One rapidly growing aspect of Army medical care

By Scott R. Gourley Medical SPC Blanca Haag, below, simulates being treated for injuries during a recent training event at the Medical Simulation Training Center (MSTC) at Joint Base (JB) Lewis-McChord, Wash. One rapidly growing aspect of Army medical care involves the use of medical simulation (MedSim) in the training of medical personnel at all levels from initial combat lifesaving skills through multiple levels of hospital care, and in the development and maintenance of specialized medical proficiencies. (Above, center) Soldiers practice combat medic skills on a computer-driven mannequin at the medical simulation center at Fort Drum, N.Y. (Opposite) Visitors from the Washington Corps of Military Attachés observe a Coast Guard class training at the MSTC at JB McGuire-Dix-Lakehurst, N.J., as part of an Army Reserve showcase hosted by the 99th Regional Support Command in May. U.S. Army/Tawny M. Dotson There is really a growing body of evidence supporting the effectiveness of clinical medical simulation, says LTC Wilson Ariza, U.S. Army program manager for medical simulation. That s because it not only improves proficiency but it also improves the performance of the health-care provider and improves patient safety. I think that s the key in telling this story. Organized under the Program Executive Office for Simulation, Training and Instrumentation (PEO STRI), Ariza s team is at the 40 ARMY December 2012

Simulation forefront of emerging medical simulation technologies. Simulation improves the competence of the provider, he explained. And it improves competence by providing a safe environment in which providers can practice as many Whether you are a medical student or a new provider you will first observe a medical procedure from a staff member, he says. That s the See one. Then you will most likely practice that procedure on a cadaver being supervised by a staff member once. U.S. Army/Hannah M. Hayner times as they want. They can master those skills. They can practice different protocols, they can apply critical decision-making skills, and they can even develop communication and interpersonal skills. According to Ariza, the current model in medicine involves a process that is commonly called See one, Do one and Teach one. U.S. Army/SFC Alyn-Michael Macleod That s it. That qualifies that provider to perform that procedure later on a patient, but that also means that a doctor who graduated from school today might not do the first one until 10 years down the road. Recognition of that fact has been an important factor in the rapidly expanding adoption of simulation in the medical field. December 2012 ARMY 41

U.S. Army/Timothy Hale Army Reserve soldiers work together to limit simulated blood loss of an injured patient during noncommissioned officer developmental training at the MSTC at Fort Bragg, N.C., where the NCOs refreshed their combat lifesaving skills in January. Medical Simulation Training Centers One critical early element of the U.S. Army s medical simulation program was the fielding of medical simulation training centers (MSTC). (See Soldier Armed, ARMY, August 2006.) Today there are 23 MSTCs located worldwide, including six in Iraq and Afghanistan. That first one went into continuous operation in 2005 to support Operation Iraqi Freedom, Ariza recalled. The medical simulation training center is a facility of about 10,000 square feet in which we have provided the sustainment training for all the EMTs [emergency medical technicians] we call them combat medics in the U.S. Army as well as the EMTs of any other service who were deploying to support Iraq and later on Afghanistan. He added that the systems are also being used to educate medics, doctors, nurses and nonmedical personnel throughout the entire U.S. Army and the sister services. In the case of nonmedical personnel, he said, Let s say you have infantrymen deploying to Iraq or Afghanistan. They could be sent to the medical simulation training center where they will learn basic combat lifesaving skills. That s where MedSim has supported the tactical enterprise. Now we have a truly integrated training platform that deploys a very comprehensive training and education medical system using simulation. LTC Ariza estimates that 40 percent of the current MSTC training mission involves combat lifesaver training. The emerging [MedSim] technologies provide training in what I call a low risk, supportive environment, where I Scott R. Gourley, a freelance writer, is a contributing editor to ARMY. can really recreate the nuances of patient care, whether in a hospital or a combat environment, he explained. I can really identify and re-create it, and they can practice as many times as they feel they need to practice. Then later on I can do the training and I can even test to see if they ve learned those levels of competency needed to save a life. The wide array of simulation methods includes mannequins, human patient simulators and body-part task trainers. Training for a servicemember is normally 40 hours, he said. The first two days are spent in a classroom, learning the curriculum and refreshing their knowledge. Through the classroom phase they also practice on part task trainers. For example, if they need to practice to start an IV in an arm, we have an IV arm trainer that is very similar to a human arm. Toward the end of the week, on the last day, we do what we call the Validation Day, he continued. Using simulation we have re-created an environment in which they are going to walk into a location, a building like one we saw in Iraq or Afghanistan. It will include a combination of medical and nonmedical personnel, and we are teaching skills to both. The enemy will be there, so they need to engage the enemy and clear the room. Then they will find out that they have patients in there: friendly, friendly allies, and possibly even one of their own, who may become a patient. Now they need to apply everything they have learned, including tactical operations, to the trauma medicine aspects. While they are doing this, we are simulating the noise and we are even simulating the smells. Any provider will tell you that a wound has a distinct smell, so the ability to re-create that distinct smell in that chaotic environment adds to that realism. I am trying to re-create the trigger and the stress that they are going to encounter so when they first see that real environment they will have done it so many times that they can fully concentrate on trauma medicine. LTC Ariza pointed to one relatively new simulator, developed in conjunction with industry and the Army s Research, Development and Engineering Command, that presents trainees with double amputee injuries. The simulator can be attached to a living role player to enhance the traumatic realism. What we were trying to do with that was to create that environment where a servicemember will have to block out some of those aspects to really concentrate on trauma medicine, applying the tourniquet, telling the soldier that he is going to be okay, and generally doing everything that he or she has practiced in the medical simulation training center to save a life, he said. 42 ARMY December 2012

