ITEC 2019 Shaping Military Medical Simulation: Blending .

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ITEC 2019ITEC Extended Abstract TemplatePresentation/PanelITEC 2019 – Shaping Military Medical Simulation: Blending trainingtechnologies to objectively measure Casualty Response System ReadinessAbstract — The Department of Defense and Military Healthcare System (MHS) are rapidly approachinga critical training and readiness gap triggered by less armed conflict and fewer combat casualties. Lineand military health system commanders alike must rely on simulation to bridge the gap between what isexperientially available (very little in the absence of combat) and what is needed for safe first-timecasualty response. The military must look at innovative training technologies designed to improvecasualty response readiness and streamline how training is delivered. The authors present a novelapproach to Tactical Combat Casualty Care (TC3) training utilizing intelligent tutoring based TC3training delivered on smart mobile devices coupled with high fidelity combat trauma manikins tested withSoldiers from United States Army Alaska. Initial findings show an overall 95% acceptance rate for thisnew technology, reduced material presentation time, improved standardization of delivery and reducedtraining time utilizing a mobile training application when compared to traditional training models. Highfidelity manikin data capture provides standardized methods to objectively measure TC3 skillperformance across the different training cohorts to provide individual and cohort readiness metrics.These data capture capabilities create potential to move simulated casualty data across integrated,connected medical and nonmedical architectures making joint casualty response system readinessmeasurement possible.ObjectivesThe military medical system has made monumentalstrides in improving combat casualty response in the past15 years of war by carefully analyzing Joint TraumaRegistry data and implementing lessons learned fromcasualties. Systemic training and application of theCommittee on Tactical Combat Casualty Care’siteratively developed TC3 curriculum is central to thissuccess. Despite these advances, 24% of casualty deathswere deemed preventable (1). Senior leaders havemandated TC3 training for all combatants in the NationalDefense Authorization Acts for 2017 and 2018, DoDI1322.24 issued in March 2018, and US Central CommandOrders in November 2017 in an effort to improve andsustain improved casualty response readiness.Unfortunately, these directives do not mandate how TC3training will be implemented. Sauer et al note “The highdegree of variance amongst deployed unit medicalpersonnel, both in terms of clinical training andoperational experience, results in inconsistent applicationand enforcement of TCCC compliance across theforce.”(2) Significant differences in TC3 interpretationand variability in training delivery methods makereadiness measurement impossible. The authors objectivewas to demonstrate the feasibility of a novel approach toTC3 training that is scalable, objectively measurable,improves training efficiency and is sustainable across theForce.IntroductionTraditional Army and TC3 training rely heavily uponsynchronous lecture-based curriculum delivered byexpert instructors, a hands-on crawl, walk, run trainingmodel, and subjective evaluation and measurement ofperformance. This runs counter to the Army’s TRADOCPamphlet 525-8-2 “The U.S Army Learning Concept forTraining and Education (ALC-TE) 2020-2040 April 2017which describes a fundamental change in the approach tolearning that requires a “progressive, continuous, learnercentric, competency-based learning environment.” TheALC-TE states, “The Army will accelerate thedevelopment of adaptive and predictive learning enginesto reinforce and prevent the typical fading and decay ofcritical knowledge and skills and expand the permanenceof knowledge to help achieve better outcomes and Soldierand civilian synthesis and adaptive capability.” (3)Effective medical training is difficult to execute andassess due to the lack of actual patients, training devicescapable of capturing objective task performance and timeconstraints. Instructors, limited by time and resources,redact TC3 presentations and practice TC3 tasks onunrealistic training devices or each other. Instructors usenoise and distractors to generate “battlefield stress” whileverbally guiding the trainee through clinical findings andthen subjectively assessing if the trainee’s interventionswere sufficient to “save” the casualty or meet thestandard.The Army’s Program Executive Office forSimulation and Training and Instrumentation (PEOSTRI) is responsible for the advance development andlifecycle management of training devices. PEO STRI’ssubordinate program office, the Joint ProgramManagement Office for Medical Modeling andSimulation (JPM MMS) is dual chartered by the Army

