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Training & Simulation Forum

Golden Hours, Platinum Minutes

14 Mar 12 | By Tim Mahon

This article appeared originally in the March/April 2012 issue of Military Training & Simulation News (www.twpltd.com) and is reproduced here by kind permission of publishers The Write Partnership Limited and Managing Editor Trevor Nash.

As a pre-teen growing up as the son of a government official in Hong Kong, I necessarily mixed with the military garrison there and was treated, when necessary, by British military doctors (and nurses) and dentists stationed there. Even at such a young age, I rapidly became aware of the necessity for training and continuing education faced by the military medical fraternity, largely because it was a constant topic of conversation.

Fast forward forty years, to the flightline at Kabul Airport. In late 2009 the opportunity came my way for a conversation with the medical team who, on French helicopters and involving personnel from three other nations, had just evacuated a Norwegian soldier from northern Afghanistan, where he had fallen victim to an improvised explosive device (IED).

That conversation gave me a fresh appreciation for the extent to which training is a vital and integral part of the military medical professional’s daily life. Underlying all the "how to treat the condition” training that is a self-evident component of preparing a corpsman there is an even more critical concern that medical trainers are all too aware they have to address. How do you instil decision-making skills in such a way that they will stay in mind when the hindbrain is being stressed by adrenalin, fear and uncertainty in a battlefield environment? How do you ‘teach’ the process of triage and the literally life or death consequences of getting such a decision right – or wrong?

The military medical community, at least as far as the treatment of serious trauma is concerned, focuses on two periods of time that are critical for the personnel in its care. The first, much talked about, is the so-called ‘Golden Hour,’ – the period in which adequate emergency treatment and evacuation to a more capable medical facility can quite literally make the difference between life and death for the patients. The second, which is arguably even more critical, is the ‘Platinum ten minutes.’ In this timeframe – in which both patient and carer are normally equally stressed – the decision as to which symptom or injury to treat first, which drug or remedy to apply first, can make or break the potential success of follow-on treatment. And those decisions need to be made under intense moral, mental and often physical pressure.

This makes the training of military medical personnel even more important today than it has been in the past. The revolution in military affairs that has taken place since the end of the Cold War and the fluctuating political and fiscal pressures that force our armed services into being our first response to humanitarian crises, emergency intervention or natural disasters as well as being the front line of our national and international defence capabilities, have all combined to make it critically important that our medical personnel in military uniform are prepared to deal with a much wider range of issues than was the case for my doctors and dentists in Hong Kong in the 1960s. Which makes a difference to the way in which they are trained.

Or does it? Talking to members of the supply side of the equation calls that assumption into question. "This is a market sector in which the two communities [military medical and emergency services medical technicians] are very much engaged in two way communications; there are major benefits in identifying and sharing best practices,” said Martin Clarke, Area Manager for Orpington-based Laerdal Medical Limited.

A brief survey of some of the issues surrounding current thinking in

medical training – for both military and civilian services – reveals the truth underlying Clarke’s statement. The clothing worn by a patient – jeans, business suit or camouflaged fatigues – makes little difference to the decisions that need to be made regarding the optimum care solution to be applied. Absent the requirements of security surrounding military operations, therefore, there are few differences in the training that needs to be provided.

Recognising this, Laerdal, for example, has standardised its approach to simulation-based training for its military customers. The company has a long established relationship with the Army Medical Services Training Centre in York, which is now its largest military customer, according to Clarke. The relationship has grown apace as requirements have continued to develop since the beginning of this decade.

"We provided the first patient simulator for the military back in 2001,” said Clarke. "That was for use in a fixed location and what changed over the next two to three years was the emergence of a requirement more suited to battlefield training. The requirement was for mobility and tremendous flexibility, which led us in a natural progression towards wireless-operated patient simulators.”

With something approaching 9,000 simulators in service with medical trainers around the world at the time, Laerdal sought to leverage its broad experience in simulation with the challenging requirements for portability and physical endurance that a battlefield capability implied. The result was SimMan 3G, a robust, rugged and reliable three tiered system that can be run automatically with pre-programmed scenarios, but also has the facility for trainers to develop their own individualised training circumstances or to inject specific digressions into an ongoing scenario in order to optimise learning for a trainee where appropriate and opportune.

SimMan 3G "very quickly overtook its competition, providing flexibility, portability and affordability to users,” said Clarke. The unit cost of such a patient simulator, according to Clarke, is in the order of £50,000, depending on the exact nature of the options and support required by the user. This makes it an affordable asset for a training environment in which the ultimate objective – the preservation of life – is one on which it is difficult, if not impossible, to assess a price.

Speaking at the time of the original launch of SimMan 3G, and cited by Laerdal at the time, Lieutenant Colonel Tim Davies from the Army Medical Training Centre said "we use scenario-based training to give individuals the opportunity to work in conditions that they have never experienced before, and to help convert them from a peace time way of thinking to a mind set necessary for military deployment. The introduction of SimMan 3G perfectly suits our objectives in this respect.”

According to Clarke, the Royal Air Force is also using the Laerdal SimMan for training its own medical personnel.

