Wild Blue Yonder on the Air - Ep. 13 - Colonel Karey Dufour (ret.) on Medical Services in a Constrained or Denied Environment (MSCODE) Published March 18, 2022 By Colonel Karey Dufour (ret.) Wild Blue Yonder -- Opinions, conclusions, and recommendations expressed or implied within are solely those of the author(s) and do not necessarily represent the views of the Air University, the United States Air Force, the Department of Defense, or any other US government agency. Dr. Margaret Sankey: Welcome to Wild Blue Yonder on the air, Today, we're joined by Colonel Karey Dufour. She is a Doctor of Nursing Practice, and she is an expert nurse manager with a lot of background in the high profile and emergency work. She was brought in to rebuild the emergency department at Kessler after Hurricane Katrina. She was selected to be a White House nurse for President George W. Bush and Vice President Biden, she has recently retired from active duty, and we're lucky to have her today to talk about a really fascinating war game that she put together while a student at the Air War College. So welcome, thank you for joining us. Col. (ret) Karey Dufour: Thank you, Dr. Sankey, it's a pleasure to be here. Sankey: Something that the Air Force Medical Service has really been proud of is the astounding advances in treatment and survivability, that the golden hour and the expectation that if people can be transported to a high standard of care, they get great outcomes is really a standard in all of our planning and expectations, can you give us some background on how that was achieved? Dufour: Sure, so we've made some remarkable progress over the last couple of decades in being in the middle of basically two different wars, and we've been able to almost perfect it to a point that we have been touting a 98% to 99% survivability rate for folks that are injured on the battlefield. And so we take a lot of great pride in that, and a large part of that is just learning from the experiences of the day-to-day that occurs, because there are never any two days that are exactly the same on a battlefield, and so there's always something to learn. And so we've learned from those, we've also learned from our sister services, particularly the Army, the Army has some substantial successes with a lot of different modalities out there, particularly like the walking blood bank and the use of whole blood, which is not something that we've normally used, these are just examples of things that have helped us achieve some great successes out there in the battlefield. But from an Air Force standpoint, and this is near and dear to my heart is the fact that we have been able to move people very, very quickly. So typically, the army medical counterparts will move from point of injury, although we have as the Air Force on occasion, been to a point of injury, particularly with our special operations forces, and they have a slightly different mission than the overall... The big Air Force mission, but being able to evacuate people very quickly and bringing them closer to definitive care has really, really made a huge difference in survivability. And so being a flight nurse the majority of my entire career, that has been something that has been near and dear to my heart, and I'm very proud of that, but as well as my colleagues are very, very proud of the fact that we've been able to move people very, very quickly to get to that golden hour and nearly perfect it. Sankey: And even building on what the medical service sees as a crown jewel, this has really become ingrained as a point of pride in identity in the US military overall, people don't get left behind, that they will be moved somewhere safe and taken care of, that's a really important part of people's professional identity, right? Dufour: Oh, absolutely, and part of that too, is it's not just for the members themselves of knowing that we're going to come back and get them, but it's really comforting for the families to know that their son or daughter, husband or wife, mom, or dad, are not going to be left behind, that we're going to do everything that we can to bring them home, hopefully in a survivability mode in which they can still continue to function through life, so that's extremely important to us. Sankey: And here's where your wargame and our conversation really needs to take a much darker turn, because as the military is shifting from planning and training for counter-insurgency and counter terrorism, we're looking at great power competition and strategic competition, a return to the kind of big operations that were last seen probably in Vietnam or Korea. And so what does that mean for this standard of care and expectation? Dufour: Well, and that is one of the things that we're having difficulty right now, kind of getting through to the masses, because I think we have been in this era of success for so long, but that was truly dependent on the fact and expected on the fact that we had control of the skies. So in these last two wars, we really were the ones who owned the sky and maintained the sky, and that allowed us to be able to do those kinds of things and do it in a rapid succession. However, we know that as we pivot to other greater powers, that near peer-peer conflict that we're looking at, or competitor that we're looking at, has very comparable capabilities that we have. And so we have to take that into consideration, that