Saving lives: simulations promise better training for combat medics.

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As improvised explosive devices continue to claim lives and maim troops, a new market has emerged for medical simulations to train combat medics.

"What's driving the need for training is the way we're fighting today," said retired Army Lt. Col. Nick Guerra, now deputy director and program manager at Computer Sciences Corp.

IED attacks are resulting in traumatic injuries that require more complex medical care than in previous wars. While more soldiers are surviving devastating attacks in Iraq and Afghanistan because they are equipped with heavier armor, they are also subject to more debilitating wounds such as multiple amputations and blindness, said Claudia Johnston, associate vice president at Texas A&M University at Corpus Christi, and creator of a Navy medical simulation project. Military armor vests protect the trunk of the body, leaving the head, legs and arms exposed. Soldiers are coping with "wound patterns we have not seen before," Johnston said.

Young medics and doctors who are unable to see and treat IED or blast-related wounds during traditional medical training face a steep and difficult learning curve in combat.

In the civilian world, doctors have the luxury of the "golden hour," which means it typically takes one hour from the time a patient calls 911 to the point of surgery. But in theater, medics have a shortened timeline for mitigating injuries. Since soldiers can be held in triage for up to 24 hours, what a medic does in the first 10 minutes is critical to the rate of survivability, Guerra asserted. Those minutes could delineate the difference between life and death, in large part because of the severity of IED wounds, he added.

"When there's an IED, there's always a concern about bleeding to death."

Guerra said that there have been cases of soldiers dying from non-lethal injuries because there wasn't enough emphasis on controlling bleeding. Traditional medical education concentrates first on clearing a patient's airway. But in combat, new lessons have been learned. "If the blood coagulation properties are not taken care of and the patient bleeds to death, the other parts don't really matter," he said.

Adding to the complexity of addressing traumatic wounds are the harsh conditions in theater. The emphasis today is on "care under fire," where medics have to defend against enemy fire before they can begin to treat the wounded, Guerra said. Hostile fire and inclement weather, such as high winds that prevent aerial evacuation, can significantly slow operations.

All of these concerns have prompted the government to seek simulators to help train medics.

"Simulations and games are concentrations of reality and offer new opportunities to rehearse care patterns and save lives," Johnston said.

Johnston's project, called the pulse virtual clinical learning lab, simulates the intensive care unit at the National Naval Medical Center in Bethesda, Md. The Navy hospital is one of the primary military centers that treat wounded soldiers returning from Iraq and Afghanistan. The virtual lab is an interactive 3-D simulation that allows military doctors to practice treating a patient at the medical center. It familiarizes the user with the facility and equipment while simultaneously teaching them to perform procedures.

The system can be programmed for a wide range of injuries or diseases in different scenarios, Johnston said. Users receive performance feedback at all skill levels, from novice to master. The first scenario in development replicates a young male soldier in shock after being injured by an IED.

"To treat the patient, the student must assess, manage and evaluate the patient and give treatment for hypovolemic shock" (rapid fluid loss that could result in organ failure), Johnston explained.

The training is especially useful for physicians who are not trauma surgeons, said Cmdr. James Dunne, head of trauma surgery at the naval medical center. He posits that this type of training "will engage the resident," more than standard education, a finding that has been suggested by others in the medical field. Several researchers reported in the Annals of Surgery--a monthly surgery journal--that medical residents trained on simulators needed 30 percent less time to perform a procedure than those taught by traditional methods.

Funded by the Office of Naval Research, the project has received $10 million during the last three years, Dunne said. Rep. Solomon Ortiz, D-Texas, chairman of the House Armed Services subcommittee on readiness and military construction, helped obtain most of the funds, Johnston said.

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Project partners include a team of medical advisors and software development firms, including BreakAway Ltd., in Hunt Valley, Md. and Digitalmill of Portland, Maine.

Another project, called the medical simulation training center, offers military doctors a lifelike replication of combat scenarios. The Army's program executive office for simulation, training and instrumentation awarded Computer Sciences Corp. a contract for the system in 2005, Guerra said. So far, 20 sites have been built, with four to six sites planned for 2008. They are set up at Army installations in the United States and overseas, including three locations in Afghanistan. CSC was contracted to hire staff, provide supplies and direct the operations and maintenance of each site, Guerra said.

Army soldiers and Marines train at the centers in scenarios that feature "downed" aircraft, combat noise and mannequins dressed as victims. Medics have to carry a wounded dummy--that weighs up to 200 pounds--over walls and other obstacles to get to a triage room where they treat yet another injured mannequin. Trainees also utilize medical devices to learn how to insert an intravenous instrument, clear a victim's airway or release pressure in a victim's chest. The "battles" can last from a few minutes to one hour, Guerra said.

Mannequins used in the simulations--manufactured by Medical Education Technologies Inc., and Laerdal Medical--can imitate breathing, talking and bleeding, and are hooked up to computer systems so instructors can track how the trainees care for them.

Soldiers are guided and evaluated by both CSC and government employees who have either medical or law enforcement experience. Seventy-five percent of instructors are military veterans, Guerra noted.

Each training site costs between $450,000 and $750,000, depending on the construction or renovation of the building and grounds used, he said.

Almost 41,200 soldiers and Marines have been trained using the system. The Air Force agency for modeling and simulation recently signaled interest as well, Guerra added.

Simulated surgery of traumatic blast wounds is another type of technology that has recently emerged as an alternative to train military doctors.

The Army has invested $240,000 into a fledgling modeling system called the wound trauma simulator, created by Mimic, a firm based in Seattle.

The wound trauma simulator replicates combat blast injuries, such as a hand embedded with shrapnel. But the simulator doesn't just show a 3-D image of a hand. It uses a technology called haptics, which involves recreating the sense of touch in virtual reality, said Mimic president Jeffrey Berkley.

The program allows the user to feel as if he is touching a fleshy human hand that changes color when pressure is applied and even "bleeds" when the shrapnel is not carefully extracted.

Mimic is interested in teaching military doctors how to operate on unusual and traumatic IED wounds, a skill that right now can't be taught in medical school.

"What we want to do is address scenarios you can't find in the civilian environment," Berkley said.

The development will begin next year, he said, and a system could be deployable in three years.

In the future, Berkley envisions that the wound trauma simulator will imitate surgeries of facial and major joint injuries to address those areas not protected by current body armor.

Mimic is also in the early stages of developing a small robot, called the trauma pod, which will operate on soldiers on the battlefield or en route to a medical facility in theater. "The idea is to keep the surgeon safe and get faster treatment to the solider before he bleeds to death," Berkley explained.

The market for military medical modeling and simulation has grown quickly during the last several years to help address the complexity of IED injuries. Experts say it is only the beginning.

"This is just the tip of the iceberg," Guerra said. The military has often taken the lead to develop virtual simulations. Medical modeling is no different. "I really think medical simulation is going to spread to all branches of the military," he said.

And once this technology is in the military, it could also be used for the wider medical community, Guerra suggested.

Berkley echoed this sentiment, saying that most military surgeons will eventually work in the civilian world, where they can take the modeling and simulation skills they learned while deployed or in training.

In addition, these technologies will gain more popularity because a predicted shortage of medical professionals will necessitate new teaching methods, Johnston predicted. The focus on modeling and simulation is also coming from the young medical workforce that expects a multimedia-learning environment, she added.

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