Medical Skillset for US Air Force PJ...

[TheOneRonin]

I'm working on building an Air Force PJ for a modern campaign that is coming up. He's about 90% complete, but I'm struggling with what medical related skills I should give him, and how many points I need to put into them.

First Aid and Diagnosis are both no-brainers, but what about Surgery, Pharmacy, Physician, etc.?

Here is a snippet from the PJ article on Wikipedia:

Originally Posted by Wikipedia

Pararescue EMT-Paramedic Training, Kirtland Air Force Base, New Mexico (22 weeks)

This course teaches how to manage trauma patients prior to evacuation and provide emergency medical treatment. Phase I is four[8] weeks of emergency medical technician basic (EMT-B) training. Phase II lasts 20 weeks and provides instruction in minor field surgery, pharmacology, combat trauma management, advanced airway management and military evacuation procedures. The airmen are then sent to Tucson, Arizona for hands-on medical training. Trainees work along side paramedics with the Tucson Fire Department as well as local hospitals. Graduates of the course are awarded National Registry of Emergency Medical Technicians-Paramedic (NREMT-P) certification.

What about Techniques or Perks that would help reflect the medical training and experience this guy would have?

Currently, I have his IQ at 13, and I'm building him off the idea that he is in his mid 30s and has about 12 - 15 years of experience as a PJ, and has spent some time in Afghanistan and a few other places in the middle east.

Any help/feedback you all could give would be really appreciated.

[Icelander]

Surgery with an Optional Specialisation in Trauma.

Depending on specific courses taken, probably a basic level of Physician and Electronic Operation (Medical).

[TheOneRonin]

Thanks for the feedback.

So what do you think is a realistic skill level for those skills?

Also, I found some more info on PJs and their medical training:

Originally Posted by www.specialtactics.com

Currently the Paramedic school is 119 training days. With 6 week rotations (explained below).

The pipeline manager tries to schedule paramedic 3rd on the list after indoc and scuba. During the aprox 6 month paramedic training, students will get 4 weeks of EMT basic with advanced A&P. The rest is dedicated to paramedic were they will get ACLS, PALS, PHTLS and 6 weeks of rotations in Albuquerque and Santa Fe, NM. The rotations are on average split 3 weeks EMS / 3 weeks in hospital. The only training outside the scope of a regular paramedic school is the in depth A&P, suturing performance, Foley cath performance, and intro to PJ medicine knowledge (i.e.. PJ drug box, DOMI & surg skills). During Paramedic training the cones operate out of PJ med rucks IAW 16-1203.

All the "dirt medicine" is taught in blocks 2 & 3 of the 3-level school. Remember, even though the Paramedic training is taught at Kirtland, it is not attached to the 3-level school. It is a pipeline school under the PJ Det. Some students get EMT-P training with just scuba, while some are done with the pipeline except for the 3-level...it all depends on exactly how the pipeline works out. The only requirement is that students are done with indoc and scuba prior to start of paramedic.

The Pararescue EMT-Basic course provides the student with a foundation for providing efficient and immediate pre-hospital medical care to the critically ill and injured patient(s). Students receive the following: 40 hours of Anatomy and Physiology; procedures for accident on-scene saftey; mechanism/nature of injuries; patient prioritization for emergency care; proper techniques for airway management and cardiopulmonary resuscitation; patient assessment and obtaining historical data; pre-hospital emergency care of simple/multiple system trauma such as controlling hemorrhage, oxygen administration; treating shock, bandaging wounds, and immobilization of fractures; assisting in childbirth, respiratory management, cardiac/diabetic/allergic emergencies, suspected posionings, and extrication of entrapped patients; Students will test after completing EMT-Basic for state/national EMT-Basic certification.