if that happens, we may not control the skies or we may not control it for quite some time, and so there may be some windows of opportunity, but we're not going to have the luxury that we had in these last two decades in order to be able to rapidly move patients to and from definitive care. And so that's where it takes that dark turn, as you mentioned, where people are struggling with having that conversation because hard choices have to be made. We have been able to do the most for the most. Because we've had relatively, I wouldn't say unlimited resources, but they've been pretty plentiful, and we've never really had an instance in which we were kind of like in the COVID-19 where nobody had PPE, for example. We really have not experienced that in the war zone for the most part, because we could get stuff pretty readily, and it really was not much of a deterrent. But in this new era of what that battle space looks like, that's a completely different... It's a different operation. And so you're exactly right, when you reference the Korea and the Vietnam in those days of having to maybe do prolonged care on the battlefield is a true reality in this next conflict, whatever that might be. Sankey: That's a really sobering thought. Have you encountered a lot of reluctance to really face head on, what this might look like? Dufour: Yes, and I'll tell you that I have experienced that in a variety of different areas, and a lot of it is when you look at the research that's being done right now and looking at how do we be able to better assess and take care and treat TBIs for example, in the field. There is continuing work that is happening with that, it is wonderful to think about that we're really trying to build that. We may not be spending as much time on really thinking about if I have somebody that has that severe a traumatic brain injury in this next battle space, that is not going to be my priority and it can't be my priority. And so when you talk to those that are so passionate about really moving that concept forward, and they're doing it all for the right reasons... Please don't get me wrong on that. They are doing it all for the right reasons, and I'm appreciative of the work that they've done, we really have to come to grips with that reality of what does that next conflict look like? And are we going to be able to do those kinds of things? And with the war game, we have demonstrated that that is probably a very unlikely situation in which we're going to be able to devote a lot of time and resources to that particular population as an example. Sankey: Civilian medicine has offered some kind of snapshot previews, whether it's the Las Vegas mass casualty shooting or maybe even COVID. What can be learned from these sorts of previews of constrained resources? Dufour: Well, I think not so much with the Las Vegas mass casualty, and part of that is because it's typically an isolated incident. Yes, it does meet the mass casualty criteria by definition, but it's relatively short-lived and everything gets controlled relatively quickly. Which is a little different than the battlefield, because sometimes you'll have multiple mass casualties that occur simultaneously and it all just kind of comes to a head. So could that happen? Yes, I think we saw a lot more in COVID-19, for example, with the PPE. So what they were doing is they were recycling PPE that otherwise would never have been considered in the past, like, Hey, this is one time, good use, it's only good for one patient, you can only wear it this one time and you have to keep replacing it. I think during COVID-19 people realized we can't operate with that in mind now, of course, that brings up all sorts of questions, right, particularly from the manufacturing companies because manufacturers are going to try to cover themselves as well and say, Hey... No, I'm sorry, but I told you that this is all that it could be used for, and if there is a negative outcome that comes from that, you can't come back and sue me because I told you that's what this was. But I think that we did a great job as a nation to realize that, Okay, maybe we can recycle, re-use, maybe we can extend its shelf life a little bit, or its exposure life a little bit more than we had anticipated. And it's because we have to, we have no choice. And so I think that COVID-19 really brought a lot of reality and saying, Hey, we need to really think about this, I think it also brought into reality that people are going to die, and there are people that we're not going to be able to save, and so we're going to have to make some choices here, and we're going to have to make them a lot earlier because we don't have the bed space in order to meet the demand that our customers are asking for. And so I think that probably COVID-19 was probably the closest to all of this that... The closest to the outcomes that we were talking about on the war game, and so it really did actually shine a huge light on a lot of things where the situations are different, the enemies were reacting the exact same way in providing a constrained environment, a resource and limited environment, truly, if you think about COVID-19 and how it initially executed was very much like an HUAD environment or at least a constrain, maybe not completely denied, but I think it was probably denied in some aspects. Sankey: One of the really fascinating aspects of your working was the