"Train as you fight", article about the International Medical Modeling and Simulation Conference in Munich

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International Medical Modeling and Simulation Conference 2017 in Munich, Photo by Bundeswehr Medical Academy / Julia Langer

You can explore the conference materials on the NATO MILMED COE Lessons Learned portal under Databases / Knowledge Management / NATO MILMED COE Events / International Medical Modeling and Simulation Conference or click here. To get access to this log-in protected site you need to be a registered user. You can register here.

Check out the article about the conference below.

Train as you fight

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Photo by Bundeswehr Medical Academy / Wolfgang Diedrich

“I hear and I forget. I see and I remember. I do and I understand.“ The Bundeswehr Medical Academy has taken to heart these wise words by the Chinese philosopher Confucius, which are more than 2,500 years old. Being well aware of the special significance practical exercises and hands-on training have in acquiring complex skills, the Academy’s staff is continuously working on new ideas for medical training. Divison G (Medical Service Capability and Force Development), which is headed by Colonel (MC) Dominique Mayer, is at the core of this effort.

Train as you fight – a very apt motto which, however, is very challenging to implement. There are limits to the simulation of the confusing chaos, deafening noise and acid smell that come with real battle, and the strangely insipid and dry taste it leaves behind. Artificial stress may be easy to generate, but can it compare with the imminent fear of death soldiers face in real combat? Deep in the back of our minds, many of us have gotten used to the comforting certainty that nothing bad can actually happen during such an exercise. A big bag of tricks is required in order to eliminate this false sense of security.

International Cooperation is a Must

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Major General (MC) Dr Gesine Krüger welcoming the international conference participants, Photo by Bundeswehr Medical Academy / Wolfgang Diedrich

“International cooperation is a must. Especially with respect to a scarce resource such as medical care. Only together with our partners will we be able to master the complex challenges we are faced with today. In the Middle East, in Northern Africa, in the East of Europe and elsewhere. As Commandant of the Bundeswehr Medical Academy, it is my sincere and heartfelt wish that we make our contribution in this field.” Major General (MC) Dr Gesine Krüger has very clear ideas about the consolidation of the relations with friendly armed forces and institutions. “In think that in this context, the NATO Centre of Excellence for Military Medicine in Budapest is one of the major hubs. The work that is being done there really cannot be overrated. I am all the more pleased that I have been closely cooperating with its director, Colonel Dr László Fazekas, since as long ago, and I am very much in favour of a few more common projects in the future.“

Fire, Smoke and Lots of Fake Blood: The More Realistic, the Better

In the middle of an exercise, a squad of marines that has taken up post in front of a half-destroyed house is absentmindedly enjoying the warming rays of the morning sun. A man approaches them and engages them in a trivial conversation. Suddenly he draws a pistol from under his jacket, points at the squad leader and pulls the trigger. Screaming, the young woman hits the ground. The wall behind her is splayed with blood. Emitting a wheezing sound, she is lying in the sand, which quickly turns a dark red...
No question, the scene is movie material. Sophisticated technical aids and plenty of acting talent enable the two simulation actors to completely immerse the other soldiers in the events surrounding them. Fiction turns reality. At least for a few decisive moments.

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Colonel Dr Daniel Irizarry: "The right first and buddy aid is the decisive factor for the survival of wounded soldiers.", Photo by Bundeswehr Medical Academy / Wolfgang Diedrich

“The right first and buddy aid is the decisive factor for the survival of wounded soldiers.“ Colonel Dr Dan Irizarry of the US Army Medical Corps is one of the leading figures behind SQUAD OVERMATCH, an ambitious training programme. “In reality, death and wounding are part of armed conflicts. We must face this truth. But what we have never been ready to accept was the unbearable fact that the majority of our wounded soldiers died before they even had a chance to reach a medical treatment facility. We absolutely had to change this.”
Scientific estimates indicate that almost one quarter of deaths during Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (Iraq) could have been avoided. A more detailed analysis has shown that the death toll suffered by special units such as the 75th Ranger Regiment was considerably lower than that of others despite their risky missions. This gave rise to the question why this was the case.

“It soon became clear to us that the main reason simply was far better training.” Without delay, Colonel Dr Dan Irizarry and his colleagues started developing methods that would enable all soldiers to reach the same training level as their comrades of the Special Forces. “We absolutely wanted to create something that was realistic, demanding and challenging, but also affordable.“
The result of this effort was SQUAD OVERMATCH: Training starts in the classroom. There, theoretical fundamentals are taught first, just like in a traditional approach. As a next step, the soldiers encounter virtual worlds where they can consolidate what they have just learned, either individually or as a member of a larger unit. To round off the experience, the training participants spend some time at a training area where simulation is at its most realistic (and includes scenes such as the one described earlier).

The Bundeswehr Medical Academy Goes International

“Cooperation with other armies is one of the most important aims of the Bundeswehr Medical Academy. We thus considered it both a pleasure and a duty to host the first conference on the subject of international modelling and simulation here in Munich from 28 to 30 March 2017 together with the NATO Centre of Excellence for Military Medicine." Lieutenant Colonel Axel Ziegler is very pleased about those three extremely productive days. “We are already looking forward to the next conference, which we hope will be on an even larger scale."

Computer-Gaming as a Way to Achieve Training Goals: Serious Games

Not only the U.S. Army but also the Bundeswehr has recognized the advantages of computer-animated learning programmes, the so-called serious games. Together with several partners, the Bundeswehr Medical Academy is working on the SANTRAIN project.