AND

Pararescue Emergency Medical Technician - Paramedic
Course Description:

The Pararescue EMT-Paramedic builds on and expands the EMT-Basic graduates knowledge gained in the EMT-Basic prerequisite course. EMT-Paramedic provides the student with more in-depth knowledge on body systems and responses to treatment protocols. The student receives: advanced instruction on managing medical/trauma patients; extensive training in a wide-range of advanced skills such as: medications administration techniques/concerns, drug dosage calculations & contraindications, intravenous therapy for all ages, advanced life support in conducting and interpreting electrocardiograms (EKGs), electrical intervention supporting cardiac functions, performing advanced endotracheal intubations in airway management, and relief of pneumothorax. The overall goal is to provide EMT-Paramedic trained pararescuemen/AF Medical Technicians (4N0X1) with the necessary emergency medical skills to function independently in an ever-changing medical emergency environment. In addition, EMT-Paramedic training fosters the philosophy of independence in his application of Pararescue Specific Medicine (peacetime or in combat) in the follow-on Pararescue Apprentice training. Students will test after completing EMT-Paramedic training for state/national EMT-Paramedic certification.

[acrosome]

I disagree- a PJ probably should not have Surgery skill. And they sure as hell shouldn't have a specialization in trauma- there are subspecialty trauma surgeons who do 2 or 3 year fellowships for that... after completing their 5 or 6 year general surgery residency- though, granted, they expend some of those points to crank up their Physician skill learning critical care, too. What a PJ should have is a very high First Aid skill, and add a low level of Physician (which IMO should include very minor "surgeries" such as lancing abscesses or removing hangnails). I don't have my rules with me, but IIRC the way that Surgery skill is described no one but a surgeon should have it (in a modern-day campaign at least). But perhaps I'm ignorant of some rules somewhere- feel free to enlighten me.

But GURPS doesn't really cover medical issues well. Better than most professions, granted, but not well. One place that it fails is that First Aid should default to general Surgery as well as Physician. Surgeons are the trauma experts. But then, First Aid covers initial treatment of a cardiac arrest, too, doesn't it? Thus, Physician. So defaulting from either would probably be best. But if you ever want to see chaos, get a radiologist to run a code...

I'm a military surgeon, and my biggest question on this skill determination would be this: does First Aid skill allow one to attempt interventions such as endotracheal intubation or tube thoracostomy? I would propose that it should, but this gets very sticky. Someone who learned First Aid in the boy scouts should clearly not attempt to place a chest tube, but a PJ probably could. High-Tech does seem to at least imply that First Aid allows attempts to intubate- it says that a First Aid person can "attempt to clear an airway" then immediately starts talking about other airway management modalities such as ET tubes. A PJ could certainly do a needle decompression, and I know that they are taught to do cricothyroidotomy. I think that this distinction is best modeled merely with a higher First Aid skill level. A PJ easily qualifies as an "expert" for First Aid-14, and that would be for one who just graduated from the course. An experienced one can be epically higher- even without considering battel experience medics attend all sorts of follow-on courses and training throughout their careers. For example I managed to get all of my medics trained in ABLS and PHTLS before my last deployment, and the Joint En-Route Care Course (JECC) would be especially appropriate for a PJ- and would up his Physician skill. A more mundane medic fresh out of training probably "only" qualifies for First Aid-12 without Physician. The Eagle Scout gets First Aid-9. Someone who took a CPR course once a few years ago is working from default.

After all, a PJ's mission is still to keep his patient alive long enough to him to a surgeon. And that's First Aid skill.

A PJ shouldn't try to do a vascular repair or IM nail a complex comminuted fracture (to restore a crippled limb, in GURPS terms). That's what Surgery skill is for, and even putting one point in surgery makes his chance of success at such things much higher than it would be in reality.

For lack of a better term there are a class of "super-medics" in the military. These include Army 18Ds and similar SOF medics such as PJs. They aren't really supposed to prescribe medications except on the battlefield, but I think that they all deserve a point in Physician skill. They hand out OTC meds and stick a fentanyl lollipop in the mouth of wounded troops.

I can't recall enough about how GURPS medicine works to say for sure but you could probably justify a single point in Diagnosis and/or Physiology if you really wanted to, but I personally think that the "super-medics" would default these from Physician. The things that "super-medics" deal with usually qualify for heavy positive bonuses to Diagnosis. It ain't hard to figure out a long bone fracture or blast amputation or gunshot wound. Nor is it hard to figure out most common problems that a soldier would present to his medic with- athlete's foot, gastroenteritis, the clap, etc. When they are in doubt, they call a doc and at least get a telephone consult. (I have worked with 18Ds with some regularity.)