Figure 1. Screenshot from TC3 ACCTon smart phone.ITEC 2019ITEC Extended Abstract Templateand the Defense Health Agency to meet the medicalsimulation training needs of the Department of Defense(DoD). JPM MMS and researchers from the Naval AirWarfare Center Training Systems Division (NAWCTSD)identified a unique opportunity to evaluate availableCOTS technologies that fully aligned with the ALC-TEand their ability to meet the TC3 training requirement.JPM MMS led an evaluation of two COTStechnologies, the Cerego learning system and KGSTrauma FX APL-HEMO whole body Human PatientSimulator (HPS), as ameans to teach andevaluate Soldier TC3skills. Cerego islearning managementand interactivetraining software thatutilizes adaptivelearning algorithmsderived fromneuroscience andcognitive science tooptimize and measurelearning. JPM MMSdeveloped TC3curriculum from thepublished Committeeon Tactical CombatCasualty Care All Combatant Curriculum to be deliveredto Soldiers via Cerego, the TC3 All Combatant CognitiveTrainer (TC3 ACCT). The KGS Trauma FX APLHEMO casualty simulator is a rugged, multitask trainerthat simulates severe trauma allowing Soldiers to practicetreating the preventable causes of combat death. Itrepresents and objectively captures performance data onclinical interventions including casualty assessment,control of massive bleeding from an extremity wound,control of massive bleeding from an inguinal wound,nasopharyngeal airway placement and needle chestdecompression. This same device is being procured bythe Army as the foundational training device for its TC3Exportable (TC3X) simulation program.Presentation/PanelApproachTo conduct this technology demonstration, the authorsenlisted the assistance of the 1st Battalion 5th InfantryRegiment at Fort Wainwright, Alaska. The chain ofcommand at all levels strongly supports realistic casualtyresponse training and requires all Soldiers to attend itsBobcat First Responder Course, developed from the TC3for All Combatants Curriculum, but modified by theunit’s medical leadership.Student demographic questionnaires indicatedstudent MOS were primarily 11B (66%) Infantryman and11C (24%) Indirect Fire Infantryman; only 10% held adifferent MOS. Sixty-six percent held the rank ofPV2/PFC, 17%, SPC, 10%, PVT, and 7%, SGT. Eightytwo percent had HS/GED level education, while 11% hadsome college but no degree, and 7% had a 2-year degree.Forty-eight percent of students had prior CLS training.The evaluation included three training conditions:1) Bobcat First Responder (BFR) course – as traditionallytaught – didactic and HPS hands on training interwoventhroughout the course (n 25), 2) TCCC knowledgetrained via the Mobile app (n 29), followed by HPStraining, and 3) BFR course with all knowledge presentedfirst (2 days), followed by HPS hands on training (BFRdidactic, n 26).Figure 3. Study conditions, timeline and assessments.Figure 2. KGS Trauma FX APL-HEMO being evaluatedand treated by a Soldier during training in Alaska.All didactic training materials were derived fromthe CoTCCC TC3 All Combatant Curriculum deliveredin three different forms. Current Bobcat training methodutilizes a modified CoTCCC TC3 All CombatantCurriculum revised by the Battalion Surgeon andPhysician Assistant based upon their priorities and taughtby a seasoned 68W Combat Medic Non-CommissionedOfficer. The Mobile App method, TC3 ACCT, used theCerego platform to deliver a modified version of TC3 AllCombatant Curriculum adapted to be delivered throughthis medium. The TC3 ACCT curriculum was developedby Cerego educational development specialists andmeticulously cross referenced by the authors to ensure allTC3 concepts were presented. The Control methodutilized directly downloaded CoTCCC’s TC3 All