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Game-based learning and exercising with SANTRAIN, Photo by Bundeswehr Medical Academy / Wolfgang Diedrich

Although the graphics and course of the game resemble popular ego shooters at first glance, it pursues completely different aims: The objective is not killing, but saving lives. In order to reach this goal, SANTRAIN uses a multitude of complex medical models, such as an authentic cardiovascular system, and combines them with basic military skills.
Before the squad goes out on patrol, the soldiers‘ ability to handle their rifles and use hand grenades is checked. Once the player has passed this test, he or she will soon encounter the first injured comrade and start practising the correct steps to be taken in casualty care.

Modern Patient Simulators: It Feels Like Real

The astonishment lasts just a fraction of a second, but is clearly visible in the young private’s face. ”Sorry, I must have taken the wrong door." In front of him, the shape of a man whose lower leg has been torn off is writhing on the floor. Directly beside him lies a motionless dog with a black, unwashed coat. All kinds of limbs are piled up on the surrounding tables. A group of military personnel and civilians are gathered around the bizarre scene, engaged in animated discussion. One has to admit that all of this looks a bit scary indeed...

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Instructors of the Bundeswehr Medical Academy demonstrating a training situation using a state-of-the-art patient simulator, Photo by Bundeswehr Medical Academy / Wolfgang Diedrich

The companies competing on the niche market for patient simulators must convince their customers with innovative and realistic products. What applies to smartphones, computers or cars equally applies here: Better is the enemy of good.
“All patient simulators that we are currently examining have different advantages and drawbacks. While one model is especially suited for the training of first aiders, another one is particularly convincing in the field of advanced clinical training.” Testing new equipment is part of Colonel Dominique Mayer’s daily job. One of the things he has learned is the fact that all-rounders that can be applied universally are a rare species. Technical devices are always a compromise; unfortunately there is no such thing as an all-in one solution suitable for every purpose.

Low Tech at its Best: HOSPEX

High-tech equipment is not always necessary. Sometimes maximum effect is achieved with a minimum of technological means. An excellent example of this is the HOSPEX tabletop exercise. Developed by the British Colonel David Vassallo, it basically consists of an impressive amount of colourfully printed paper: There are big, schematic representations of camps and medical treatment facilities of various types and sizes, a wide range of incident and casualty cards as well as detailed depictions of resources such as drugs, blood plasma or dressing materials.

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International cooperation during the HOSPEX workshop, Photo by Bundeswehr Medical Academy / Wolfgang Diedrich

In other words: The general surgeon with the Royal Army Medical Corps who has decades of operational experience has really thought of everything that is required to familiarize the exercise participants with the medical evacuation chain from the point of wounding to redeployment back home. And the best thing is that HOSPEX can easily be carried in a briefcase and can be adapted to all conceivable scenarios, no matter whether they are military or civilian.

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A big thank you goes to the father of HOSPEX (from left to right): Conference organizer Col (MC) Dominique Mayer, Col David Vassallo and Deputy Director MILMED COE Col (MC) Dr Salvatore Schmidt, Photo by Bundeswehr Medical Academy / Wolfgang Diedrich

The complete HOSPEX setup somewhat resembles a traditional board game for the whole family. However, a kitchen table will not do. In fact, a classroom is needed as the number of potential players amounts to dozens. Actually, it is possible to set up an entire field hospital.
It is particularly interesting to watch how quickly the players get immersed in this seemingly simple game. Although only little cardboard cards are moving to and fro, all participants are soon playing their roles wholeheartedly. If only it was always as easy to trigger group-dynamic processes. As far as the cost-benefit ratio is concerned, HOSPEX definitely is unmatched.

Thinking Outside the Box

“My former commander, Major General (MC) Dr Stephan Schoeps, who today is the Deputy Surgeon General of the Bundeswehr Medical Service, has taught me to always look at what other nations do first rather than reinventing the wheel ourselves. This principle has proved its worth.” Lieutenant Colonel Markus Schardt is one of the originators of the Conference on Modeling and Simulation. "The event has allowed us to think outside our own box by looking beyond borders and learning about the different approaches to medical training taken by other armed forces. Once again it became clear that the Americans, Belgians, British, Lithuanians, Dutch, Czechs, Romanians, Slovaks and Hungarians also have excellent ideas of their own. Now as before, the important thing is being ready to learn from each other and to exchange our views on a regular basis."

In a Nutshell: It’s the Combination that Counts

Comprehensive, practice-oriented, realistic and efficient medical training rests on several pillars. Technological means can support and facilitate the learning process, but they can certainly not completely replace traditional ways of imparting and acquiring knowledge. Studying textbooks at night will remain part of the deal – nothing beats real swotting.
Realistic serious games such as SANTRAIN, state-of-the-art patient simulators and the HOSPEX tabletop exercise should definitely be part of the future spectrum of training tools. It is decisive that the individual elements complement each other and form a balanced whole.
Sophisticated exercise scenarios such as the ones simulated in SQUAD OVERMATCH without doubt represent the top of what is feasible today and certainly call for respect. Other armed forces can only benefit from this.
In spite of all progress, however, we must not forget one thing. There is a decisive question that still remains unanswered: How many casualties and what patterns of injuries must be expected if worst comes to worst? We will report about one answer to that challenging riddle next time.

Article by LTC Oliver Pikkemaat, LTC Axel Ziegler (Bundeswehr)

You can explore the conference materials on the NATO MILMED COE Lessons Learned portal under Databases / Knowledge Management / NATO MILMED COE Events / International Medical Modeling and Simulation Conference or click here. To get access to this log-in protected site you need to be a registered user. You can register here.

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