way that it got into these kind of tactical level details, and it also uncovered a lot of really important ethical implications, not just the kind of legal liability you brought up, but the special circumstances of being a military medical person. You're in a strange position of being non-combatants, but you're non-combatants who service a weapon system, it's just a human weapon system. Can you tell me about that role? Dufour: Yeah, and what came up in the war game primarily was the fact that... So we are officers or from my perspective, I'm an officer first and I'm a nurse second. And so that is really kind of counterintuitive to the overall civilian population, because when you're a medical provider, if you're a physician, a nurse, a med tech, whatever that capacity might be, then that's what you do in the civilian sector. But when you're in the military, you're that military person first. And then whatever your AFSC is, your specialty code is that's second. And so being a medic in a military environment brings its own set of challenges because you're exactly right. We are considered non-combatants, we have the red crosses on our ID cards, we used to carry Geneva Convention cards that show that we were medics, but in all honesty, if we really think about the laws of arm conflict, the people that we are normally in conflict with are not following the laws of arm conflict, we're taking the high road in conflict, and so we know what we would do if we were ever experiencing their medics, we would ask that they would respect the same, but they typically don't. So really, if you think about it, we're kind of like, Yeah, we're non-combatants, but we are treating those combatants that are going back out there and doing... And executing the mission. And so, yes, there is a little bit of that duality of profession, if you will, because we have to balance both. So for example, if I am told, Hey, look, I need to have as many of those minimals that you have to go back out to the war front and execute the mission, because I have to save this base, then I'm up against one order and it's a lawful order that says, Here, I need to have these combatants back, but you also have the professional... As a medical professional, you have that obligation as well, that you're basically... Okay, if you're injured the most, then the expectation is I need to go treat you, you're the one that's more critical and I need to take care of you first, so there's that constant ethical battle that happens between the two professions and it creates a potential moral dilemma or moral injury, when that occurs. Sankey: That makes me think back all the way to World War II, when there are limited supplies of penicillin and they're planning for D-Day and ultimately it's decided not to give those early antibiotics to people who are really critically injured, they give them to people who essentially have STIs in order to sort of get them prepped up and deployable to do a really important mission, and it's sobering really to think that we're back to making those kind of decisions. We're not used to it. Dufour: Absolutely, and that's where we ran into a lot of the... You could see the participants in the war game just completely crunching when we kept forcing that situation on them, because they were like, Well... But that's not what I would do. Well, what would you do? Well, I would do this. Well, you don't have the resources, so what would you do? And it was like this constant vicious cycle, and you could just see the turmoil that was occurring within these participants because they couldn't accept it, they were like, No, but I don't want to do it this way, because that's not what my medical profession tells me I need to do, but this is what your commander is telling you that they need to do, or everybody's going to die. You could just see the turmoil that was occurring in those first two days of the war game. Sankey: You bring up a really important point in terms of the form that your scholarship took, because I know you worked with Colonel Paul Nelson, who was the Surgeon General's chair at Air University, and he's had some excellent students who had done papers that explored these issues. And it's really, very different reading their professional studies paper that looks at this, but as you zeroed in on just now, it's something very different to put people on the spot and make them wear those shoes. And so how did you come to take those ideas and think to put them into a working scenario? Dufour: This had been started actually by a couple of different students, and so Colonel Patrick Parsons, he had started with Air War College, but before him was Major Betty Hoettels, who was at Air Command Staff College at the time. And so it really kind of started with her piece and working with UW Powell at the (LeMay) War Game Center and kind of setting up spiral one, which was kind of looking at what medics do in that battle space in particular. And then Patrick really set the stage to create the second spiral, and that's the one that I executed. So he looked at a lot of the philosophical sort of big contextual pieces of that, and what that informed us was, okay, so now what kind of situations or scenarios do we have to write that test these contextual pieces? And trying to get people to think outside the box and think about what that dilemma might look like, and how are you going to address