The concept of modeling and simulation (M & S) has long been an integral part of war-fighter military training dating to before World War II when pilots and infantry soldiers would train with simulators and mockups to prepare for battle. Army and Navy aviators would practice flying in simulated cockpits. It was not until the turn of this century that M & S saw application in healthcare. The most recent wars involving the United States and coalition partners have created the need for more training and practice in life-saving procedures on the battlefield and in the hospital. Therefore, in the 1960s, simulation was accepted as a successful addition to the preparation of medical personnel.
The Need
The mortality rate of combat wounds in World War II was up to 30% but dropped to 24% in the Vietnam war.[1] However, in the 1990-1991 conflict in the Persian Gulf War, the 24% mortality rate remained.[2] Then, in 1997, the Tactical Combat Casualty Care (TCCC) program was developed for the Special Operations medical community based on injury-patterns from the prior wars.[1] This program established pre-hospital trauma-care guidelines for the front lines and was the reinitiation of tourniquets as a front-line technique for hemorrhage management.[1][2][3][4] Further, there have been reports that 90% of combat-related deaths occur before the war-fighter can reach a Military Treatment Facility (MTF), thus emphasizing the importance of battlefield care.[1] Multiple similar reports called for more consistent training and implementation of the already practiced TCCC course for medics and the line soldiers.[1][2][3][4][5][6] In 1999, the Army focused on providing better medical care downrange and increased training for combat medics. This expanded training included simulation as a core element.[7] Analysis of the recent wars in Iraq and Afghanistan, after the inclusion of simulation in training, found that the mortality rate from combat-related wounds dropped to 10%, despite the increase in trauma the new weapons of war bring and that upwards of 25%, of deaths were potentially survivable.[4][5]
Despite the improvements in training, as many soldiers were dying from preventable deaths, as previously reported, still in 2005, the U.S. Army Medical Command released an Operational Needs Statement that reported a significant gap in battle-focused skills for Combat Medics.[8] The concern was that medics all over the country were receiving different training on different equipment, and therefore, there was no standardization and no sustainment of skills.[8]
The Response
In response to this report, the Medical Simulation Training Center (MSTC) program was quickly established in the United States Army in November of 2005 with the intention to build, sustain, and standardize the skills of the enlisted Army Combat Medics.[8][9] This setup employs training lanes to simulate combat injuries and allow for the use of hands-on skills training, which is standardized from installation to installation.[8] Soldiers learn self-aid skills, buddy-aid skills, and combat lifesaver skills with a focus on the three major potentially survivable causes of death: extremity hemorrhage, tension pneumothorax, and airway obstruction, which were chosen based on data from the Vietnam War.[3][8] The goal was to stop the “preventable deaths” and to decrease the overall 10% mortality that deployed soldiers were still facing at the front lines.