And remember, you can default Surgery from Physician in case your "super medic" does want to try something heroic like removing an appendix in a submarine on the bottom of Tokyo Bay. (Yes, that actually happened during World War II.)

Any PJs out there are free to lend better information.

EDIT---

I just took a look at the medical rules in Basic Set and I stand by the above. Of particular importance is that Physician skill allows one to attempt trauma maintenance (B423), so the "super-medics" should probably have it, if only at a low level, so that they can transport vented patients. But their low level of Physician skill means that if they try to do so for more than a short while they will eventually fail, which is also realistic. (No "super-medic" could manage a VAD or ECMO, no matter how talented they might be. I'd send a nurse or physician on that flight...) Also, all of the functions descibed for Surgery skill on B424 are far beyond the scope of practice of a "super-medic"- recall that First Aid is used to stop bleeding under the optional Bleeding rules, so they don't need Surgery for that. (I.e. they use tourniquets, they don't do vascular repairs...) Splinting a fracture is First Aid. Setting a simple fracture (a lasting crippling injury) might be doable defaulting to Surgery from Physician. But fixing a permanent crippling injury, which is possible at TL7+, probably needs Surgery skill- specifically the Orthopedics and/or Vascular specialties. I wouldn't allow a default, personally.

FWIW, the current plan is to make all U.S. military flight medics qualify as paramedics (i.e. EMT-P). This would probably give them First Aid-12 with one point in Physician skill so that they, too, can do trauma maintenance to transport an intensive care patient. OTOH a Navy IDC focuses on primary care, so they might be best represented with the "basic" First Aid-12 but put more than one point in Physician. This gets really shady, though- an IDC is probably a better "physician" than a paramedic as far as diagnosing and treating primary-care kinds of problems, but isn't taught en-route care.

Even worse, there is no specialization for Physician skill, except for by species. If you could split it into Primary Care vs Critical Care vs Immunology vs Cardiology vs Rehab Medicine etc it would be a good thing. I guess you could, but it isn't specifically stated in RAW. In such a case the IDC and 18D would specialize in Primary Care and the PJ and flight medics in Critical Care.

Meh. As I said- the GURPS model is imperfect.

Pharmacy is the skill to produce drugs. A medic should not have it. Hell, the vast majority of doctors don't have it- their use of drugs is covered by Physician skill. I think that most of the Electronics that Icelander is talking about Operating (vents, monitors, etc) should be covered by Physician skill and for some even Professional Skill (Nursing). I'd reserve Electronics Operation (Medical) for operating an Xray, CAT scan, Nuclear Medicine scanner, Radiation Therapy device, automated lab testing machines, and such. And, frankly, I would subspecialize it into those categories.

Damn. I just opened another can of worms by bringing up nursing... but I'll stop.

And as I said, I might be ignorant of some rules somewhere. Correct me if I'm wrong.

[Kraydak]

119 days of intensive education will give about 8 skill points. Maybe 4 in First Aid, 1 each in Diagnosis and Physician and 2 in appropriate techniques/perks?

[Pursuivant]

Originally Posted by TheOneRonin

I'm working on building an Air Force PJ for a modern campaign that is coming up.

Start with a Combat Medic template.

Swap "Soldier" for whatever the equivalent would be for the Air Force - obviously there are some soldiering skills include there, but also the sort of things that airmen learn but soldiers don't. Maybe substitute Soldier for Crewman (Aircraft) - if the GM allows it - to cover things like use of aircrew survival equipment.

Obviously Parachuting, maybe Climbing (for Rappelling), Survival and Electronics Operations (Communication) if those are taught.

Maybe techniques in First Aid and Parachuting.

For a veteran, boost skills, maybe add a level of Rank and some Reputation. Add Savoir Faire (Military), Tactics, maybe weapons skills, and possibly Area Knowledge (Afghanistan) if he's moved around a bit "in country" rather than just being stuck on a base someplace.