Along with situations like traumatic amputations and other combat casualties, the simulation technology at the MSTC can be used to create unique crisis scenarios like heart attacks, hypothermia or other complex medical situations. You also have different degrees of combat chaos that can be added to the scenario. You can also add different scenarios that they might encounter later on. This is not just about Iraq or Afghanistan. Look what happened in Haiti not too long ago. We had a situation in which hospitals were destroyed or so full that they couldn t take any more patients, he said. The state-of-the-art MSTC equipment also includes video scene recording. While we are videotaping, we let the servicemember go through the entire scenario. We do not stop the training; that s not realistic. We believe that learning occurs at the end of the session, which normally takes a good hour, when we go back into a room and play the video and point to any mistakes, he said. In this job as I travel to different locations around the world it is very reassuring when servicemembers tell me, I ve been in combat and this is as real as it gets, he added. In fact, it s so realistic that there have been some instances when we have triggered PTSD [post-traumatic stress disorder]. We re very careful of that now, and we have different medical personnel available in case anyone feels the need to talk to someone. Asked about the incorporation of theater-lessonslearned into the MSTCs, Ariza noted the close cooperation across DoD and with entities like the Lessons Learned Center at the AMEDD [U.S. Army Medical Department] Center and School at which we constantly have meetings to make sure that we capture those lessons learned from Iraq and Afghanistan and that they are incorporated into all of our 23 MSTCs. That s why we incorporated things like the simulator for double amputation, because we learned that was an injury that servicemembers were seeing and that we needed to re-create that environment. I m a strong believer in knowledge management being able to share those lessons that we have learned that will improve patient care and improve patient safety, he added. Going even further, that type of lessons-learned analysis has also triggered new equipment, Ariza said. For example, when we realized the enterprise U.S. Army and DoD that we were seeing a certain type of injury, people analyzed the data and came out with a new type of body armor that covered a lot more of the body. Ariza highlighted a 2009 DoD Defense Health Board assessment of the types of training being conducted at the MSTCs as well as at other agencies. The outcome of that Tactical Combat Casualty Care study is that at the time more than three years ago we had saved more than 1,000 lives, he said. For my team and for myself, the fact that we can go home thinking that we had saved so many lives because of what we do here is a great feeling. Levels of Care Along with use at the MSTCs for first responder training, Army MedSim technologies are being applied across expanding areas of medical training. Medical simulation is no longer just for trauma medicine or first responders, Ariza says. As you move that patient from the street in Iraq, Afghanistan or even Haiti, that patient then goes to the next level of care, which in this case may be the operating room after the emergency room. With simulation we are now able to recreate that same patient moving through the levels of care. We have been able to use simulations in hospitals not only to generate the emphasis of treatment but also the teams concept. When a patient gets into the emergency room or the operating room, there are doctors, nurses and other technicians, and it is critical how we communicate and work as a cohesive team. What simulation has done is to allow those providers in fixed facilities to also refine their communication skills, and we can do the testing to see how we work as a team, he said. Soldiers with the 61st Chemical Company practice inserting chest needle decompressions at the MSTC on Joint Base Lewis-McChord during a Tactical Combat Casualty Course in March. Chest needle decompressions are used when a patient has tension pneumothorax, a leading preventable cause of battlefield deaths. U.S. Army/SPC Hannah Frenchick December 2012 ARMY 43