Originally, the plan was to have 35 of these centers around the world, which was later scaled back to a total of 25.[10] There are currently 21 MSTC facilities located both in the continental United States (CONUS) and outside the continental United States (OCONUS) to train the 35000 U.S. Army medics, as well as all deploying soldiers.[8] These facilities teach and reinforce the TCCC curriculum. Using engaging and hands-on methods, medics will renew TCCC training while also developing and practicing more advanced skills like chest tubes and tracheotomies on simulators both in calm and simulated distressed settings.[3][8][9][11] These facilities also train the combat lifesavers, a non-medical soldier designated by each squad to be trained in more advanced medical skills [9]. MSTC facilities enabled medics to help train every solider to use their individual first aid kits (IFAK), and its components, both for self-aid and to potentially save the life of a fellow comrade.[3][8][9][11] Facilities have grown to incorporate augmented reality, moulage patients, task trainers, live tissue models, perfused and non-perfused cadavers, and even a working dog mannequin to help medics learn life-saving techniques for the canines on the front lines.[11][12] In the first 3 to 4 years of practice, these facilities trained several thousand soldiers. Towards the height of the Iraq and Afghanistan conflicts, the MSTCs saw 70000 to 90000 trainees annually, with a peak of over 120,000 soldiers in just 17 MSTCs in 2009. They were able to provide training for everything from Basic Lifesaving (BLS) to Emergency Medical Technician (EMT) recertification training.[9][11]
Since the assimilation of the MSTC programs into medic training, the U.S. Army Medical Department (AMEDD), medical simulation training has been declared a mission-essential imperative for both training new providers and reintegrating those from deployment.[7]
The U.S. Navy has used simulation as a training aid in several contexts. The USNS MERCY and the USNS COMFORT are two large hospital ships that perform regular, advanced-phase training to prepare and test the capabilities of the ship and the crew. These drills utilize cut-suit simulators and simulated patients to allow for the practice of movement of personnel as well as at-sea life-saving procedures. The U.S. Navy Medical Department has run simulation drills with live actors and mannequins to practice mass-causality events on many different types of naval vessels (surface ships and submarines) prior to operational deployments.[13] The Navy employs a three-module team known as the Expeditionary Resuscitative Surgical System (ERSS) to provide care on-board amphibious or other large ship platforms at sea.[13] This system includes the Expeditionary Trauma Team (ETT), Expeditionary Surgical Team (EST), and the En Route Care Team (ECT).[13] The ERSS teams are frequently composed of sailors who have not previously worked together; therefore, simulation drills allow them to develop an efficient and effective working relationship to provide the best care during operations. The U.S. Navy has mastered the ability to incorporate simulation into their medical training so well, that the Royal Navy of Great Britain has sent teams to Norfolk, VA to investigate the use of simulation training aboard their aircraft carriers.
Navy medical corpsmen assigned to the United States Marine Corps (USMC) are trained at the unit level using simulators. The individual medical battalions run their own, independent training with task trainers and mannequin simulators in a tactical field environment [13]. Recognizing the importance of service-wide standardization of training, particularly with the incorporation of simulation, the USMC has submitted a proposition for funding and, in the last couple of years, is seeing more funding put towards unification and standardization of medical training, particularly with simulation.[13]
One of the critical roles U. S. Air Force medical technicians play is air evacuation of critically ill patients. In 2002, three Centers for Sustainment of Trauma and Readiness Skills (C-STARS) was established to better train Air Force personnel in the Critical Care Air Transport Teams (CCATT) in Baltimore, St. Louis, and Cincinnati.[4][14] These were established after the reviews of Operation Desert Storm revealed that 90% of combat-related deaths occur before reaching a hospital.[4][14] Thus, the improvement of the skills of the transport team may decrease that number. Further, successful CCATT teams have allowed the medical personnel to be farther away from the frontlines.[14] This training program lasts two weeks and incorporates simulated environments of war with limited visibility and loud background noises while providing medical care.[14] They utilize mannequin simulators to reenact large injuries and the movement of personnel, along with smaller task-trainers, to simulate small procedures and interventions.[14] More recently, the Air Force has stood up the Aeromedical Simulation Training and Education Center (ASTEC), which is the first of its kind to specifically model and train providers for the provision of medical care in a simulated en-route care environment.[14]
Expansion of Military Healthcare Simulation
The MSTC and other military medic training programs did not include physician and nurse training, and there was a new gap observed in military medicine between the maintenance of skills needed on the battlefield and the skills needed for hospitalized patients. To address the needs of patients admitted to military treatment facilities, the military healthcare system (MHS) began establishing hospital and school-based simulation centers to enhance clinical training and experience among physicians and nurses.[7]
In 1999, the Uniformed Services University of the Health Sciences, a military medical and graduate nursing school, established the first simulation center to enhance medical education and training. This Val G. Hemming simulation center employs live actor simulation, mannequins, task trainers, and virtual reality, based simulation to train medical students, graduate-level nursing students, and Graduate Medical Education (GME) trainees. The partnership between the medical school and the simulation center ensures that well-trained military physicians and nurses treat patients who reach higher-level care centers. It is demonstrating improved outcomes of trainees in published works, too numerous to cite.[15][16][17][18][19] It remains the largest and most comprehensive simulation center in the MHS.
