Recent Advances in Forward Surgical Team Training at the U.S. Army Trauma Training Department

* Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136.

* Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136.

* Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136.

* Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136.

* Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136.

* Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136.

* Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136.

* Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136.

† U.S. Army Trauma Training Department, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136.

* Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136.

† U.S. Army Trauma Training Department, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136.

* Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136.

† U.S. Army Trauma Training Department, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Avenue, Miami, FL 33136.

The opinions expressed in this article are solely those of the authors and do not represent those of any military or government agency.

Military Medicine, Volume 181, Issue 6, June 2016, Pages 553–559, https://doi.org/10.7205/MILMED-D-15-00084

Cite

Casey J. Allen, Richard J. Straker, Clark R. Murray, William M. Hannay, Mena M. Hanna, Jonathan P. Meizoso, Ronald J. Manning, Carl I. Schulman, Jason M. Seery, Kenneth G. Proctor, Recent Advances in Forward Surgical Team Training at the U.S. Army Trauma Training Department, Military Medicine, Volume 181, Issue 6, June 2016, Pages 553–559, https://doi.org/10.7205/MILMED-D-15-00084

ABSTRACT

U.S. Army Forward Surgical Teams (FSTs) are elite, multidisciplinary units that are highly mobile, and rapidly deployable. The mission of the FST is to provide resuscitative and damage control surgery for stabilization of life-threatening injuries in austere environments. The Army Trauma Training Center began in 2001 at the University of Miami Ryder Trauma Center under the direction of COL T. E. Knuth, MC USA (Ret.), as a multimodality combination of lectures, laboratory exercises, and clinical experiences that provided the only predeployment mass casualty and clinical trauma training center for all FSTs. Each of the subsequent five directors has restructured the training based on dynamic feedback from trainees, current military needs, and on the rapid advances in combat casualty care. We have highlighted these evolutionary changes at the Army Trauma Training Center in previous reviews. Under the current director, LTC J. M. Seery, MC USA, there are new team-building exercises, mobile learning modules and simulators, and other alternative methods in the mass casualty exercise. This report summarizes the latest updates to the state of the art training since the last review.

INTRODUCTION

U.S. Army Forward Surgical Teams (FSTs) are elite, multidisciplinary 20 to 30 person units usually comprised of general and orthopedic surgeons, nurse anesthetists, registered nurses, licensed practical nurses, operating room (OR) technicians, emergency medical technicians, and a health care administrator. The mission of the FST is to provide resuscitative and damage control surgery for the stabilization of life-, limb-, and eyesight-threatening injuries in austere environments. Casualties are then rapidly evacuated to higher levels of definitive care. The FST is highly mobile and rapidly deployable, and in conjunction with combat support hospitals, has replaced the Mobile Army Surgical Hospital and Field Hospitals of the past. 1 The FST is often the initial recipient for mass casualty (MASCAL) events related to combat, terrorist activities, or natural disasters. 1

The U.S. Army Trauma Training Center (ATTC) was established in 2001 at the University of Miami Miller School of Medicine/Ryder Trauma Center as the only predeployment MASCAL and clinical trauma training center for all FSTs. The U.S. Navy began a similar program at University of Southern California/Los Angeles County Medical Center, and the U.S. Air Force initiated Centers for the Sustainment of Trauma and Readiness Skills (C-STARS) at busy academic medical centers: R. Adams Cowley Shock Trauma Center at the University of Maryland (C-STARS Baltimore) and Saint Louis University (C-STARS St. Louis). Each of the military trauma training centers focuses on didactics, state-of-the-art simulation, and expeditionary equipment training specific to their mission, as well as actual clinical experience in the acute management of trauma patients. Each is integral to delivering lifesaving combat casualty care in theater and each has a unique mission. 1 Currently, we live in an increasingly “Defense Health Agency” world, where doctrine and capabilities are tri-service. In a 2012 supplement in the Journal of Trauma, the training at each service branch was compared and contrasted. The purpose of this report is to summarize the latest updates to the state of the art training at the ATTC since that last review.

The initial ATTC director, COL T. E. Knuth, MC USA (Ret.), devised a 2-week program composed of a multimodality combination of lectures and laboratory exercises (Phase 1), as well as clinical experiences (Phases 2 and 3). The personnel complete pre- and postrotational surveys to measure their competency in FST function. The postrotational survey additionally includes sections to rank the perceived usefulness of all training exercises in which they participated. Each of the subsequent five directors has restructured the training based on feedback from the surveys, current military needs, and on the rapid advances in combat casualty care. We have highlighted these evolutionary changes at the ATTC in our previous reviews. 1 , – 3 The program currently contacts all trainees via e-mail at about 6 months after deployment for input regarding areas that would improve their preparedness for their ultimate tasks.

