Closing The Real-Time Readiness Gap

3 Live Patient

The U.S. Army’s San Antonio Military Medical Center, Army Medical Command, Fort Sam Houston, TX, is applying advanced simulation technologies to training, research, and patient care challenges.

By Steve Melito, TDM Correspondent

San Antonio Military Medical Center (SAMMC) is the Department of Defense’s largest inpatient medical facility. Located at Fort Sam Houston, TX, this certified Level 1 Trauma Center spans 2.1 million square feet and counts 425 beds. As the hospital component of the Brooke Army Medical Center (BAMC), SAMMC has also cared for thousands of service members injured in Operations Iraqi Freedom and Enduring Freedom.In addition to patient care functions,this state-of-the-art facility provides a range of education, training, and research programs. Part of Army Medical Command, the hospital houses a Simulation Center that has received a rare accreditation by the Society for Simulation in Healthcare (SSH)  for simulation instruction and research,which Lieutenant Colonel Rhonda Deen, theMedical Director of the SAMMC Simulation Center says “validates the high quality of the medical training at SAMMC.”

Simulation and Innovation

Simulation-based education is a technique rather than a technology, but advancements help keep institutions such as SAMMC on the cutting edge of trauma care. Emerging technologies are exciting, of course, but supporting the mission can mean applying available simulators in innovative ways. Current military operations also inform training and delivery. “Advances in medical (especially surgical) care and understanding of the physiology of traumatic injuries have occurred with each successive conflict,” writes Dr. Mark Bowyer, MD, FACS (Fellow, American College of  Surgeons) and DMCC (Diploma in the Medical Care of Catastrophes), in an article for Surgical Clinics of North America entitled “Surgical Education in the New Millennium: A Military Perspective.” Dr. Bowyer, the Ben Eisenman Professor of Surgery, Director of Surgical Simulation, and Chief of the Division of Trauma and Combat Surgery of the Uniformed Services University of Health Sciences, also emphasizes the importance of simulators. In an article called “Simulation for Trauma and Casualty Care” for Minimally Invasive Therapy & Allied Technologies, he explains that “advances in both technology and application of simulators will continue to affect trauma skills training for the foreseeable future.”

An Organizational Resource

Today, the SAMMC SIM Center is one of the busiest of 10 facilities supported by the Army’s Central Simulation Committee, and just the second such facility to earn SSH accreditation. The SIM Center works with the U.S. Army Institute of Surgical Research, which operates the Army Burn Center at SAMMC, and supports Forward Surgical Teams who train with tools such as the Burn Navigator, a medical simulator that helps teach non-burn specialists how to make medical decisions regarding patient resuscitation. “The Simulation Center is an organizational resource,” explains Robert V. Coffman, the SIM Center’s Simulation Administrator. In addition to current research programs, the SIM Center evaluates new projects that validate simulation as a viable tool for training and education. The Center also provides support for 35 graduate medical education (GME) programs and subprograms, nine Army and Air Force enlisted training programs, an emergency medical technician refresher course, and annual skills validation training.

Objectives, Outcomes, and Improvements 

There are also 17 nursing and credentialing courses such as advanced cardiac life support and pediatric advanced life support. “We support pre- and post-deployment training for any group, unit, or individual that seeks to sharpen their skills,” says Coffman, noting that many program objectives are set by outside credentialing organizations. To integrate simulation with new or existing  curricula, the SIM Center’s simulation administrator and medical director first evaluate participants’ needs.

“Once we determine if simulation can indeed assist with the desired outcome, we work with the program to create measurable objectives and task-oriented checklists to evaluate the training,” notes Coffman. Modifiable critical-thinking rubrics help. Student performance is tracked at the organizational level and reviewed by the GME program director. Remediation occurs when necessary, and a scenario’s complexity can be modified to meet the needs of learners. Instructors who use the SIM Center to enhance training are selected by their program director and must meet faculty criteria from the San Antonio Uniformed  Services Health Education Consortium. Instructors for the credentialing course are monitored by the Cardiopulmonary Resuscitation Office and required by both the American Heart Association and Military Training Network to maintain their teaching credentials.