Maybe add Language (Pasto) at Broken level if he's had to do a lot of clinic work or work extensively with local troops.

With respect to Acrosome, I agree that this guy is going to have bit of Physician skill, if he is a "super-medic" as described. But, he might have a point in Surgery skill as GURPS defines it, but it's going to be specialized in Field ExpedientTrauma Surgery.

Admittedly, this specialization is a bit of a stretch, but it would be even more hyperspecialized than trauma surgery, allowing the character to ignore some penalties for poor conditions and equipment, but at the penalty of him not being able to do all the sorts of things that an actual trauma surgeon could.

For example, he's going to be rock steady if he has to put a chest tube into a convulsing patient while riding in the back of a Humvee, but he's not going to be so great at removing shrapnel from the patient's liver.

Alternately, he might be able to certain surgical procedures as Techniques based off of Physician skill. In that case, most would be Hard.

What I'm trying to go for here is that there are medical procedures which can be learned independent of overall medical skill and I think that folks who fall into the "super medic" or "not quite surgeon" category have learned some of them.

[TheOneRonin]

Excellent feedback, everyone. I feel really confident about the rest of the skillsets for the PJ, but I've just not had to deal with any of the medical skills/rolls in GURPS.

I do have a few other comments, however:

@ Acrosome: Looks like you have some real experience working with the kind of guys I'm looking to emulate. I was originally planning on building an 18D, but I read that the washout rate for PJs is somewhere around 90+%, so it seems like they would have a broader and higher level of skills than the 18Ds, even though the 18D medical training is 46 weeks vs. 24 for the PJs. (though I know a portion of that is vet training) In your experience, which guys come out of training with better trauma/life saving skill sets?

@ Pursuivant: A few things, here. PJs get a lot of ground combat/soldier-ish training, so I believe that "Soldier" is the appropriate skill for them. I've got most of the rest of the skills already accounted for, based on the research I've done and personal experience I have (former US Army Infantry and Certified Combat Lifesaver). I would be more than happy to post what I have so far if you or anyone else is interested. Also, I like your idea of the Field Expedient specialization of Surgery. And do you know which book has the different techniques that would go along with Surgery?

[Fred Brackin]

Originally Posted by acrosome

II don't have my rules with me, but IIRC the way that Surgery skill is described no one but a surgeon should have it (in a modern-day campaign at least). But perhaps I'm ignorant of some rules somewhere- feel free to enlighten me.

I'm a military surgeon, and my biggest question on this skill determination would be this: does First Aid skill allow one to attempt interventions such as endotracheal intubation or tube thoracostomy?

Bio-Tech allows someone to attempt intubation with a straight Physicisian Roll of a First Aid-4. Surgery is not mentioned but surely surgeons can intubate.

Dealing with what I believe to be realistic Gurps skill levels I would not have someone with First Aid only attempting intubation on a regular basis.

A key point is the rule on p.138 of Bio-tech that gives anyone who has Surgery but not Physician a -5 to perform any proceedure _except_ "field-expediant surgery" which it e.g.s as "stiching wounds, removing arrwheads, bullets or shrapnel, etc".

I beleive (but have no specifics to support) that this "field expediant surgery" is also meant to include the game rules specific task of "stabilizing a mortal wound". In the Real World I would think this was mostly dealing with critical bleeding in the field.

From general talk, some of it during palytest I beleive that the most highly trained military personnel who yet do not have an M.D. are meant to ahve Surgery for thsi sort of "field expediant" sort of thing.

I would include P.J.s in this category.

[acrosome]

@ TheOneRonin: I've worked with 18Ds. I've only met a few PJs, never worked with one, but I think I have a good grasp of what they do. The issue is really just the way the GURPS rules work.

I agree that Soldier works. It is specialized, like Soldier/TL6 (Wehrmacht) or Soldier/TL3 (Armsman). In this case it is Soldier/TL8 (U.S. Air Force) and would cover knowing how to safely approach an aircraft that has it's engines on, donning an MCU-2/P mask and protective suit, and all the other stuff covered in Airman basic training, etc. But Crewman (Aircraft) makes sense, too- PJs spend an awful lot of time on aircraft.