U.S. Army/SPC Loren Cook SSG Teresa Greening (right), an instructor at the MSTC, Joint Base Lewis-McChord, conducts a needle chest decompression on a training mannequin as SGT Joshua Long applies a tourniquet. Training at the MSTC allows medics to retain their emergency medical technician certification with the national registry. We feel very proud that our simulations and training are credited with saving more than 1,000 lives, and also that all of the other services have been trained in our facilities. They want to see what we are doing so that they don t have to reinvent the wheel in their own training facilities, he added. Another recent milestone was the signing of an interagency agreement by PEO STRI and Secretary of Veterans Affairs (VA) Eric Shinseki, which establishes PM MedSim as the acquisition arm for medical simulation across the entire VA system of more than 150 hospitals. Ariza credits the new arrangement with providing continuity of care for medical simulation equipment used across the Army as well as the VA system. Other outreach efforts have created MedSim synergies with Florida s new Medical City at Lake Nona, Florida Hospital Nicholson Center, and University of South Florida Center for Advanced Clinical Learning and Simulation. We have now sent the message to the world that the central corridor of Florida has become the epicenter of medical simulation, he said. I tell my team that we are being pioneers in this office in transforming the way that we practice medicine, not only in the military but in the world. The Army s 23 MSTCs train an average of 120,000 individuals each year, and in the middle of 2012 the program passed the milestone of a half million people trained. 44 ARMY December 2012 That is just at the MSTCs, Ariza stressed. That s not counting all of the VA providers and all of the doctors and nurses training with medical simulation in U.S. Army hospitals. In terms of the growing embrace of medical simulation, he says, It s very difficult to change a culture. We ve been doing things one way for so many years, so why should we use medical simulation when we haven t done that before? It has taken a lot of effort to demonstrate the clear benefits so that now the entire medical enterprise not only military medicine but also civilian medicine incorporates medical simulation in their day-to-day operations. Emphasizing a strong team effort, he pointed to growing outreach from his office across the Army as well as to other services looking for the best type of simulator to fulfill a particular requirement. They are seeking advice as to what is the best prototype or simulator to fulfill a requirement, he said. One mistake that is occasionally made is that a hospital may buy the highest end simulator when a simpler one will do. You don t need a complex simulator to teach a basic medical procedure. For example, you can use an IV arm part task trainer to teach starting an IV. Asked about his vision for new technologies and the way ahead, Ariza offered his belief that virtual technologies and long distance learning will be vital to ensuring that medical providers stay current in an environment of fewer combat deployments. For the past 10 years we have had a large percentage of the force forward-deployed. So, although we were extremely busy, we had a balance. Now that more of the force will be coming home we must be able to continue providing them with the skills that they need to practice medicine, and we believe, from the simulation perspective, that virtual training and long distance learning will be key to be able to maintain those skills, he said. I ve been forward-deployed many times, he concluded, and everyone who is forward-deployed knows that if they become a casualty they will receive the best combat medical care known in the history of warfare. That knowledge enables many of us to accomplish any difficult mission under extraordinary circumstances. That s one of the biggest combat multipliers on the battlefield. Our warfighters know that we have the best-trained personnel and that we have given our providers the very best training and resources to take care of them if they become a casualty. They are surviving, and that s a great news story for those great Americans out there.