Before instructors can teach in the Simulation Center, however, they must take a “Not Just for Dummies” course, which is offered monthly. This four-hour overview describes the SIM Center’s medical simulators and outlines best practices for teaching with them. “The emphasis,” Coffman says, “is to let the simulator be your tool—not your table.” In other words, instructors need to leverage  the simulator’s physiology. For instructors who are “comfortable and familiar” with  prompt-based teaching methods then, “using simulation requires a paradigm shift,” Coffman explains.

Technology Changes the Training Paradigm 

When the SSH accredited the Simulation Center for instruction and research, Maria Gallegos of BAMC Public Affairs cited three SIM Center studies: 1) external validation of a virtual reality transurethral resection of the prostate (TURP) simulator; 2) assessment of users to control simulated junctional hemorrhage with the combat-ready clamp; and 3) trauma resuscitation evaluation times and correlating human-patient simulation training differences. Each SIM Center study examined one or more medical simulation  technologies, and some studies suggest possibilities for follow-on research.

For the first study, an external validation of an established virtual reality (VR) technology, the selected simulator was from Medical Education Technologies, Inc. of Sarasota, FL. One of the first of its kind in the U.S., this VR TURP simulator measures performance by time, blood loss, and excess tissue loss. “The outcomes were favorable from a simulation perspective,” Coffman explains, “but more studies would have to be conducted.”

Today, products for potential follow-on research include robotic models such as the Melerit PelvicVision. Made by Melerit Medical of Linköping, Sweden, PelvicVision provides a full procedure VR real-time simulation model. In an abstract available from the U.S. National Library of Medicine National Institutes of Health, researchers concluded that “the simulator could be used in the early training of urology residents without risk of negative outcome.” PelvicVision’s features include a modified resectoscope connected to a robotic arm with haptic feedback, foot pedals, and a standard desktop computer.

As part of its research, the SAMMC Simulation Center also assessed the use of the combat-ready clamp (CRC) to control simulated junctional hemorrhaging in a high thigh wound. Because of its location, such an injury cannot be treated with a typical tourniquet.

As Coffman explains, the soldier with the thigh wound in the movie Blackhawk Down “could have potentially been saved using the CRC.” To replicate bleeding, the SIM Center used a medium-fidelity mannequin with the physiological capabilities of a pressurized circulatory system. The CRC features a vise-like compression disk and base  plate that provides bidirectional pressure to stop collateral flow and hemorrhaging. Durable, collapsible, and lightweight, this medical device can be assembled and applied in less than a minute. According to the distributor’s website, the CRC “is the first CoTCCC recommended device” when an extremity wound is not amenable to a tourniquet, a reference to Committee on Tactical Combat Casualty Care (CoTCCC) treatment guidelines.

To correlate trauma resuscitation evaluation times with human patient simulation differences, the SAMMC Simulation Center modified the Laerdal SimMan 3G. Made by Laerdal Medical of Wappingers Falls, N.Y., the SimMan 3G is a wireless simulator with an instructor tablet and patient monitoring. After configuring the mannequin to replicate the typical traumas seen in the ER, the SAMMC SIM Center used the software and an evaluator to time-stamp actions and treatments.

Additional Task Trainers

Coffman notes that additional task trainers are used for more invasive replication. Technologies include the TraumaMan System from Simulab Corporation of Seattle, WA. An anatomical surgical mannequin, this simulator features realistic bleeding tissues and four surgical zones. At the SIM Center, the insertion of chest tubes and the acquisition of emergency airway access were demonstrated. Other applications for the TraumaMan System include needle decompression and IV cutdown. TechLine Technologies of Willow Grove, PA, also provides state-of-the-art medical simulators, including the Tactical Operation Medical Manikin (TOMManikin). Developed in collaboration with Innovative Tactical Training Solutions (ITTS), TOMManikin is what David Parry, Vice President at Techline, calls a “breathing, bleeding, talking  mannequin with a pulse.” The Philadelphia-area company also offers wearable wound simulators that do not require make-up or adhesives and that allow medical trainees to practice their hemorrhage control skills beyond bandaging. With the TOMManikin, multiple appendages present a variety of wounds, including gunshot, blast, and burn injuries. Trainees can practice point-of-injury care in multiple combat scenarios, such as machine gun, IED, and helicopter attacks.