The Charles A. Andersen Simulation Center at Madigan Army Medical Center was established as the first hospital-based simulation center in March 2002.[20] This facility was initially used for soldiers preparing for deployment, but after the success of the MSTCs, it quickly developed into a training center for Obstetrics & Gynecology, General Surgery, Anesthesiology, and Otolaryngology health care professionals.[20] As robotic surgery began to demonstrate advantages for patient safety with surgical advancements, the USU and Andersen simulation centers acquired robotics simulators in 2005 to start to train their surgeons on this new technique.[7][21][22] Army Graduate Medical Education (GME) expanded to allow for simulation training sites at 10 Army MTFs.[7][20]
The United States Air Force subsequently acknowledged the need for healthcare simulation within their service and developed the Air Force Medical Modeling and Simulation Training (AFMMAST) in 2008 to establish and coordinate simulation centers around the globe.[10] The main focus was to train medical staff in battlefield and hospital medicine skills using simulation before deploying to war.[10]
The U. S. Navy Medical Department established the Naval Medical Modeling and Simulation Training (NMMAST) program in 2014 to coordinate the implementation of 12 simulation centers in Navy medical treatment facilities around the world. This new office worked with existing large hospital simulation centers at Naval Medical Center Portsmouth and Naval Medical Center San Diego to disseminate best practices.[7][10] In San Diego, the first simulation training events took place on local movie sets to enhance the simulation. These programs focused on developing skills for both in-hospital skills, as well as field medical skills before deployment.[10] In Portsmouth, simulation center personnel brought mannequins and task trainers pier side to conduct simulated casualty drills on navy ships.
Several studies have demonstrated that after deployments, surgical subspecialists take a significant amount of time to return to their perceived skill baseline after coming home.[23][24] Further, there has been a lot of effort to work to maintain skills for military surgeons state-side as there is a concern that on smaller bases, the volume is too low for high-risk patients.[25] In response, the newly established Defense Health Agency created a central coordinating office for healthcare simulation across all services in 2015. The Department of Defense Medical Modeling and Simulation Office (DMMSO) was charged with getting the Army, Navy, and Air Force simulation efforts to work more cohesively in developing and implementing simulation methods to train, gain, build, and sustain medical skills for deployment readiness and to refresh skills needed for subspecialty skills.[10] The office also began to standardize the procurement of equipment and operators needed for healthcare simulation. The office was also responsible for setting requirements for healthcare simulation across the entire MHS and for standardizing the training of instructors in simulation.
Multiple studies have demonstrated the impact of simulation on medical training. Simulation-based learning demonstrates improved skills for all participants and increased skill retention.[26][27][28] Further, there is evidence that simulation improves the standardization of skill acquisition and development, which supports the goals of the military through the addition of these training curriculums.[28][29] These studies further validate the efforts the MHS has implemented to better care for the soldiers, sailors, airmen, and marines.
As the military begins to work towards a unified medical force under the Defense of Health Agency, the goals for the advancement of military medicine will continue to require simulation as a critical aspect of training and maintenance of skills. The future of military medical simulation includes working towards remote surgical interventions to allow for those on the front lines of the battlefield or deployed aboard a ship to receive a life-saving surgery from a remote surgeon. These programs allow for the military to create the most prepared and skilled force of medics, corpsmen, technicians, nurses, and physicians to aid those in harm's way.
The Future of Military Healthcare Simulation
The future of simulation within the military healthcare system is bright. There are many areas in which the military is using simulation methodologies to enhance skills needed to care for service members in battle and themselves and their family members when hospitalized in military treatment facilities. Among the areas of active interest are:
This article was completed with multiple interviews from those involved with the creation, development, and introduction of much of the reviewed systems and curriculums. Special thanks to COL (ret) S. Deering, MAJ G. O’Keefe, SGM L. Moore, G. Vallegjo, MSG R. Gonzalez, J. Higman, CAPT M. Spooner, LCDR D. Weltch, J. Ruisi, COL (ret) E. Lockrow, B. Roth, and R. Garza.