it? And so this was done... This had been a couple of years in the making by the time we got to the war game that I executed the spiral two war game. Dufour: And so really, their great work is what set the stage for these discussions and these questions that we had that really put people in a situation of turmoil. And people went home those evenings and they would think through these processes, and so the next morning when we would bring them back, we'd say, Okay, we're going to do some morning... What we call morning percolations and say, Okay, so what did you think about? What are some of the things that came to mind? And the sense of reality that finally hit them was like, Holy smoke, what am I going to do with this? And this is truly... If I really think through this, this is truly something that I would probably have to answer in the future, and how am I going to handle that? Sankey: I'd love to talk more about some of these specific wrinkles because I was just really struck by things that you prophetically targeted things like you're probably going to need to treat military animals maybe ahead of civilians in some cases, and thinking about the evacuation of service dogs from Afghanistan recently, that was... I keep thinking, man, they were dead to rights on a lot of these questions. What were some of those wrinkles that really put people into turmoil that you think are going to be the most distressing or the most urgent? Dufour: So, I think one of the big things that came up was that clipping of the switch kind of thing, and so it was now having to kind of go against the grain of what typical medical triage is, which is, I'm going to triage you as an emergent, urgent, minimal, expectant, and I do that initial triage, and then the first people I would typically do in a normal medical triage scenario is I go to my immediate first and I take care of them. But when I have to flip the switch in which now I have a commander that says, I need to have people back out there as quickly as possible because I need to repair the run way, and I need to get these F-16 out, because I need to provide defense to this base, and to this population. And so, I think that's where people now, we're being forced to have to look at the minimals, which would have been the last to be looked at, to now being the first to be looked at, and it just completely reverses my sense of urgency. And so, that was a very enlightening and eye-opening experience for many of us to include me which I already knew what I was going to be asking, but to hear it from the participants, they just reinforced the fear that I had as well going, yeah, this is a very real thing. You mentioned the working dogs, and people think, well, obviously human life has to go above the animal life. Well, not necessarily, because if you think about the role of the military working dog, the military working dog is what provides the security. And so, I would have to maybe treat that entity first, dog or human, if that is the requirement where I need to provide security then that might be the priority that I have to place over somebody who's got a traumatic brain injury, and that is a hard thing for folks to really think about, and they're used working on two-legged beings, now I've got four-legged beings and they're like, wait a minute, I didn't go to school to learn how to work on dogs, and so... That added an extra layer of complexity to the situation. So yes, absolutely that was... Those were some of those issues. The other issues that came up is, what you want me actually take stuff that I've already used in another patient and then take it off of them and use it on a different patient, well, if that's all that you have, what are you going to do? And then that opened up a whole other entity of, oh my gosh, well, this is an infection control issue, but as we mentioned just earlier, that is the exact scenario that we more or less had to work through with COVID-19. So, you're exactly right, when you say there's a lot of these things that have already come out that we were looking at it from a conceptual standpoint, but we were faced almost two years later with a very similar situation. And so those were some of the things that did come up. Sankey: The war game was also really interesting in that it looked at some of these conflicts in terms of priorities and triaging in the bigger picture of what this might do in terms of an international relationship, the relations with a host nation, as well as the kind of public affairs problem, the expectation of families back home is really high, what happens when that abruptly changes and their confidence in the way that the military takes care of its people, and so this went way beyond the medicals issues too, didn't it? Dufour: It did, because this is really not a medical problem, this is truly an operational problem, and so this is something that is big Air Force not just the medical world, because you're right, when we start changing our tactics like that and you start having much higher casualty morbidity mortality rates, people start asking, well, why? You did so well in the last war what happened in this one? And so people start asking questions. Now, the interesting thing about this is that we had a member on the war game team that was from the University of Minnesota, Dr. Faizal and she actually did a piece as part of this war game and part of the