"We have introduced SimBaby and SimJunior, the latter representing a child of around seven to eight years of age,” said Clarke, adding that there are significant differences that need to be incorporated into such simulators. The physiological modelling has to fit the age of the simulated patient in order to provide a high fidelity training experience; the heart rate and blood pressure of an eight year old, for example, is radically different from that of a more mature patient and the trainee needs to be able to recognise and react to circumstances intuitively.

"The changes in requirement continue to emerge,” said Clarke. "Our full range of mannequins are giving rise to a full range of more capable patient simulators and we are seeing an increasing and definite need for these to be deployed at the point of care rather than in a bespoke simulation centre.”

On the other side of the Atlantic, CAE Healthcare, fresh from its acquisition of Sarasota, Florida-based METI in 2011, is also addressing the need for mobile, wireless-operated patient simulators for the military. "The demand for tetherless mobile mannequins to help address the ‘platinum ten minutes’ aspect of training has increased dramatically for the military,” said Geoff Bates, Business Development Manager Army, Navy East and Marines East for CAE Healthcare.

The company’s answer to the emerging requirement has been to develop the CAESAR patient simulator, which visitors to ITEC and I/ITSEC over the last twelve months will have seen CAE showcasing with justified pride. Its development was described as being centred on "organic growth from current capabilities,” by a company spokesman at I/ITSEC in Florida in December 2011.

CAESAR is a comprehensive and realistic mannequin, optimised for rough handling (such as the ‘fireman’s carry’) in challenging environments such as a forward operating location on deployed operations.

Accompanied by a ruggedised tablet computer and "weather resistant, though not sully submersible,” according to Bates, CAESAR provides a capable and flexible platform for a wide variety of training tasks ranging from stabilisation and emergency trauma treatment to preparation for casualty evacuation. "We have optimised the solution for pre-deployment training and also to take advantage of any in-theatre down time that might be usefully dedicated to continuing training,” said Bates.

CAESAR goes into production in the first quarter of 2012, according to company sources. Priced at around $100,000, the first unit has already been delivered to a NATO user.

Medical simulation is not just about mannequins, however. At Imperial College in London, Professor Roger L. Kneebone, Professor of Surgical Education in the Department of Surgery and Cancer, leads an unorthodox and creative research team that is increasingly focused on the use of simulation to provide affordable and effects-oriented training to clinicians and emergency medical technicians.

Speaking at the Low-Cost Training Trends & Technology seminar in London last November, Kneebone highlighted the development of a hybrid simulation solution for surgical training. Combining the use of professional actors with inanimate models and highly realistic (disturbingly so) wound and trauma simulation, Kneebone graphically demonstrated how a low-cost but highly focused approach can provide a high fidelity training environment that simultaneously stresses and educates surgical team trainees.

A further innovation that Kneebone’s team has championed is the continuing use of distributed simulation to achieve challenging training objectives. Using an inflatable operating theatre simulation in combination with the hybrid simulation facilities developed over the last few years, Kneebone’s team has produced an immensely realistic environment for training that is of considerable interest to those seeking to provide cost-efficient and highly targeted training scenarios for military, paramilitary and civil medical personnel alike.

Moving back from the ‘forward edge of the battlefield’ to the rear echelon medical facilities that are typical of deployed military operations in the current international security environment, the need for training solutions to keep pace with advances in surgical technique has never been more important. These advances, in raw terms, mean that casualties who may have been effectively written off as irretrievably traumatised in previous conflicts can now be saved on a routine basis. But only if the medical personnel are adequately trained in the use and deployment of the techniques that surgical advances demand.

Step forward Mimic Technologies, Inc., of Seattle, Washington. Recognising that the emergence of the Da Vinci surgical robot has changed medical practice – and made solutions available for formerly intractable conditions – Mimic is a company that has focused its resources on a single issue: making available a cost-effective simulation-based training tool for Da Vinci operating teams.

Dr. Jeff Berkley, Mimic’s Chief Executive Officer, Chairman and founder, started the company in 2011 when he "realised that the medical community had to get into surgical robotics.” Using DARPA money to help fund research and development, the company quickly developed a Da Vinci simulator that then entered an extended period of test and evaluation between 2003 and 2010.

"What we have seen is that simulation has had a profound effect on the target community,” says Berkley. A primary advantage of using the simulator is that the demand for training time on the ‘live’ facility disappears – an advantage the military can readily appreciate, since it mimics (no pun intended) the reality of equipment availability within other aspects of the services training environment.

In addition, the demand for more effective use of fiscal resources – as crucial to the civilian world as the military, if not more so, in current straitened circumstances – means that the procurement of a $100,000 simulator is infinitely more attractive than the acquisition of another $1.8 million robot, according to Berkley. The company’s sole product has been sold to a wide variety of existing Da Vinci users (there are more than 2,000 of the robots currently in service around the world), including the US Veteran’s Administration, Army and Navy.

The world for military medical personnel may have changed in recent years, as the demands for more intensive use of our armed forces in a wider variety of operational situations increases. It is interesting – and encouraging – to note, however, that training is not taking place in a spirit of splendid isolation, but is taking full advantage of the lessons to be learned and the evolution of best practices in every domain in which medical training is practised. And that has to be good for all of us…

[Image courtesy of Laerdal Medical Limited shows the company’s SimMan 3G medical simulator]

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