Introduction

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. 

Issues of Concern

The Need

In World War II, the mortality rate of combat wounds 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 reinitiated 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), 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, a report in 2005 noted no significant change in the number of soldiers dying from preventable deaths, and the U.S. Army Medical Command released an Operational Needs Statement noting a significant gap in battle-focused skills for Combat Medics. 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]

Medical Decision Making and Leadership Development

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 hands-on skills training, which is standardized across installations.[8] Soldiers learn self-aid skills, buddy-aid skills, and combat lifesaver skills, focusing on the three major potentially survivable causes of death chosen based on data from the Vietnam War: extremity hemorrhage, tension pneumothorax, and airway obstruction.[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 worldwide, which was later scaled back to a total of 25.[10] There are currently 21 MSTC facilities located in the continental United States (CONUS) and outside the continental United States (OCONUS) to train the 35000 U.S. Army medics and 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 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 soldier to use their individual first aid kits (IFAK) and its components, both for self-aid and potentially save a fallen comrade's life.[3][8][9][11] Facilities have grown to incorporate augmented reality, moulage patients, task trainers, live tissue models, and perfused or non-perfused cadavers.  The training even expounded to include working dog mannequins 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 and 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, and other world military forces are learning from their success. The Royal Navy of Great Britain has sent teams to Norfolk, VA, to investigate the use of simulation training aboard their own 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, the USMC has begun funding propositions in the last couple of years for the unification and standardization of medical training incorporating 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] Successful CCATT teams have decreased the rate of prehospital combat-related deaths and 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]  

Continuing Education

Expansion of Military Healthcare Simulation

The MSTC and other military medic training programs did not include physician and nurse training. 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 patients' needs admitted to military treatment facilities, the military healthcare system (MHS) began establishing a 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 (USUHS), 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. The center helps train medical students, graduate-level nursing students, and Graduate Medical Education (GME) trainees. The center demonstrates 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 USUHS and Andersen simulation centers acquired robotics simulators in 2005 to start to train their surgeons on this new technique.[7][21][22] Army 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 worldwide.[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 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.

Clinical Significance

Several studies have demonstrated that surgical subspecialists take a significant amount of time to return to their perceived skill baseline after coming home after deployments.[23][24] Further, there has been a lot of effort 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 military's goals 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.

Pearls and Other Issues

As the military begins to work towards a unified medical force under the Defense 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.

Enhancing Healthcare Team Outcomes

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:

• AR/VR: the expended use of augmented reality (AR) and virtual reality (VR) screen-based simulation to recreate environments of care. At the USUHS Simcenter, an immersive VR theater is being used to train teams of providers in multiple causality situation and aero-medical evacuation of patients. Head-mounted VR displays are being tested in Army field environments to see if this type of simulation method can help first responders recognize and treat life-threatening hemorrhage and airway emergencies.
• Joint Medical Simulation Instructional Methods (JMedSIM): With the increasing emphasis on simulation, there is a pressing need to train more healthcare personnel to deliver healthcare simulation to learners. To that end, the MHS has launched JMedSIM, a standardized simulation instructor/operator online course that will allow simulation instructors to become familiar with effective training methods in healthcare simulation. The goal is for all those who employ simulation for training will be certified through this route.
• Graduate education in simulation: There is a need for more advanced education and research in simulation methodology as it applies to operational military medicine. The USUHS has partnered with the Naval Postgraduate School in Monterey, California, to offer a jointly sponsored certificate program in healthcare simulation. These graduate-level courses have been taken by over 100 personnel in the last six years and are designed to educate the next generation of healthcare simulation professionals. A master's level degree in healthcare simulation is now in the final stages of planning and execution.
• Specific skills project: The MHS has recognized the need to tailor simulation to the individual skills of the physicians and nurses taking care of service members in deployed settings. The Department of Defense has developed specific knowledge, skill, and attribute (KSA) skillsets for each medical specialty. The KSA is essentially an annual tasklist and serves as a marker for how prepared a practitioner is for deployed medical operations. To augment the standard medical practice of the provider in garrison and meet the KSA goals, simulation methods will be implemented where applicable.

This article was completed with multiple interviews with those involved with creating, developing, and introducing much of the reviewed systems and curriculums. Special thanks to COL (ret) S. Deering, MAJ G. O’Keefe, SGM L. Moore, G. Vallejo, MSG R. Gonzalez, J. Higman, CAPT M. Spooner, LCDR D. Weltch, J. Ruisi, COL (ret) E. Lockrow, B. Roth, and R. Garza.