You Need Me on That Wall! The World of Military Medicine

Happy 2023 to all, and thank you for joining us for a very special column. As physician anesthesiologists, we work on the “front lines” of perioperative medicine – we take in-house calls, cover obstetrical and trauma units, and provide transplant and other urgent/emergent care at all hours. As practicing clinicians, military physicians do all of the above, but as members of the armed forces, they can find themselves on the “front lines” literally and figuratively. Military doctors have the responsibility of keeping our country, our fellow citizens, and our armed forces personnel healthy, protected, and safe from harm. These doctors may provide care in an existing military hospital, a temporary hospital in a forward area, an aircraft, or on a sea-going vessel and can be deployed at a moment’s notice to the far corners of the world.

Dr. Bryan Laliberte is an active-duty Army officer and practicing anesthesiologist who will explain the service lifestyle and also give us a glimpse into how military perioperative medicine works.

(Editor’s Note: The views expressed in the following interview are those of the author and do not reflect the official policy or position of the U.S. Army, Department of Defense, or the U.S. government.)

Bryan, welcome! Please describe your current position and responsibilities.

I recently moved back to Walter Reed National Military Medical Center where I am the Chief of the Pediatric Anesthesia Section, overseeing six other pediatric anesthesiologists, and serving as a liaison to the pediatric surgical subspecialists and the Pediatric Department. I also serve as the Director of the Uniformed Services Society of Anesthesiologists and as Chair of the ASA Committee on Uniformed Services and Veterans’ Affairs.

You mentioned that you just moved. Where were you previously?

I spent the last three years in Landstuhl, Germany, serving as the Chief of the Division of Anesthesiology at Landstuhl Regional Medical Center (LRMC). LRMC is a level II trauma center and the largest American military medical center outside of the United States. The facility plays a strategic role as the sole evacuation and tertiary referral center for five combatant commands. I supervised a department of 12 anesthesiologists, 20 nurse anesthetists, and five anesthesia technicians and Army medics. I was able to help lead our hospital and division through numerous challenging crises. The first was the COVID-19 pandemic, where we appropriately established ourselves as the airway experts, developing policies and procedures for intubation and extubation of infected patients. Numerous anesthesiologists in our department served as de facto critical care physicians during periods of high ICU usage and low surgical caseload. Then, in August and September of 2021, we were intimately involved in Operation Allies Refuge. This operation was the evacuation of American military personnel and Afghan citizens to Germany, an amazing effort to care for a large volume of trauma patients. As the sole pediatric anesthesiologist, I assisted my critical care colleagues in the triage and initial care of the numerous pediatric patients we received, as initially we had no pediatric intensivists. Our staff worked nearly around the clock during the first week of receiving patients. We were also able to work alongside German physicians and surgeons to treat all of these casualties. Being able to care for both my military brethren and to provide humanitarian assistance to foreign nationals certainly was one of my proudest moments.

What attracted you to the Army, and how did you get started?

I joined the Army via the Health Professions Scholarship Program (HPSP), which is a tuition assistance scholarship granted in exchange for a commission in the U.S. military and a commitment to serve in the Armed Forces upon graduation. I had several friends from college who had signed on for the HPSP and heard great things from them about the military. I had considered attending one of the service academies after high school and didn’t end up going, but I still had an underlying desire to serve and realized that this would be my way to do so.

Have you ever been deployed to a forward area?

In 2017, I was deployed to Iraq with a combat support hospital (CSH) and served as the chief of anesthesiology. I spent most of my time in one of the major cities in Iraq, but for two months I was sent forward with a general surgeon and emergency medicine physician to staff a small base with a multinational coalition. We supported Iraqi, American, and Australian special forces operations by providing “golden hour” damage control surgery and stabilization and allowing for safe transfer to higher-level care. We completed over 30 surgeries in those two months and were able to save countless lives. We operated on Army litters (stretchers) and two sawhorses with portable respirators, monitors, tanked oxygen, and intravenous anesthetics. We also completed our own surgical equipment sterilization onsite, an interesting skill to learn on the fly.

What is the most interesting or memorable place you have seen on deployment?