professional studies paper that I had submitted, which was talking about what does it look... What is the civilian population, what do they really think about that? And I was actually quite surprised at the conclusion she came up with, and really from a PA standpoint, we were just thinking, oh my gosh, the people, American people are not going to want to accept this, and they're actually much more accepting of this notion, than we are I believe as the military members. And so from American people, I think because it's not on our land, it's in another area, and it's dealing with military folks while it is a sad situation, they understand that that is the call of the soldier, the airmen, the sailor, the marine that goes out there and does their thing. And so basically her conclusion was that they may not be as affected as you think they might be. So, again, a lot of this was conceptual, but it was also from the standpoint of the lessons that we learned from world war 2, Korea, Vietnam. And so they may not be quite as bothered by it, than the folks that are actually wearing the suit and the uniform that are doing the job itself, that's probably going to be a very different conversation, but they're there in the middle of the fight. So it's a different context. Now, when you're looking at the host nation, we have an obligation, as it stands right now that if we have host nation folks that are on our bases, it is our job to protect them as well, and so we're going to have to make some choices, and if that host nation individual is not in a critical component, then they're going to be in that they may be in the... I'm sorry, but you're going to have to wait because this operational person is right now, needs to go out before I need to treat you, that is going to create a little bit of friction and then could that hinder or effect relations in the future? Absolutely, absolutely. But we're learning for some of those lessons and some of these are being looked at and tested in South Korea, for example. When we talked about this, people who are not on the Peninsula were kind of mortified by this conversation, whereas those that were actually from the Peninsula were like, we kind of already talk about these things and we've already worked through some of these, and so some of those lessons that we were trying to get through, we were getting from those that are doing the job every day and have thought about a lot of these concepts and brought it back to us for us to understand that okay, it's not so far off the mark. Sankey: You mentioned earlier that Air Force Special Operations folks have learned some interesting things talking about... And sometimes in the field, making these kinds of hard decisions. Dufour: Yes, and as a matter of fact, we had a few of them in the room with us that were also another great population in which they were drawn from their experiences and bringing that context into the conversation, while Special Operations is a much smaller community, and the population they serve are typically much smaller as well, there are a lot of concepts that they looked at, and partially because they are so used to working in contested environments, I wouldn't say that they're completely denied, because most of the time they break through it, but they have their own challenges in order to be able to get into those contested environments, and so learning how to work in those environments, that was really great context to bring back to the group to say, okay, but here's what happens with special operations, of course, then the counter was always, yeah, but there's only a handful of you guys and we're looking at 3000 people. True, but can those concepts be applied, and so we started talking about how that could be applied in a much bigger construct, and I think people started to make that realization about halfway through the second day going, You know what? We are going to have to change how we look at this. Sankey: It was such a great use of your time, and in fact, Colonel Nelson used a lot of people's expertise and time while at Air University to do this, and one of the perks of doing things that at the LeMay war-gaming center is that you could pull from a lot of what you guys identified as Dual Professionals. So we had JAG, we got chaplains, we've got medical people, what is that dual professional identity and why does it come into friction in these kind of scenarios? Dufour: Well. Again, like I mentioned before, with the fact that we are military members first, and we are whatever that profession is, second. And so we are sometimes put in situations in which we have to go against our Professional oaths that we all took and the commitments that we took, because our primary mission is to be military members first, and there's that mission as a military member that you have to make sure succeeds. Now, I think in years past we have been able, especially with the last two decades, we've done a great job of being able to parse that out a little bit better and make it very clear that we were medical professionals and yes, we were so military, but it allowed us to kind of bring more of that medical professional as well as the Jags and the chaplains, it allowed them to be able to work in their profession, and it was as a military member versus your military member who happens to have this skill set. And so I think that it's going to be a difficult situation