A collaboration between Techline Technologies and Innovative Tactical Training Solutions (ITTS), the TOMManikin is a trauma mannequin simulator for use in the field and classroom. Multiple appendages present a variety of wounds, including gunshot, blast, and burns to provide full mission profiles in combat scenarios. (ITTS)

These simulated battlefield conditions “drive your scenario with tactical combat casualty care,” Parry explains. He says that the TOMManikin is equipped with an MP3 player for patient voice recordings, which lets trainers add tactical details such as information about the direction in which shots were fired and teaches trainees how to interact with and remove injured personnel. According to Parry, the TOMManikin is also extremely rugged.

These simulators have been subjected to and survived the crush of concrete and vehicles, and have also been dropped from airplanes. By the end of the year, TechLine Technologies expects to release what Parry calls a “water version” of the TOMManikin for marine rescues such as “man overboard drills.”

Expanded Education, Google Glass, and Hybrid Simulation

Medical simulation is evolving rapidly, and facilities like the SAMMC SIM Center regularly learn of new products with exciting possibilities. At the same time, medical professionals also devise new applications for existing products. “Emerging technologies are great,” Coffman says, “but thinking outside the box using current simulators has so many benefits.” As an example, he cites the work of Dr. Bonnie Haupt at Veterans Affairs Connecticut Healthcare Systems.In a practice dissertation for the Doctorate in Nursing Program at Sacred Heart University, Dr. Haupt provided pre-operative education to veterans who were scheduled to receive coronary artery bypass graft surgeries. Coffman says that Dr. Haupt’s research found that “veterans who participated in simulation education revealed a significant increase in knowledge and satisfaction over traditional teaching methods,” including a reduction in patient anxiety.

For Coffman, Dr. Haupt’s study suggests that simulation education is a “valuable tool” not just for training medical professionals, but also for educating patients and their families. “I would love to get SAMMC in for a follow-on study,” he adds. Just as apps for handheld mobile devices help medical trainees to test their knowledge and build critical thinking skills, patients and their families might better understand why specific treatment decisions are made.

In addition to this research, Coffman is also optimistic about Google Glass, which he says “will be a huge leg up for training evaluation.” By enabling an evaluator to see what a student is focusing upon, Google Glass can help trainers to provide individualized feedback with regard to technologies such as CT, X-Ray, or ultrasound.

In this way, evaluators can share a trainee’s point-of-view and “really get into their mind and see their rationale for patient care,” Coffman says. Technologies such as the HC1 headset computer project from Motorola Solutions may also hold possibilities. Powered by voice command and equipped for remote video chats and the display of complex schematics, the HC1 uses Microsoft Windows and can connect via WiFi, Bluetooth, or mobile hot spot. Designed for harsh environments and remote locations, this hands-free mobile computer could also let trainers see what trainees see.

Hybrid simulation is also expected to play a major role in medical training. According to Coffman, examples include the prompt birthing simulator, which allows real-time patient interaction with a trained actor or standardized patient (SP) while a simulator recreates the complication of a simulated birth. The cut suit, another hybrid simulation example, involves an SP who acts as if he or she were involved in a traumatic accident. The suit replaces actual injuries that must be treated while a patient is conscious. “This adds the realism that static or even hi-fi mannequin lack,” Coffman says.

Looking Ahead

The future of simulation-based medical education is promising, and Coffman is excited to see its evolution and advocate for its use. He notes that tracking the validity of simulation training can be difficult, but that the benefits outweigh the challenges. “I bet that if you had the opportunity to ask a care provider immediately following a critical incident if simulation training helped at all,” Coffman says, “they would respond with a resounding ‘yes’.”

Top photo caption: Simulation-based medical education and training may also include the use of live patients (Fort Carson Medical Simulation Training Center).

This article was originally published in the Q3 2014 issue of Combat & Casualty Care magazine.