[1] | Kotwal RS,Montgomery HR,Kotwal BM,Champion HR,Butler FK Jr,Mabry RL,Cain JS,Blackbourne LH,Mechler KK,Holcomb JB, Eliminating preventable death on the battlefield. Archives of surgery (Chicago, Ill. : 1960). 2011 Dec; [PubMed PMID: 21844425] |
[2] | Gawande A, Casualties of war--military care for the wounded from Iraq and Afghanistan. The New England journal of medicine. 2004 Dec 9 [PubMed PMID: 15590948] |
[3] | Blackbourne LH,Baer DG,Eastridge BJ,Kheirabadi B,Bagley S,Kragh JF Jr,Cap AP,Dubick MA,Morrison JJ,Midwinter MJ,Butler FK,Kotwal RS,Holcomb JB, Military medical revolution: prehospital combat casualty care. The journal of trauma and acute care surgery. 2012 Dec [PubMed PMID: 23192058] |
[4] | Eastridge BJ,Mabry RL,Seguin P,Cantrell J,Tops T,Uribe P,Mallett O,Zubko T,Oetjen-Gerdes L,Rasmussen TE,Butler FK,Kotwal RS,Holcomb JB,Wade C,Champion H,Lawnick M,Moores L,Blackbourne LH, Death on the battlefield (2001-2011): implications for the future of combat casualty care. The journal of trauma and acute care surgery. 2012 Dec; [PubMed PMID: 23192066] |
[5] | Kelly JF,Ritenour AE,McLaughlin DF,Bagg KA,Apodaca AN,Mallak CT,Pearse L,Lawnick MM,Champion HR,Wade CE,Holcomb JB, Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006. The Journal of trauma. 2008 Feb; [PubMed PMID: 18376168] |
[6] | Holcomb JB,McMullin NR,Pearse L,Caruso J,Wade CE,Oetjen-Gerdes L,Champion HR,Lawnick M,Farr W,Rodriguez S,Butler FK, Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001-2004. Annals of surgery. 2007 Jun; [PubMed PMID: 17522526] |
[7] | Deering S,Sawyer T,Mikita J,Maurer D,Roth BJ, The Central Simulation Committee (CSC): a model for centralization and standardization of simulation-based medical education in the U.S. Army healthcare system. Military medicine. 2012 Jul [PubMed PMID: 22808890] |
[8] | McCarthy M, US military revamps combat medic training and care. Lancet (London, England). 2003 Feb 8 [PubMed PMID: 12583953] |
[9] | Hemman EA, Improving combat medic learning using a personal computer-based virtual training simulator. Military medicine. 2005 Sep [PubMed PMID: 16261973] |
[10] | Linde AS,Kunkler K, The Evolution of Medical Training Simulation in the U.S. Military. Studies in health technology and informatics. 2016 [PubMed PMID: 27046580] |
[11] | Sohn VY,Miller JP,Koeller CA,Gibson SO,Azarow KS,Myers JB,Beekley AC,Sebesta JA,Christensen JB,Rush RM Jr, From the combat medic to the forward surgical team: the Madigan model for improving trauma readiness of brigade combat teams fighting the Global War on Terror. The Journal of surgical research. 2007 Mar [PubMed PMID: 17196987] |
[12] | Butler FK, Leadership lessons learned in Tactical Combat Casualty Care. The journal of trauma and acute care surgery. 2017 Jun [PubMed PMID: 28333837] |
[13] | Brethauer SA,Chao A,Chambers LW,Green DJ,Brown C,Rhee P,Bohman HR, Invasion vs insurgency: US Navy/Marine Corps forward surgical care during Operation Iraqi Freedom. Archives of surgery (Chicago, Ill. : 1960). 2008 Jun [PubMed PMID: 18559749] |
[14] | Maddry JK,Mora AG,Savell SC,Perez CA,Mason PE,Aden JK,Bebarta VS, Impact of Critical Care Air Transport Team (CCATT) ventilator management on combat mortality. The journal of trauma and acute care surgery. 2018 Jan; [PubMed PMID: 28570350] |
