For this edition’s “History of Military Emergency Medicine” excerpt, we’re highlighting an interview between GSACEP and COL(R) Raymond Ten Eyck. Dr. Ten Eyck served as the Consultant to the Air Force Surgeon General for fourteen years, from 1984 until 1998. During that time, the Air Force established two residency programs in emergency medicine, and grew from 11 Emergency Physicians to over 100. His tenure as consultant witnessed the expansion of the emergency physician’s role in the Air Force from someone who covered required shifts in the emergency room while away from their “real job,” to the current state of a sought-after specialist manning mobile field surgical team and critical care transport roles. As always, If you want to learn more about how you can support GSACEP’s “History of Military Emergency Medicine Project”, or have a story you feel should be included, visit History of Military EM
GSACEP: What would you say are key moments in history that had an effect on military emergency medicine, like the Beirut bombing in 1983, or Desert Shield/Desert Storm?
TEN EYCK: My time in the Air Force was almost all during the Cold War until the very end. It was the time when Clancy wrote “Red Storm Rising.” And it was a great book because it was a real threat.
That is what everybody dreaded, and it never happened, thank God. So we didn’t have a lot of events that showed the wartime needs that emergency medicine could meet. In fact, one of the things that I did as consultant was participate for a couple of years on a group called War Meds that was defining potential roles for emergency physicians in a wartime environment.
Now, the mission of the Air Force is to fly, fight, and win. The prime physicians to the line–since the medical corps works for the line (line being the pilots, the navigators, the nonmedical people)--were flight surgeons. The primary mission of the flight surgeons is to keep the flyers and the flight crews healthy and in the air and combat-ready. So, all of the specialties outside flight medicine are second-tier specialties from a line perspective.
So if you go back to World War II, the procedure was to have big pre-positioned buildings with depots of resources, equipment, and staff to treat the injured. Essentially we are talking about big and immobile fixed facilities that were going to be planted around Europe in the event that things went wrong. Med Wars was looking at what injuries were likely to be seen [in a modern war], and what tasks would be required to care for those injuries.
For the first time, Air Force Emergency Medicine was at the table. This was a fairly small group of people and not all specialties were represented. So the fact that I was there as an emergency physician was clear evidence of progress in the way the Air Force was looking at emergency medicine. So as they assessed each task and who could do it, it turned out that emergency physicians could do an awful lot of these tasks. Even though it was a whole different model, we were able to get our foot in the door of what capabilities emergency physicians had that could contribute to supporting combat forces.
GSACEP: Tell us of your time at the Uniformed Services University of Health Sciences.
TEN EYCK: I was in charge of the fourth-year curriculum, which involved both emergency department didactics and experience. We were quite fortunate, because we had not just a month of exposure to the students but we had exposure to the students in three of the four years and we had two full months of their time when they were fourth-year students.
We had a Marine Corps line officer who helped with the field exercises, and it was an opportunity for me to learn a lot about field medicine that really wasn’t a big part of the Air Force at the time. We were in the Cold War, so we would wear the blue uniform and deliver civilian-type medical care, because that was what was needed at the time. So I had an opportunity to learn more about field medicine, and I brought some of my experiences from emergency medicine and my interest as an educator.
GSACEP: You had the opportunity for research. You wrote Concepts in Triage Care and Morbidity in Hurricane Frederick for example.
TEN EYCK: The triage concepts was written with the group at USUHS, and it had to do with the field exercises and things we were learning from both emergency department experiences and mass casualty exercise experiences that were part of the curriculum. The Hurricane Frederick paper was written while I was at Keesler and was about our experience from running an emergency department during and after a major hurricane where there was extensive damage, no electricity except for emergency generators, in the area for a week or so afterwards. What was very interesting was that we had a number of ambulance calls during the height of the Level 3 hurricane. It was not a Katrina, but it had sustained winds in the 120 mile per hour range, so it was a significant storm. During the height of it, we had to very seriously screen all the calls, because sending people out in that environment was a big risk. We still ended up sending out a couple of ambulances. All the patients that came in on them, although they sounded terrible on the phone, were fine. They didn’t need an ambulance, probably didn’t need to be seen in a hospital. The only true emergency we had during the storm was an older man who drove himself in at the tail end of the storm with an acute MI, acute heart attack, who did fine.
One of the items of pride and also our albatross in emergency medicine is that everybody can close up their clinics while they go repair the damages and haul their boats out of the water and fix their roofs and stuff like that, whereas the ED has to keep running. Both the variety of pathology that we saw as well as the numbers of patients we saw in that week after the storm was probably the most significant thing. We were very busy. People who were just trying to get back to their normal life sustained injuries. We saw lots of chainsaw injuries and trauma from people falling off of roofs. We never say [in Emergency Medicine], “Okay, this is all we can take. We’re closed.” We just keep taking them, and as the rest of the system is allowed to recover in a more orderly manner, we had to really increase our efforts. Despite that challenge, the folks in my department just did an outstanding job meeting the need.
GSACEP: You were the consultant during Operation Desert Shield/Desert Storm. Give us an overview of how the Air Force planned to use emergency physicians.
TEN EYCK: During Desert Storm I was at Wright-Patterson. The War Med concept was still out there, and they sent a contingent of people from Wright-Pat to man a facility in England. It was a fixed facility with pre-established depots of equipment, and they would be taking care of casualties evacuated to them. It was again essentially that World War II concept of care with big fixed facilities and movement of casualties rapidly through the echelons of care.
GSACEP: Talk to us about mobile emergency care and Expeditionary Medical Support units.
TEN EYCK: A lot of the changes on the concept of operations for Air Force operational medicine occurred when a general surgeon named P.K. Carlton was stationed in Europe. There was a terrorist takeover of a civilian cruise ship and the US sent out a military response. Dr. Carlton was involved in some of the planning of the medical support for that event.
He initiated and really pushed the concept for an Air Force operation medical force with a much smaller footprint. This was a big difference from the traditional concept that involved setting up a hospital and being ready to operate in two weeks. He pushed the idea of using airframes and small mobile units to be much more capable of rapid-response. With that change, it became apparent that you needed physicians, nurses, and technicians who could do both critical care as well as a wide variety of other types of care. Although not everybody might remember it that way, I really do believe that General Carlton’s actions created the environment in which the values of Air Force Emergency Medicine in operational medicine came to the forefront. He subsequently became the Air Force Surgeon General a few years later and was able to further develop these changes which helped position the Air Force for the operational medical needs of our troops for the last 20 years.
At the same time, as emergency physicians were providing care to many beneficiaries in our hospitals and medical centers, their value in the medical system was continuing to grow and they were being recognized as skilled clinicians and specialists. I think those two things together really helped to change the roles of emergency physicians in the Air Force.