in which people are going to have to be more along the lines of, okay, if you're going to be classified as a non-combatant, then you have to follow suit, but understand that who you're serving are those combatants, so there's an indirect relationship in which you are now supporting the combatant, does that really make you a non-combat and that created a lot of discussion because you are a non-combat supporting a combatant, does that make you part of the weapon system, and that's where the struggle begins. Sankey: And that would, wow, get kind of extra hairy, if you're looking at our total force situation, where people have to move much more fluidly, say, as a national guard position who is used to being in the civilian world, and then is put into that military context. Did the war game get into any of that? Dufour: We did have... We did have some reservists that were in the room and I think we had a couple of guardsmen, so we had a lot of folks that were in the room that were kind of serving... That wearing in a couple of hats where they were reservists and then they were a medic or they were reservists, and they were headquarters member doing another job as a GS, and so we had some folks that were wearing many hats, but we didn't dive into it too too much because it was one of those things that we recognized that this was something that was going to have to be studied a lot more in the future. Sankey: Well, that tees up my next question really beautifully, which is, this was a stunning war game, and your write up of it is fascinating. Some other medical personnel followed up on this by looking at chemical, biological, nuclear events, and we hope to have them on here of course, absolutely snowed under with COVID duties, so I hope to get them all on the same teams call at some point in the future, what additional research to be done, what should be spun off of this... Not just to keep it in the front of people's minds, but to explore some more of these ramifications. Dufour: So a couple of things that we thought was beyond the scope of the war game that really needed to be looked at a little bit more was kind of going back to the medical profession in which not just do we have to answer to the military, but each one of us who are licensed professionals, your physicians, your nurses, your respiratory therapists, like the folks that are licensed by a governing board, for example, they have a set of rules, and so you're supposed to be following those rules in order to maintain your licensure. Now, if you're put in a situation as a military member in which now I have to let those immediate. I have to push them off to the side to get to my less critical, but the ones I can put out on the battlefield quicker to take care of the mission, really kind of goes counter to what those boards say. So if there are bad outcomes, then what happens in that case, in which now does the member lose their license because they didn't follow their licensure, whatever their state regulators said they had to follow, and so that was one of the things that we thought this is something we have to address, but this has to be addressed at a later time because this could be its own war game scenario of looking through. Another thing that we looked at as kind of what we call a killer or accomplice. So again, that's that member that's really having to fulfill being that person that is helping the combatant, so a non-combatant helping that combatant, so are they really a true non-combatant or are they just an accomplice to a combatant. And so that was another thing that we probably need to take a little bit more of a look at particular on the legal side and say okay, is this really... Are we legally okay with this? The other thing is the trust in the medical system. So, when we talk about an operational triage, which is the least goes first and then more serious goes last. So, if we look at that operational versus our traditional triage as it is right now, what happens then from that standpoint of that soldier who's sitting there, who is maybe in an urgent situation, and I have to say, well, I'm sorry, but your job is not required...right now, so I need to put you off to the side while I take care of this other individual who has to go back out to the battlefield. Now, obviously, there has to be some communication that occurs there, but how do you think that that soldier, sailor, airman or marine who is sitting in that capacity, when they're used to being the ones that would be taken a look at first and, hey, I'm potentially dying here, but they're not getting any care because the focus is being put on a different population, what does that trust look like? And that trust in the medical system is going to be challenged. We always talk about the communication gaps, how do we communicate this to the population that we're immediately serving, but then how do we talk about it and communicate why we had to do what we did in a strategic arena. And that's where we started involving, even though we might be in a different part of the world, we still own answer to the Americans. And how do we communicate that. We also looked at human remains because we know that mortality and morbidity is going to be much higher in this next conflict, there's inevitably going to have a situation in which we're going to have many more human remains. And what do we do with them? If we don't have the