Originally Posted by Fred Brackin

Bio-Tech allows someone to attempt intubation with a straight Physicisian (sic) Roll of a First Aid-4. Surgery is not mentioned but surely surgeons can intubate.

Ah, thanks for the reminder to check Bio-Tech...

But I think you're confusing endotracheal intubation with performing a tracheotomy (Bio-Tech123). What you quoted above is for a tracheotomy. Bio-Tech mentions that paramedics at TL6+ often perform endotracheal intubation but does not list a skill. Or my lysdexia is acting up or something.

Originally Posted by Fred Brackin

Dealing with what I believe to be realistic Gurps skill levels I would not have someone with First Aid only attempting intubation on a regular basis.

If you can attempt to cut open someone's neck for a tracheotomy with a -4 penalty to First Aid I would at worst allow an intubation attempt at the same penalty. And in fact I'd argue to use a smaller one, like -2, so that the Eagle Scout would have to get really lucky but the "Super-Medic" would usually be successful. Having observed and/or proctored "super medics" through many intubations I can tell you that the 75%-ish success rate from an effective skill of 12 (i.e. First Aid-14 at -2) is not unrealistic.

Hell, anyone who has watched an episode of ER could probably attempt it at default. This would give a really high failure rate, simulating intubating the esophagus (which is not uncommon) or right main-stem (also very common).

Originally Posted by Fred Brackin

A key point is the rule on p.138 of Bio-tech that gives anyone who has Surgery but not Physician a -5 to perform any proceedure _except_ "field-expediant surgery" which it e.g.s as "stiching wounds, removing arrwheads, bullets or shrapnel, etc".

I beleive (but have no specifics to support) that this "field expediant surgery" is also meant to include the game rules specific task of "stabilizing a mortal wound". In the Real World I would think this was mostly dealing with critical bleeding in the field.

From general talk, some of it during palytest I beleive that the most highly trained military personnel who yet do not have an M.D. are meant to ahve Surgery for thsi sort of "field expediant" sort of thing.

I would include P.J.s in this category.

Ah! give me a moment to look that one up... I'm looking, but do you have a page reference? But I'm pretty sure that this will be another area in which the GURPS medical model fails quite epically.

EDIT--

Ah, yes, as a by-the-way: Bio-Tech131- setting a bone only requires Physician skill, replacing the B424 rules for repairing lasting crippling injuries. I guess I wasn't totally full-of-crap on that one.

OTOH Bio-Tech136 says that Electronics Operation (Medical) is required to hook someone up to life support, so it isn't just reserved for CT Techs, etc. Which I guess isn't totally bizarre, since this would allow Respiratory Techs to hook them up- something that RTs do do. I'm not sure if PJs are trained to hook someone up to a vent, though I would at the least trust one to transport a patient that was already hooked up. (I'd prefer to send a flight nurse, though. That's what they're for.) I need more info to make a call on that one, but my bet is that they are not so trained. 18Ds aren't. But both of them absolutely can intubate and BVM- I think that's covered by First Aid.

Aha! I found the Surgery-without-Physician thing, Bio-Tech138, and I disagree with it, depending upon what they mean by "removing bullets, arrowheads, or shrapnel." Or rather, I interpret that rule differently than you. I think it was rather specifically meant to simulate the barbers who used to do war surgery, pull arrowheads, cauterize wounds, etc., at low TLs. Sort of the same way Surgery works in Low-Tech, only covering bonesetting and such. I would let anyone with (modern) Physician skill stitch a wound or pluck shallow shrapnel at no penalty if I were GM. The primary-care docs at battalion aid stations do it all the time, and none of them have Surgery skill. Hell, some of them are pediatricians or immunologists.

