Simulation Training Duplicates Experience of Shipboard Trauma Care

by U.S. Medicine

September 4, 2013

SAN DIEGO — When a servicemember experiences physical trauma during deployment, it’s usually during circumstances that are loud, chaotic and happening at a speed too quickly to be followed by the untrained eye. The same is true of treating trauma victims, especially when it occurs aboard ship.

Naval Fleet Surgical Teams (FSTs) are expected to evaluate and treat wounded servicemembers in conditions of limited space and resources with the speed, efficiency and accuracy of any civilian surgical team working in the comforts of a hospital. To help them accomplish this, the Naval Medical Center San Diego’s (NMCSD) Medical and Surgical Simulation Center/Bioskills Training Center has created an operational trauma training program designed for FSTs to learn to work together in high-stress, traumatic situations.

It is, to date, the most accurate simulation of the shipboard world these sailors will face and, according to the creators of the course, has made every one of them better prepared for what they’ll likely encounter during deployment.

For several years, NMCSD has sponsored the American College of Surgeons’ Advanced Surgical Skills for Exposure in Trauma (ASSET) and Emergency War Surgery courses — trauma-based courses for surgeons to help them get exposure to injuries seen in an operational setting.

The Bioskills Training Center (BTC) was designed to use the training modalities learned in that course to train doctors, nurses and corpsmen to be better prepared for what they would see in-theater.

The BTC opened in April 2012 so that military surgeons could obtain experience treating vital-trauma injuries common in a combat environment before they ever see an actual combat victim. Shortly after the BTC opened, it was combined with the existing Medical and Surgical Simulation Center (MSST), creating a hybrid cadaveric and mannequin-based simulation platform.

In 2011, Cmdr. Tuan Hoang, right, explained what emergency medical services were available from Navy corpsmen during Fleet Week in San Francisco. Photo by Lance Cpl. Timothy Lenzo

“We were responding to the growing needs of operational medicine to train doctors, nurses and corpsmen with leading technologies that really simulate what our people will see in the battlefield and an operational setting, whether that’s on a ship or in a tent in Afghanistan,” explained Cmdr. Chris Cornelissen, DO, department head of the Bioskills Training Center and Medical Surgical Simulation Center staff anesthesiologist.

The BTC/MSST has more than 5,000 square feet of usable training space, housing 10 training stations with cadavers, 13 microscope stations for large-scale training, as well as macrovascular and microvascular training labs.

“We’re one of the only centers in DoD that has the capability to have both macro and microvascular training,” Cornelissen said. “We also have an extensive array of cameras to beam images up to operating rooms here in the NMCSD. Actual surgeons participating in patient surgeries can see the techniques being performed in the cadaveric lab.”

Simulating the Shipboard Experience

Expertise and resources, along with the dedication to providing the best preparation possible for military medical personnel led Cmdr. Tuan Hoang, MD, to partner with the BTC to create a location where Fleet Surgical Teams could gain unprecedented levels of pre-deployment trauma training.

Hoang, senior course director at Naval Hospital Camp Pendleton, approached BTC about creating a training regimen that could not only teach complex team-building but also create believable mock scenarios of what FSTs could encounter while serving aboard Navy ships.

The facilities at the BTC fit Hoang’s needs perfectly.

“The operating room here is very similar in size to what we would encounter on our ships,” Hoang said. “And when we have our staff come in and assist [the BTC] staff, we can set it up so it’ll be very similar to what we’re finding on our amphibious platforms. Once we’ve done that mockup, we can bring the team very much into that environment and then allow the team to focus.”

The program consists of about two weeks of training modules spread out over several months. The training begins with basic lecture training and high-speed simulations, and then moves to the cadaver lab.

“We’re using more cadavers in this course, which wasn’t really done by anyone else in the way we did it,” Cornelissen said. “Personnel get to go down and look at the tissue level of complexity in a real trauma scenario.”

From the lab, class members move on to the trauma simulations. Those simulations can be anything from a servicemember who moments earlier stepped on a landmine, to a sailor blinded by a flight deck explosion. The mock scenario portion of the training culminates in a mass-casualty event — the kind of situation that can cause even experienced medical personnel to panic.

The simulations even include the complex methods of communication that occur on ship, in which medical personnel do not always have all the necessary data at their fingertips.

“All the information that goes up and down and parallel across the different sections [of the simulated ship] are done electronically. This brings a lot of realism into the training,” Hoang said. “Because that’s how it’s going to be on the ship. And there’s an even higher level of complexity, because there’s not going to be someone telling you what’s going on, and you have to gather that information in multiple ways and manage that information appropriately so you can manage your patient care.”

But the most important aspect of the training, in Hoang’s opinion, is teaching the FST personnel to function as a team.

“Traditionally, the Fleet Deployment Program had been focused on more of an individual first-responder readiness or on a medical department level — a mass-casualty type of exercise,” Hoang said. “There was minimal concentration on injury patterns, management and communication [among the team members].”

“The trauma-training course was specifically designed to address this critical gap, concentrating on the team-based approach to education personnel from corpsmen all the way to physicians and surgeons,” he added. “We teach them [as a group] how to triage a single victim to a mass-casualty environment, and we do so with limited assets and constrained physically.”

More Confident Surgical Team

As of May, two of nine FSTs have completed the training course. According to its creators, personnel who have gone through the program are more confident and better able quickly to make the right decisions.

The average time for personnel to evaluate a patient and decide where they need to be sent was almost cut in half. The number of critical events that were missed during simulations dropped from six before the training to one after the training.

With personnel asked pre- and post-training to rate on a scale of 1 to 10 how confident they were in a scenario, confidence scores post-training went up an average of 4 to 5 points compared to pre-training.

The next question course’s creators are seeking to answer is how well the FSTs do at the six month-mark. Will they have sustained their skill levels after months away from the training environment?

“We have simulation capabilities on the ship, so they can keep up with their skills,” Hoang said.

The goal currently is for each FST that undergoes training to become part of the next iteration of training for future deployers.

“One FST team will go through and train the next team, and then that team will train the next one [during] their workup and integration phase on ship,” Hoang said. “We’re also putting a quality assurance group together to make sure we’re moving in a purposeful direction and that we have the ability to do quality assurance and improvement on the course as we move forward.”

Another goal is to duplicate elsewhere the work being done at the BTC. The training program is currently a limited FST initiative, but there has been interest from Navy personnel to see if the program can be used to train teams stationed in the Atlantic.

“Hopefully in months rather than years, we’ll have the ability to share this type of training experience with our colleagues on the East Coast,” Hoang said.

“We’ve been entrusted with very unique opportunities in both equipment and personnel, and the vision and enthusiasm to drive a curriculum to where it’s needed,” added Cornelissen. “We look forward to showcasing this to Navy medical leadership and receiving their support.” 

Cmdr. Christopher Cornelissen, right-center, explains simulation equipment to Adm. James Winnefeld, Jr., Vice Chairman for the Joint Chiefs of Staff, right, and Rear Adm. C. Forrest Faison III, Commander of Naval Medical Center San Diego and Navy Medicine West, while Eduardo Medina, manager of the medical and surgical simulation center demonstrates. U.S. Navy photo by Mass Communication Specialist 2nd Class Chad A. Bascom

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