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The wars in Iraq and Afghanistan have seen US Soldiers surviving injuries that as recently as the late 1990s were certain to be fatal. This is the result of implementing lessons learned, improved realistic training and the amazing work done at the Combat Support Hospitals (CSH). With all the improvements to point of injury (POI) care, no one has addressed how to prepare the average combat soldier with the most realistic medical training possible. This paper will discuss the effects that pre-deployment live tissue training had for the Paratroopers of the 4th Squadron, 73rd Cavalry Regiment (ABN) during an eight month deployment to the Maiwand and Zharay Districts of Afghanistan.
In order to better prepare the warfighter for the upcoming deployment the Commander of 4th BCT, 82nd ABN DIV, COL Brian Mennes, directed the implementation of a more advanced Medical training course based on the Ranger First Responder program. The result was Fury First Responder (FFR). The premise of FFR was to teach the common soldier basic and advanced trauma skills and then reinforce those skills using hip-pocket training, outcomes based training, and scenarios during Intensive Training Cycles (ITC). As a BCT program, FFR was able to be easily resourced and conducted without the administrative processes associated with Combat Lifesaver (CLS).
FFR took from the tenants of Tactical Combat Casualty Care (TCCC) and applied them using the MARCH Principals (MARCH is a TCCC centric acronym that stands for Massive hemorrhage, Airway, Respirations, Circulation, Head injury and hypothermia. It replaced the old civilian ABC acronym). The initial phase of the course was a quick didactic portion that was meant to act as an introduction to the basics of TCCC. The next phase was a round robin training event that initially focused on deliberate hands-on instruction. The areas covered consisted of application of a tourniquet, packing a wound and pressure dressings, inserting the nasal pharyngeal airway (NPA) and King LT airway adjuncts, application of an occlusive dressing and needle thoracentesis. Initially training was done in ACUs with the focus on enforcing correct techniques. On day two the round robin continued but this time with tactical vests and combat gear. Simple scenarios were also added to make the students think about the injury and problem solve in order to develop a solution. On the third and final day the students conducted multiple Situational Training Exercise (STX) lanes. The scenarios were developed to be as realistic as possible. The basic premise revolved around a mounted or dismounted patrol and a casualty producing event. Soldiers closest to the POI provided initial care while everyone else returned fire and/or pulled security.
Immediately after the introduction of the FFR program the squadron began to incorporate casualties into every training event making them a key component to success or failure. This allowed the troop commanders to get a basic sense of their soldiers’ medical skill level. The introduction of casualties during a training event is a huge win for any medical planner. The issue is that medical training, while important, is usually an afterthought. The primary focus is always the combat centric mission essential tasks while the medical tasks are factored in but without the same level of realism. Also it is not practical to pre-moulage a soldier prior to a training event as it would interfere with the primary training objective. The result is often a casualty with notional wounds and no visual references to work with.
During the squadron’s National Training Center (NTC) rotation there were multiple mass casualty events (MASCAL) that required non-medic soldiers to augment and, in some cases, assume the role of the medic. While the squadron received kudos for having combat soldiers that were more proficient at medical skills than the average unit, it was felt that our soldiers were not at the level they needed to be. Returning from the NTC rotation the problem set we identified was how do we as a squadron solidify the medical skills we have been training. Finding a solution to the problem became more critical as the unit that the squadron was relieving in Afghanistan began sending casualty reports as part of their regular updates.
The ideas that were tossed around included using the Fort Bragg Medical Skills Training Center (MSTC), conducting a comprehensive medical field problem or contracting a private company to facilitate live tissue training for the entire squadron. We decided on live tissue training because nothing else can come close to replicating the experience of treating traumatic injuries. It was important for us to choose a civilian medical education company that had a good reputation within the military community for providing a quality realistic product. With the potential for negative reactions from certain advocacy groups it was equally important that we use a company that had a good track record for following all DoD and Department of the Army regulations regarding live tissue. All live tissue models that were used were completely anesthetized for the duration of this training and euthanized in a humane manner upon completion.
Once we decided on the company to use it was necessary to establish guidelines for what skills the non-medic soldiers would be allowed to practice. The tasks allowed for the non-medics were based on FFR. Additionally, medics would be allowed to conduct a supervised cricothyroidotomy. The use of an off post site came with the added benefit of ballistic wounding. Ballistic wounding would allow the instructors to create wounds that closely resemble the blast injuries that the squadron would face in Afghanistan. The method of instruction was based on each troop conducting the training for one day, approximately 12 hours total. The morning would be dedicated to a quick PowerPoint instruction on MARCH followed by two hours of hands on live tissue training with an instructor. The afternoon was dedicated to an unannounced MASCAL event and mission type scenarios that incorporated actions on the objective, point of injury care, and quick evacuation to a Casualty Collection Point (CCP). In all each platoon ran through four scenarios over the course of the afternoon.