In between transitional year internship and residency, I was fortunate enough to be stationed in Egypt as a General Medical Officer in support of the Multinational Force & Observers (MFO). The MFO mission is to supervise the implementation of the security provisions of the Egyptian-Israeli Treaty of 1976. I was assigned as the officer-in-charge (OIC) of the South Camp Medical Clinic in the city of Sharm el-Sheikh at the southern tip of the Sinai Peninsula. I worked alongside numerous active duty and reserves units caring for a multinational force, including sailors from Italy, contractors from Britain, and soldiers from Uruguay, Hungary, Fiji, and Australia, among other countries. This is where I really started to learn how to be an Army officer – since internship is so busy medically, you don’t have much time to learn the military lingo, rank structure, and pace of operations. When my clinic was unable to provide acute urgent medical care or chronic disease surveillance, we organized medical evacuation via Blackhawk helicopter (in emergent/urgent situations) or transfer to Egyptian/Israeli medical centers (for more routine services). My vacation time was used to travel to all of the amazing Egyptian and Israeli archaeological and cultural sites. Other free time was spent golfing and scuba diving in the beautiful Red Sea.

Nonphysician practitioners often have greater levels of autonomy in the military. Can you comment on this, positively or negatively?

While this statement is true, I do believe that the military values its physician leaders and looks to them to exemplify high standards. Within the anesthesiology community, anesthesiologists are still seen as the leaders in an anesthesia care team model, always available and ever-ready.

How do you handle conflicts between people in roles where the clinical hierarchy and the rank is disproportionate? For example, the circulating RN who outranks the attending surgeon?

I have been fortunate enough in my 15-plus years of service to have not seen this become much of an issue. While subconsciously it may play a small role in some interactions, I have never seen it affect patient care. I’m not saying that it’s not an issue, just not so in my experience. I firmly believe (as stated above) that military physicians do provide the necessary determination to lead care teams, while also allowing the experience of other senior clinical personnel to shine through when appropriate.

What is the biggest challenge military medicine faces today?

While we do not have to concern ourselves with surprise medical billing, rural pass-through legislation, or Medicare payment reform, I do believe there are many challenges in medicine that we share with our civilian counterparts. Issues of physician burnout, staffing shortages, and drug shortages are major problems for our military medical treatment facilities. One of the active challenges is the transition of the operations of all military medical centers to the Defense Health Agency. This means taking control of the hospitals away from the individual military services (Army, Navy, Air Force) and giving it to one joint unit. It remains to be seen how this will affect the staff of the medical centers/clinics and patients. Another major challenge will be how the military recruits physicians, nurses, and other medical personnel. With the overall winding down of a state of war, there may not be as much opportunity to use wartime as a patriotic motivator for service, which could lead to decreased recruitment/retention. Lastly, the entire Military Health System (MHS) is adopting a new electronic health record known as MHS Genesis. While implementation has been difficult, it is hoped that once fully in place it will allow for seamless transition of medical care from facility to facility when service members change locations.

What is the most interesting or crazy thing you have seen on active duty?

Some of the most interesting things I’ve seen are also some of the most terrifying. The injuries produced from war are things seen nowhere else: caring for quad-amputees, dealing with chemical weapons, intubating a patient through a hole in their trachea caused by an IED explosion to their neck. But, alongside these horrific events, I saw fantastic teammates care for and heal these casualties of war.

What do you like to do when off duty?

With four children at home, my life often revolves around their activities and sports. But I do enjoy running (I’ve run the Army Ten Miler in Washington, D.C. each of the last 15 years), gardening, baking, watching movies with my wife and kids, and cheering on my beloved New England Patriots and Boston Red Sox.

Any parting words for ASA members?

I have loved every minute of getting to care for our nation’s heroes. The military medical community is one that rallies around these soldiers, sailors, and airmen in order to get them back to work. We are also able to provide them the peace of mind that their families are well taken care of. I advise anyone with a desire to serve to reach out to me or other military physicians to learn more. Additionally, there is a Health Professions Loan Repayment Program, whereby you can join the military after finishing residency and enjoy loan repayment in return for your service. Finally, I would like to thank ASA and all of its members for always being great supporters of me and my military colleagues.