proper refrigeration, we don't have the proper supplies to package them up and get them ready to move, if they're sitting there for quite an extended period of time, how do we do that? Long-term infection control, and I think that with COVID-19, with the group that worked on the SE-BRM aspect of it, I would venture to say that there's probably a lot of what they talked about from a biologic standpoint that probably came to fruition was tested during COVID-19. And so I would be curious to see because I had not read any of their paper, so I'm not sure what that ended up being, but I bet that some of the principles that they talked about were being tested as well. And then joint operations. So, we did have maybe in the room, we were unable to get army folks in there, and so now when we're working in a joint environment, what does that look like? So, if the Air Force starts doing operational triage, will the army accept that? Will the Navy accept that? And are they going to do the exact same thing are we going to work counter to each other. And so joint operations, we did not have a whole lot of that, and quite frankly, we just didn't have the time to be able to explore it. And then looking at NGOS, those non-governmental organizations... Sorry, it just doesn't want to come out today. When we're looking at NGOs, there's a fine line there because why they sometimes can get into some of those contested environments much easier than we can is because their philosophy is different. They're going in in a non-threatening way, whereas the military is perceived as something that is threatened or threatening, I should say. And so when you start asking for the help of the NGOs, they don't have to help, because really, if they do help the military, then what does that do to their commitment to that country that they swore had no governmental commitment? They are going in as maybe missions from a church, and so when we start asking them to help, what does that do to their legal status. So those were some of the areas that we looked at. The other thing is like disarming patients, do we really want to disarm those patients when we bring them into the environment because we may not have security in the area that we're treating because we're all hands on deck trying to take care of the mass casualty. What if a patient continues holding on to their weapon and actually saves a bunch of medics that are doing their work because they saw a bad guy come in. That is something that we needed to talk about because our normal traditional way is as soon as they walk in the door, they get frisked and everybody leaves their weapons at the door. Is that really a good idea or is it not? We just didn't have the time to look at that. And then lastly, you talked about this earlier, is the military working dog, and what does that do and how do you send that message to the human being that has to take a back seat to a military working dog that has to go back out on patrol and provide security, how is that engagement going to work? And we know that that has got to probably solicit some kind of rub of some kind to say, What do you mean, you treated a dog before me, I don't get it. And so it's something that has to be addressed and looked at a little bit more. Sankey: Something else really pressing it that you identified, that came up in a big way trying to organize your colleagues to talk about The CBRN book, is that the participants in the War Game were pretty rattled and I think needed some debriefing and some after-care, our COVID colleagues are really stressed making these kind of decisions, there are some real moral injury. How should we be planning to take care of the medical people who take care of us? Dufour: And that is a great question, and this has been a question that has been asked for quite some time, particularly with these decade-long conflicts that we've been involved in. And really bringing that mental health back to the forefront and making it a part of the planning process. And not part of the, Oh, I forgot about this and now I have to do a reactive response, and I think we are doing a much better job of that in the military, but I don't believe that the civilian side was quite ready for that kind of response because I think with mass casualties like Las Vegas, you mentioned that earlier, I think that there are some debriefing that happens with that, and people can talk through that immediate crisis. And that is a point in time in which you can take care of the situation, and you have those crisis teams that come in for that. But what happens to those long-term crises like we're having with COVID-19. No one expected that this was ever going to last... We're almost two years into this, it'll be two years, come next February, March time frame, and we have been working in this kind of environment, and granted, we've seen the sunlight on some days and then another round comes in or a different variant comes in. And so what happens is, this is just a perpetual grind that people go through day in and day out, and they become very numb to the situation, and so it's harder to bring in those crisis action teams because you never know what point is going to actually be that critical point. You don't know, you can... With the Las Vegas shooting, you could pick that one event and you can say, Okay, this was the event in which you can work around, but with COVID-19, where