ITEC 2019ITEC Extended Abstract TemplatePresentation/PanelCombatant curriculum website and delivered withoutdeletion of content by a seasoned 68W NCO as didacticlectures.Each training cohort underwent pre and post testingof cognitive knowledge and hands on skills. Hands onposttest evaluation utilized the KGS APL-HEMOoperated in a simulated combat environment by seasoned68W NCOs with a standardized scenario.ResultsLearning using the AppTime on taskStudents in the mobile app condition spent an average5.37 hrs on the app to complete the didactic training (andapproximately 1 hour of instructor scenario review onday 2). Students in the BFR classroom condition spentapproximately 12 hours in face to face instruction time.Knowledge gainStudents using the App demonstrated a significantincrease in TCCC knowledge from pre-test to post test(t 11.14; p .00001). In separate analysis, even studentswith prior CLS training demonstrated significantknowledge gain using the mobile app (t 8.75; p .05).Students learning through face to face didactic instructionalso demonstrated a significant increase in TCCCKnowledge from pre-test to post-test (t 4.9; p .05)Similar gains in knowledge were seen for both App andface to face cohorts as measured by the change inknowledge scores from pre to post test (XgainApp 5.31;XgainBFR-D 5.33; F .0005; p .05).Student knowledge gains after an average 5.37 hrsusing the app (plus 1-hour scenario review) wascomparable to knowledge gains after 12 hours face toface instruction.Hemorrhage control performanceSample size is limited due to challenges associated withdata collection protocols and HPS technical operations.Complete data sets were captured from 28 students, 15 inthe BFR-didactic condition, 9 in the mobile appconditions and 4 in the traditional BFR condition.Descriptive data are provided in Figure 2 and 3.Figure 4. Mean time to start bleeding control.Figure 5. Mean estimated blood loss.Not surprisingly, the traditional BFR cohort applied thetourniquet the quickest of the 3 groups (x 11secs)because the teaching modeled has instructors perform nonotice “Tourniquet Drills” on themselves during lecturesto keep students awake and build muscle memory for thistask. This was followed by students in the mobile appcondition (x 26secs), and finally the control condition(x 49secs). In terms of volume blood loss, differencesbetween students in the mobile app condition and thetraditional BFR group were negligible (Xapp 584; XBFR 583), and substantially less than the control condition(XBFR-didactic 635).ConfidenceStudents reported ratings of confidence in ability toperform TCCC tasks, including: move a casualty, apply atourniquet, assess AVPU, apply a hemostatic dressing,apply an eye patch, assess shock, prevent hypothermia,complete a casualty card, and adhere to treatmentpriorities (MARCH) resulted in no significant differencesin post training confidence across the 3 training cohorts.Figure 3 reports the mean level of confidence from 1 notconfident to 5 completely confident. No significantdifferences were found across conditions, in selfreported, post training levels of confidence in ability toperformance TCCC tasks.

ITEC 2019ITEC Extended Abstract TemplatePresentation/Panelrequirements, taxing leadership and creating battlefieldfriction that impact mission command while diminishingmorale, fighting spirit and casualty survival.Figure 6. Confidence in the ability to perform TC3 Tasks.Figure 8. Elements of combat power.Perceptions of the learning experienceStudents were asked ten questions related to 1) theirexperience learning via the app, 2) ease of use andimmersion when using the App, and 3) generalizability ofthe learning method. Ninety-six percent of students usingthe mobile app reported that it was easy to learn TCCCknowledge using the app, 92% reported the app was easyto use, and 88% would like other courses to be deliveredusing the app.Figure 7. Mobile app perceptions of training (n 24).DiscussionEfficient, effective combat casualty response is critical towinning in a complex world. The moral imperative tosave lives on the battlefield is obvious. What is lessobvious is the deleterious effects poor casualty responsehas on unit combat efficiency and speed of action. Theseare critical elements required to rapidly create and sustainthe combat power necessary to win.Army Field Manual 3-0 Operations defines the elementsof combat power. It is not difficult to imagine how poor,inefficient casualty response, fostered by ineffectivetraining, unnecessarily affects combat power by limitingmaneuver, stressing sustainment, increasing protectionThis demonstration shows how TC3 ACCT and highfidelity casualty simulators combined can be used toprovide realism and measurability to casualty responsetraining to ultimately improve the Commander’s abilityto generate and sustain combat power.By integrating casualty response into almost everytraining event, gathering casualty response data thatshapes training and prioritizing casualty response trainingon par with physical fitness, small unit tactics andmarksmanship, units like the 75th Ranger Regiment havesignificantly lower preventable combat death (3%) thanthe general-purpose force (16%). GEN James Mattis,CENTCOM Commander on 18 January 2013 writes,“Findings on the difference between the Rangerexperience and DoD at large appear attributable to theRanger Casualty Response System, which is a commanddirected program that aggressively teaches the TacticalCombat Casualty Care curriculum to all unit personnel,integrates TCCC into small unit tactics and battle drills,and uses a unit based trauma registry for performanceimprovement and directed procurement.” (5) Thisdemonstration provides a potential way forward tooperationalize and scale casualty response training.Critics may argue that special operations units likethe Rangers have more time and dedicated resources toaccomplish casualty response training. One way toincrease training opportunities in the general-purposeforce is to maximize “downtime” by decentralizing andpersonalizing training. TC3 ACCT provides a scalableoption for “adaptive and predictive learning” that movescloser to the “Army’s Vision to immerse Soldiers andArmy Civilians in progressive, continuous, learner centriccompetency-based learning environment from their firstday of Service.” Properly placed trauma manikins couldprovide Soldiers opportunities to get the “sets and reps”required to create muscle memory when evaluating andtreating casualties.TC3 ACCT demonstrates a novel capability to buildand master cognitive knowledge, but that is not enough toensure readiness. That knowledge must be demonstratedthrough objectively measured action. Commanders