Also, no, I don't think that it is meant to cover stabilizing a mortal wound. That has it's own section (Bio-Tech137) and from the description given IMHO would require true Surgery skill. I think this is meant to simulate the "golden hour". I'm conflicted, though, because I can think of a few "mortal wounds" such as tension pneumothorax that could be addressed by a medic. But then again exsanguinating hemorrhage is a "mortal wound" but has it's own special rules. I think tension PTX is just lost in the granularity and you should require Surgery skill to stabilize a mortal wound per those rules. Which you could do defaulting from Physician.

OTOH I guess the field-expedient-Surgery rule isn't a bad rule to simulate what "super-medics" do, but then you'd have to make sure that they don't get Physician skill or pretty soon your medic is going to be doing aortic valve replacements. And I guess you'd have to let the doc who hooked up the vents for transport cover the trauma maintenance rules, not the PJ or flight medic himself. And what would you do with an IDC (who definitely would have Physician skill) who later changes to a flight medic (and thus would learn your field-expedient-Surgery)? Poof- AVRs, again.

So, yeah, I have no solution- ask your GM. I'm sure I'm just being very persnickety because I know so much about the field. We need a Kromm or Pulver ruling, I guess.

If I were your GM, what you need would covered by a very high First Aid skill and a point or so in Physician (Critical Care) skill without Surgery skill. I'd allow Physician skill to cover trivial "surgeries" like lancing boils, removing moles, stitching simple woulds, and plucking superficial shrapnel or gravel.

[cosmicfish]

OP: You had sent me some of the files you had put together early this year, and I apologize for not getting back to you - what little free time I had for this project got sucked up by a medical issue that I am just now coming out of. On the bright side, I am a little more familiar with certain real-world medical specialties! Including Neurosurgery (which I do not think can be represented in GURPS until an explicit Torture skill is created)!

I had previously made up an 18D template (covering just that MOS section and not the remainder of the SF pipeline):

Attributes: IQ 13
Perks: Efficient (Diagnosis), Efficient (First Aid)
Skills: Diagnosis (Human) 14 [8], Electronics Operation (Medical) 12 [1], Electronics Repair (Medical) 12 [1], Field Dentistry (First Aid) 14 [1], Field Surgery (First Aid) 14 [4], First Aid (Human) 17 [12], Physician (Human) 12 [2], Physiology (Human) 11 [1], Veterinary 11 [1]

Where Field Dentistry (Tech/A, Prereq-4 default) and Field Surgery (Tech/H, Prereq-6 default) cover field-expedient, emergency appications of those skills and techniques.

Now, please note that there are some subtle but important distinctions between 18D's and PJ's. 18D's receive a fair amount of general medical knowledge, as they are trained to operate for extended periods in the field and provide long term care for not only their team, but also the people and livestock of the foreign units they are interfacing with. PJ's lack some of this breadth but receive (supposedly) a greater depth of knowledge in the specifics of combat-medicine, and are in this specific area reputed to be (at least marginally) the finest such medics in the world. Considering that the duration and intensity (and therefore point cost, roughly) of the medical portions of the training are about the same, I would consider something like the following:

Attributes: IQ 13
Perks: Efficient (Diagnosis), Efficient (First Aid)
Skills: Diagnosis (Human) 13 [4], Electronics Operation (Medical) 13 [2], Electronics Repair(Medical) 12 [1], Field Surgery (First Aid) 17 [6], First Aid (Human) 18 [16], Physician (Human) 11 [1], Physiology (Human) 11 [1]

I dropped Field Dentistry and Veterinary entirely as being outside the scope of the PJ's training. I reduced Diagnosis and Physician and raised First Aid, Field Surgery, and Electronics Operation to represent that PJ's are more focused on trauma and operate with more access to high-tech tools. This is just a quick attempt at a package comparable to my 18D template, and has the same point cost - I do not claim that it is perfect, and probably needs some tweaking.

Although neither template shows it, one think I would consider adding would be something like this:

Perk: Rugged (Skill Name) [1/2], allows character to ignore up to 2pts of environmental penalties to the skill per point invested. In the case of combat medics, Rugged (First Aid) would reflect that they are specifically trained to render aid under conditions that conventional paramedics would consider intolerable. Might also be good for other specialties as well, to reflect one of the prime differences between military and civilian training.