you have a long-term prolonged type of environment, there's not a one detail. It's just COVID is the detail but it's lasted so long. How do you properly debrief? And I'm not sure that debriefing is necessarily the right answer for this particular group, but it's probably more ongoing assessments that have to happen much more frequently, and so it's more of like a barometer check than it is a debrief, if that makes sense. Sankey: So a lot of these things, when you planned the wargame you didn't expect to see them play out in this kind of national level health operation, but lurking in the background of everything we do in PME, in the military at large, is orienting towards great power competition. This is a big reality for everything we do. And so as we wrap up our conversation, what are the sort of guide rails that we should have in mind as we think about the future and how it's changed from the great successes that the military and military medicine have had? Dufour: I think probably the biggest guide rail is just the guidance. When you're thinking about it, from the way that we write doctrine and the way that we write regulations, I think a big part of that becomes a hindrance to us when we have to focus on something a little bit differently. So instead of doctrine and regulations telling people what to think, they really should be designed in a way that they teach us how to think. And part of that is leadership has to be able to accept what those frontline folks are... What those decisions are that those front line folks are making. And so I think what came out of the War Game in particular, and it was one of those threads that was weaved through everything that we talked about, because in the military we're so regulation-driven. We have doctrine, and people don't understand the difference between regulations and doctrine. Doctrine is kind of the conceptual thing, but for some reason, people think that is the way that I need to perform or I'm going to get in trouble if I don't do it that way. Regulations... I mean, in the military, we write regulations and regulations are meant to be followed, and when people don't follow the regulations, there's a consequence to that. Sometimes that's letters of reprimand, sometimes it's Article 15, sometimes that's actually discharge from the military. People are so... They're very rule-bound in the military, and that is just the nature of what we do, but while that is one of our successes, it's also one of our failures, because we tell people, You've got to follow the regulation, this is what the military is all about. We got to follow this, this is all good order and discipline, but if we write it in such a way that we do not give latitude for people to make on-the-spot decisions and say, you know what, I have to put the rule book aside, because in this case, I have to do this for the greater good. People are not willing to do that, they're very risk-averse to doing that, and part of that is because they feel that their leadership it will not trust the decision that they had to make at that point in time, and it will come back to haunt them at a later time. And so I think if there's one thing that really we have to work on, and this is something that's immediate, is the way that we write that doctrine and the regulations and the instructions that we have out there, that we should be using it as more of a live document in which we have to be able to address... So the Army does a great job of this. When we talk about standard operating procedures, they don't paint themselves into a regulation box, they're like, Okay, today these are the rules, but tomorrow something might happen, so we might have to tweak that and it doesn't require an Act of Congress in order to get it through and approved. I think that we, from an Air Force standpoint, really have to start working on the guidance and allow people, our airmen out there in whatever profession it is, we have to allow them the latitude and give them guidance that allows them to say, Okay, this is how you're going to think not what you're going to think. If that makes sense. Sankey: Oh, it not only makes sense, but just let me say we're proud to have you as one of our Air War College alumni, because this is exactly the kind of critical thinking and thoughtful process management that we're really trying to achieve. So I would give you an A on that final exam. Absolutely. Dufour: Thank you. That's wonderful. [laughter] Sankey: Well, I can't think of a better way to end. Although what we've been talking about is a sobering reality, this is really why we want people in PME to have the space to test these ideas, to think through them, to have the kind of guidance from officers, from the lawyers, from a whole spectrum of medical professionals, and so I want to thank you for talking to us today. I hope we can follow up with our other medical colleagues, and I certainly appreciate all you do and wish you the best in your future projects. Dufour: Well, thank you so much, it was a pleasure to be here and thank you. It's been an honor for you to ask me to do this because this is something that I was passionate about the entire time I was at Air War College, and I have been passionate about in my entire career. I just didn't realize how passionate I was until I was given the opportunity at Air War College to really think through this process. So thank you very much.