limited resources will become the standard of care. To ensure that Commanders can exercise the concept of mission command, Army medicine must standardize skill development, skill evaluation, and skill sustainment through the ICTLs and rotations at civilian trauma institutions.

References:

1. BBC News. 2023. “‘Dying by the Dozens Every Day’ - Ukraine Losses Climb,” August 29, 2023, sec. Europe. https://www.bbc.com/news/world-europe-66581217.

2. Carius, Brandon M, Michael D April, and Steve G Schauer. 2020. “Procedural Volume within Military Treatment Facilities— Implications for a Ready Medical Force.” Military Medicine 185, no. 7-8 (June): e977–81. https://doi.org/10.1093/milmed/usaa001.

3. “Combat Casualty Care Course.” 2024. Military Health System. 2024. https://health.mil/Military-Health-Topics/Education-and-Training/DMRTI/Course-Information/Combat-Casualty-Care-Course.

4. Department of the Army. 2019. Review of ADP 6-0 Mission Command: Command and Control of Army Forces. 2019. https://armypubs.army.mil/epubs/DR_pubs/DR_a/ARN34403-ADP_6-0-000-WEB-3.pdf.

5. Fandre, Matthew. 2020. “Medical Changes Needed for Large-Scale Combat Operations Observations from Mission Command Training Program Warfighter Exercises.” Army University Press. May 2020. https://www.armyupress.army.mil/Journals/Military-Review/English-Edition-Archives/May-June-2020/Fandre-Medical-Changes/.

7. "FM 4-02.” n.d.https://armypubs.army.mil/epubs/DR_pubs/DR_a/ARN35791-FM_4-02-001-WEB-3.pdf.

8. Holcomb, John B., Lynn G. Stansbury, Howard R. Champion, Charles Wade, and Ronald F. Bellamy. 2006. “Understanding Combat Casualty Care Statistics.” The Journal of Trauma: Injury, Infection, and Critical Care 60, no. 2 (February): 397–401. https://doi.org/10.1097/01.ta.0000203581.75241.f1.

9. “Individual Critical Task List.” 2022. https://rdl.train.army.mil/catalog-ws/view/100.ATSC/1A5C1DD0-ACE2-4185-A37EB90B98211757-1646771705330/report.pdf.

10. Kilburn, Jeremy P, Stephanie M Streit, W Patrick Luan, Jamie Lindly, Angelica Honsberg, Buddhadeb Dawn, Ryan G K Mihata, et al. 2023. “Beyond Trauma: High-Volume Critical Care Medicine in a Military Medical Center–Based Military– Civilian Partnership.” Military Medicine, July (July). https://doi.org/10.1093/milmed/usad262.

11. “Large-Scale Combat Operations Will Bring New Medical Ethics Challenges.” 2023. War on the Rocks. December 8, 2023. https://warontherocks.com/2023/12/large-scale-combat-operations-will-bring-new-medical-ethics-challenges/.

12. U.S. Department of Defense. 2017. “Casualty Status.” https://www.defense.gov/casualty.pdf