The primary goal of the training was to reinforce critical medical skills with as realistic training as possible. That goal was easily accomplished but there were several intangibles gained as well. Each soldier took away differing lessons from the training. Several soldiers reported that they now truly believed that the FFR medical training would save a life. They were also amazed at how much trauma and blood loss the live tissue models could endure and still survive. The most important of these intangibles was the confidence they gained in the trauma skills of their platoon Medics. A correlation can easily be made between willingness of the average Soldier to place himself in harm’s way based on the confidence he has in his medic’s capabilities to fix him should he get hurt.
Arguments can be made for or against the use of live tissue training for non-Medics. What cannot be argued is that every single one of the 46 traumatic injuries that the squadron had a hand in treating or evacuating during the first 115 days of the deployment was initially cared for by non-medics. Of those 46 casualties, one was the fourth quadruple amputee in the history of US Army Medicine to have survived his wounds. Another person to have survived similar injuries within the last year is a Navy EOD technician attached to a Naval Special Warfare unit. The medics assigned to those units must complete the US Army’s Special Operations Medic course, which conducts extensive live tissue training. The additional training also factored in a 19-year-old PFC medic’s ability to perform a successful cricothyroidotomy. The current failure rate in theater for cricothyroidotomies performed by medics is over 30%. Of the squadron’s three KIA’s, one was a high lower extremity double amputee that was talking as he entered the CSH’s trauma bay. The success rate at that CSH for casualties that arrive with a pulse is 98%. The fact that the Soldier was alive when he arrived at the CSH is a testament to the abilities of the Medics and first responders that were on the ground.
The Army Medical Department (AMEDD) has a pre-deployment training program called Brigade Combat Team Trauma Training (BCT3) that is used to give medics a quick refresher on trauma skills prior to deployment. FFR and BCT3 are very similar in how the courses are laid out. The BCT3 model could be expanded and adapted to provide similar training for all deploying Soldiers within a BCT. There are several key changes that should be made if BCT3 were to be expanded. First, there needs to be a selection process to ensure that the medic instructors have credible combat medicine backgrounds. Emphasis should be placed on medics that have multiple years of experience with either maneuver battalions or brigade support medical companies. The credibility of the instructor will make or break any combat medicine class. Soldiers are quick to pick up on competency and experience levels of their instructors. Second, infantry, cavalry, or armor soldiers should be incorporated into the training cadre. We should not expect realistic infantry STX lanes from medical personnel just as we would not expect realistic medical scenarios from an infantryman. It is critical that this training be conducted while maintaining platoon or company integrity.
There are many within the Army Medical community who are less than enthusiastic in supporting any type of live tissue training, with the exception of medical professionals and special operations medical personnel. Our squadron ran into these roadblocks as we planned our last live tissue training event. Arguments ranged from the standard worries of pictures being taken to the belief that live tissue training was solely within the realm of AMEDD and USASOC. The arguments invariably seem to fall into two categories: wanting to protect the ability of established institutions to conduct live tissue training or declaring that there is minimal value in providing live tissue training to non-medic conventional soldiers. We have multiple documented incidents that clearly show that the live tissue training our paratroopers received prior to deployment to Afghanistan was instrumental in lives being saved on the battlefield. There are numerous documented cases where the tactical situation does not allow for the medic to reach the casualty until 20 to 30 minutes post injury and sometimes not at all. If non-medic soldiers receive prerequisite training beforehand and the event is conducted with the proper decorum then there is no acceptable argument against not allowing them to participate in this course in preparation for deployment.
What many AMEDD leaders fail to realize is that the initial care provider is almost always the casualty’s buddy. The extra edge that live tissue training provides could be the difference that affects a non-medic’s confidence in attempting a lifesaving intervention. The question we need to ask ourselves as an institution is; do the sensibilities of a vocal minority of the population and the expense of the training outweigh the loss of just one soldier’s life. Those first 60 minutes are the golden hour of care. Having the best care that military medicine has to offer at a Role 2/3 facility means nothing if the casualty cannot survive from the point of injury to that facility. Great strides have been made in battlefield care during the past 9 years and further measures need to be undertaken to ensure that we are doing everything possible to save lives in the future.