[15] | Goolsby CA,Goodwin TL,Vest RM, Hybrid simulation improves medical student procedural confidence during EM clerkship. Military medicine. 2014 Nov [PubMed PMID: 25373045] |
[16] | Deering S,Rowland J, Obstetric emergency simulation. Seminars in perinatology. 2013 Jun [PubMed PMID: 23721775] |
[17] | Deering S,Auguste T,Lockrow E, Obstetric simulation for medical student, resident, and fellow education. Seminars in perinatology. 2013 Jun [PubMed PMID: 23721768] |
[18] | Calohan J,Pauli E,Combs T,Creel A,Convoy S,Owen R, Using Simulation in a Psychiatric Mental Health Nurse Practitioner Doctoral Program. Journal of professional nursing : official journal of the American Association of Colleges of Nursing. 2016 Nov - Dec [PubMed PMID: 27964816] |
[19] | Goolsby C,Branting A,Ausman J,Williams D,Ausman C,David J,Allard R, Systematic Review of Live Tissue Versus Simulation Education for Prehospital Trauma Providers. Military medicine. 2017 Sep [PubMed PMID: 28885943] |
[20] | Deering S, Anderson Simulation Center at Madigan Army Medical Center. Journal of surgical education. 2010 Nov-Dec [PubMed PMID: 21156309] |
[21] | Whitehurst SV,Lockrow EG,Lendvay TS,Propst AM,Dunlow SG,Rosemeyer CJ,Gobern JM,White LW,Skinner A,Buller JL, Comparison of two simulation systems to support robotic-assisted surgical training: a pilot study (Swine model). Journal of minimally invasive gynecology. 2015 Mar-Apr [PubMed PMID: 25543068] |
[22] | Macedonia CR,Gherman RB,Satin AJ, Simulation laboratories for training in obstetrics and gynecology. Obstetrics and gynecology. 2003 Aug [PubMed PMID: 12907117] |
[23] | Deering SH,Kavanagh LB,Chinn MK,Choi Y,Rush RM Jr,Haque I, Objective Evaluation of the Effects of Deployment on Laparoscopic Skills: The Simulation and Deployment Laparoscopic Skills Study. Military medicine. 2016 Sep [PubMed PMID: 27612353] |
[24] | Deering SH,Rush RM Jr,Lesperance RN,Roth BJ, Perceived effects of deployments on surgeon and physician skills in the US Army Medical Department. American journal of surgery. 2011 May [PubMed PMID: 21545919] |
[25] | Edwards MJ,Edwards KD,White C,Shepps C,Shackelford S, Saving the Military Surgeon: Maintaining Critical Clinical Skills in a Changing Military and Medical Environment. Journal of the American College of Surgeons. 2016 Jun [PubMed PMID: 27185158] |
[26] | Motola I,Devine LA,Chung HS,Sullivan JE,Issenberg SB, Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82. Medical teacher. 2013 Oct [PubMed PMID: 23941678] |
[27] | Issenberg SB,McGaghie WC,Petrusa ER,Lee Gordon D,Scalese RJ, Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical teacher. 2005 Jan [PubMed PMID: 16147767] |
[28] | Ericsson KA, Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice. Academic medicine : journal of the Association of American Medical Colleges. 2015 Nov [PubMed PMID: 26375267] |
[29] | McGaghie WC,Issenberg SB,Petrusa ER,Scalese RJ, Effect of practice on standardised learning outcomes in simulation-based medical education. Medical education. 2006 Aug [PubMed PMID: 16869926] |