ITEC 2019ITEC Extended Abstract Templatewould never accept cognitive marksmanship trainingalone to verify readiness. On the contrary, Soldiers mustobjectively qualify on a standardized range by firing theirweapon. The same standards must be applied to casualtyresponse. While perhaps easier and more readilyavailable, Soldiers training on each other or on lowfidelity casualty care training devices do not providesufficient realism to prepare the Soldier, nor do theyprovide sufficient objective measurement to inform thecommander about readiness. The trauma manikin used inthis demonstration provided objective measurement ofindividual skill performance, created a common standardtied to clinical relevance, and allowed the Soldier to buildrealistic confidence in their ability to use their IndividualFirst Aid Kit to save casualties. The trauma manikin inthis demonstration fills a critical experiential gap becausein the absence of war, these casualties simply do notexist. It also provides first responders the ability tomentally, psychologically, and technically prepare forsevere, emotionally disturbing decisions and woundscommon in combat.Lessons Learned/Future WorkSeveral lessons can be drawn from this technologydemonstration. First, today’s technologically savvySoldier is a different type of learner than trainees of thepast. The Army can capitalize on this opportunity byrapidly adopting COTS technologies geared tomillennials.Second, the importance of commandemphasis on casualty response training cannot beoverstated. Third, today’s combat trauma manikins fill acritical requirement for realistic casualties to train on andlearn from. The alternative, to learn on real casualtiesfrom the next war, which is historically how we havepracticed, is morally bankrupt with today’s technology.These technologies provide Commanders scalable,distributive capability to measure and maintain Soldierreadiness and observe collective readiness whilegathering actionable data to influence training priorities.However, it is not enough that these technologiesexist as stand-alone capabilities. The future of Armytraining is the incorporation of live, virtual andconstructive simulation into a comprehensive, lifelonglearning process.Medical knowledge, skills andreadiness cannot exist alone and in isolation from theCommanders training paradigm. These technologies mustbe linked to a Medical Simulation Training Architecturethat is interwoven with the larger Army and DoDsimulated training environment. The JPM MMS hasalready taken significant steps toward this connectivitythrough prototype efforts currently underway.Presentation/Paneland haptic skill readiness. Taken in aggregate, this datacan be used to estimate the knowledge, skills, abilitiesand weaknesses of a unit and guide scarce trainingresources to unit weaknesses. Casualty response trainingis not only morally required, but also contributes to theunit’s ability to maximize combat power and ultimatelySoldier and unit lethality. Given the existence of thesetechnologies, it is no longer morally acceptable to usereal world casualties in future combat operations as alearning curve for readiness.ReferencesR.S. Kotwal, H.R. Montgomery, B.M. Kotwal, H.R.Champion, F.K. Butler Jr, R.L. Mabry, J.S. Cain, L.H.Blackbourne, K.K. Mechler, J.B. Holcomb, Arch Surg.146(12):1350-8 (2011)CENTCOM Report Saving Lives on the Battlefield (PartII)- One Year Later: A Joint Theater Trauma System &Joint Trauma System Review of Pre-Hospital TraumaCare in Combined Joint Operating Area – Afghanistan(CJOA-A)14 May aving-lives-on-the-battlefield-ii-final.pdfTRADOC Pamphlet 825-8-2 The U.S. Army LearningConcept for Training and Education 2020-2040 APR2017DoD Instruction 1322.24 Medical Readiness Training(MRT) March 16, 2018 http://www.esd.whs.mil/DD/J. Mattis, CENTCOM Commander Memorandum toChiefs of Services “Killed in Action (KIA) ReductionInitiative.” 18 JAN 2013FM 3-0 Operations. Headquarters, Department of theArmy. OCT 2017Author/Speaker BiographiesDr. Dan Irizarry, MD, COL(R)Dr. Irizarry is KGS Trauma FX’s Senior MedicalSimulation Advisor, an expert in special operationsmedicine, simulation, and technology acquisition, servedin the US Joint Project Manager for Medical Modelingand Simulation Office and founded the Allied Centre forMedical Education, NATOs only SOF medicinesimulation center.Dr. Dawn Riddle (PhD)ConclusionsThe authors present a successful, scalable, novelapproach to point-of-need TC3 training that educatesSoldiers while objectively measuring individual cognitiveDr. Riddle is a Naval Air Warf

performance. This runs counter to the Army’s TRADOC Pamphlet 525 -8 2 “The U.S Army Learning Concept for Training and Education (ALC -TE) 2020 2040 April 2017 which describes a fundamental change in the approach to learning that requires a “progressive, continuous, lea

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