AAMC Reporter: September 2006

Operations Shape Military Doctors

Under the bluish shadows of a nearby mountain range, young men and women in military uniforms cover the landscape. Some lie scattered on the ground, writhing and groaning for attention. Others are still and unresponsive. Still others slalom between the bodies, juggling armfuls of medicine and bandages.

"Hey, buddy!" one asks a young man on the ground. "How's your leg?"

"It's ok."

A third person watches over the exchange. "He's a primary leg injury?" she asks.

"Yeah. I gave him morphine before, and he's not bleeding anymore."

"So what's his priority?"

"He's evac. He'll need surgery, but we won't have to cut the leg off."

Later on, as the action winds down, a young woman rests on a stretcher. A young medic approaches her.

"So you got shot in the arm, huh?"

She smiles at him. "Yes."

"And how does that make you feel inside?"

Using her supposedly wounded arm, she playfully slaps his leg as both break into giggles.

Welcome to Pandakar.

Although you can't plot it on any map, to the young men and women hunkered for nine days here beneath Pennsylvania's share of the Appalachian Mountains, Pandakar is quite real. It is the fictional home of Operation Bushmaster and Operation Kerkesner, two large-scale military exercises that ran concurrently this summer and are designed to train and test medical students enrolled in the Uniformed Services University of the Health Sciences (USUHS), based near Washington in Bethesda, Md.

Operation Kerkesner introduces first-year USUHS students to combat simulation and field medicine. Operation Bushmaster brings about 90 fourth-year medical students into highly realistic combat situations from psychiatric evaluations to enemy ambushes, and culminates with a surprise, full-scale mass casualty exercise. Both operations act as final exams for unique courses in the USUHS department of military and emergency medicine.

"It's one thing to lecture to them and tell them stories, but it is profoundly different to experience it first hand," said Capt. Trueman Sharp, MC, USN, chairman of the department of military and emergency medicine, which runs the operations. "Even though it's a simulation, it turns out to be a huge experience."

The two operations took place July 11-20 in Fort Indiantown Gap, Pa., the primary training site for the Pennsylvania National Guard. USUHS, which trains physicians for the Army, Navy, Air Force, and U.S. Public Health Service has now performed these medical war games in some iteration for 27 years. In addition to USUHS medical students, graduate nursing students and military medical students from Great Britain, Mexico, and Japan participate in the operations. But with tensions and conflict in the Middle East and elsewhere seemingly unlikely to dissipate anytime soon — and with USUHS training about 25 percent of all active-duty military doctors — the operations are as meaningful as ever.

"The nature of trauma and disease in field combat is different than in other places," Sharp said. "We expect USUHS graduates to go out to Iraq and Afghanistan and function in difficult circumstances. Clearly, if you look at Iraq and Afghanistan, many of our service members have serious acute injuries, and a significant number of these injuries will be fatal if not identified and managed properly. That's what we're out to help these students do with these operations."

At Operation Kerkesner, 11 training "lanes" with names such as Tactical Combat Casualty Care and Care Under Fire test and train students in mock combat situations for approximately 45 minutes, evaluating not only medical skill but also leadership, poise, decision-making, and strategy. For many students, this is their first time in the field.

As one group completed the Tactical Combat Casualty Care exercise, which compelled students to handle enemy gunfire and a fake improvised explosive device (IED) near wounded patients, the non-commissioned officer in charge of the lane, Navy Hospital Corpsman First Class Jeremy Hevron, gathered the students together and dissected their performance. His feedback was as gently delivered as it was pragmatic.

"Remember, the first goal is to not get shot," Hevron said. "The second goal is always to engage and destroy the enemy. If the enemy is destroyed, then you're not taking fire, which means you'll never have to do medicine.

When an IED appears," he continued, "tell someone to carry it over to a streambed or any depression in the ground. If it detonates during that process, well, that's one letter home instead of five."

"Order Out of Chaos"

While first-year students are engaged in Kerkesner, fourth-year students are immersed in the more advanced and realistic Operation Bushmaster. Before arriving in Pennsylvania, students are briefed on Pandakar and encouraged to research the country on a university-created Web site. Each student has a chance to play several roles over the course of the exercises, including commanding officer, physician, medic, triage and security officer, and evacuation personnel.

Various military medical staff observe and assist students in the process. Bushmaster faculty grade students on surgical and point-of-injury care, leadership, and combat stress control. According to Sharp, however, the emphasis is not on getting high marks but on gaining field experience.

"Grading helps motivate them, but we don't want that to be the focus," Sharp said. "It's a tricky thing.More than anything else, we want this to be very much a medical experience with lots of discussion and feedback."

"We want to simulate as best we can the environment they would find in the Middle East or anywhere in combat. It is an austere environment. There is limited IV fluid, and there is a limited pharmacy. They have to learn how to operate in this resource-constrained situation," Sharp said.

Each of the two Operation Bushmaster sessions lasts three days, not including a day and a half of training before the actual exercises begin. Each group of 15 to 16 students deals with a different scenario for four hours, followed by an "after-act review" for feedback, with each four-hour "block" equaling an entire day's worth of activities in a real-life situation. Students manage "non-battle injuries" such as sprained ankles and sore throats; various trauma, operational, and logistical complications; and cultural awareness issues such as treating combat detainees in accordance with the Geneva Conventions.

However, perhaps the highlight and principal component of the exercises is treating combat injuries in a highly realistic "mass casualty exercise." With at least 30 to 40 field injuries that students must address, Sharp said the aim is to "bring order out of chaos." Creating as lifelike a simulation as possible falls in part to a team of moulage artists. In a staging area that is part chemistry lab and part Hollywood movie set, the moulage team uses wax, latex, paint, and make-up to closely mimic a wide range of injuries, from bullet wounds and missing limbs to open skull fractures and even a missing mandible.

"We're trying to take the shock value out of the injuries," said Patti Kraus, a research coordinator with the USUHS Division of Military Internal Medicine who volunteers as a moulage artist at Operation Bushmaster. "That way, the students will be better able to deal with these things when they happen in real life. We use real photos to try and re-create these wounds as closely as possible, so when they get into the field, they don't have to guess. They know."

First-year students don the moulage and serve as the simulated patients in Bushmaster's mass casualty exercises.

"It was a stroke of genius to have the first-year students acting as patients," Sharp said. "They get trained to display the symptoms and characteristics of the problems they are going to portray. They learn a lot about the disease or injury they are portraying, and they see things from the patient perspective."

Overall, students said they see the value inherent in the operation.

"Seeing patients in a wartime situation and a limited resources situation is huge," said Air Force Second Lieutenant Eric Vaillant, a fourth-year medical student participating in Operation Bushmaster.

"A lot goes into the logistics behind setting up these kinds of things," Vaillant said. "It's not just a matter of, can you treat a person. It's a matter of, can you prepare for it. We get to see how we handle certain things, and how the people around us handle things. They say every good plan lasts about five minutes. You have a plan that you rehearse, but then it all goes to pot, and they say, 'What are you going to do now? How flexible are you at adapting when the plan doesn't hold up?'"

— By Scott Harris

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