The ATTC FST program has been extensively refined over the years to further improve predeployment training in combat trauma medical care. Two primary skills are emphasized; teamwork using clear team roles and knowledge of trauma management. The core of the 20–30 person FST is a 5-member team that depends on effective implementation of these two skills, and the ATTC program was restructured to accommodate these goals. The core 5 refers to the left medic, right medic, team leader, nurse, and anesthesia that are directly involved with the patient at hand. Evidence-based updates to lectures with reinforcement of Advanced Trauma Life Support, inclusion of novel equipment and procedures in clinical skills laboratories, team-building exercises, simulation training exercises and continual critical feedback are all focused on preparation for future live combat situations.

Under the current director, LTC J. M. Seery, MC USA, the ATTC has undergone many changes as part of a slow paradigm shift in the training platform. While the overall mission of the program to provide predeployment trauma training and validation at the end of a unit's normal training readiness cycle has remained fairly consistent over the past 14 years, the vision and philosophy has evolved. The three main goals are to provide basic and advanced trauma refresher training, combat trauma unique concepts and skills, and develop the group into a strongly functioning team to improve patient outcomes on the battlefield. There are new team-building exercises, mobile learning modules, major changes in the MASCAL exercise, new lectures and skills stations that better match current theory, and lessons learned from recent patient injuries. The ATTC staff train not only conventional Army surgical units for combat deployments but also surgical units supporting other Department of Defense (DoD) austere surgical teams, including the Forces Command Global Response Force mission, the Defense Chemical Biological Radiological Nuclear Response Force mission, various Disaster Relief/Humanitarian Assistance mission, Presidential Support missions, as well as Army and Air Force special operations resuscitation and surgical teams, and a variety of international students. In addition, in August of 2014, as part of the Army Medical Department Center and School transformation, the program was renamed the Army Trauma Training Department (ATTD). Currently, it still directs the Army Trauma Training Course and the Combat Extremity Surgery Course, and may soon add new training courses.

NEW DIDACTICS

Because of dynamic feedback, more team training exercises are now emphasized during the didactic component of the course. The didactic component begins with a refresher on initial triage and management of the trauma patient, followed by a review of the various roles on the team, and then how to transition between roles in an emergency situation while functioning as a coordinated unit ( Table I).

Didactic Curriculum at the ATTC

ATTC, Army Trauma Training Center; STX, Situational Training Exercise; OR, Operating Room; Evac, Evacuation; Ops, Operations; ASSET, Advanced Surgical Skills for Exposure in Trauma; TRU, trauma resuscitation unit.

Didactic Curriculum at the ATTC

ATTC, Army Trauma Training Center; STX, Situational Training Exercise; OR, Operating Room; Evac, Evacuation; Ops, Operations; ASSET, Advanced Surgical Skills for Exposure in Trauma; TRU, trauma resuscitation unit.

Phase 1 lectures have been reformatted as indicated in Table II. Tactical Combat Casualty Care (TCCC) guidelines provide the knowledge necessary to make the best clinical decisions based on the patient in the tactical environment. Clinical Practice Guidelines (CPGs) are reviewed to solidify critical concepts necessary to excel in administration of acute trauma care. Phase 1 now includes more team-building exercises and leadership skills interspersed between lectures and medical procedural training. Students are informally assessed continuously to ensure execution of proper team fundamentals. The first true test is an unexpected trauma event with a standardized moulage patient transported by Miami Dade county air rescue service. An After Action Review (AAR) is conducted on the team's performance with special emphasis on leadership and teamwork.

Phase 1 Before and After Institutional Changes

DoD, Department of Defense; CPG, Clinical Practice Guidelines; TCCC, Tactical Combat Casualty Care; MASCAL, Mass Casualty; ASSET, Advanced Surgical Skills for Exposure in Trauma; ACS, American College of Surgeons; ASSET, Advanced Surgical Skills for Exposure in Trauma; FAST, Focused Assessment with Sonography in Trauma; FATE, Focused Assessed Transthoracic Echo.

Phase 1 Before and After Institutional Changes

DoD, Department of Defense; CPG, Clinical Practice Guidelines; TCCC, Tactical Combat Casualty Care; MASCAL, Mass Casualty; ASSET, Advanced Surgical Skills for Exposure in Trauma; ACS, American College of Surgeons; ASSET, Advanced Surgical Skills for Exposure in Trauma; FAST, Focused Assessment with Sonography in Trauma; FATE, Focused Assessed Transthoracic Echo.

Evidence-based studies have demonstrated a direct correlation between team training and effective early management of traumatic injuries in the civilian setting. 4 , 5 Creation of Team Strategies and Tools to Enhance Performance and Patient Safety by the DoD and its incorporation into all military health systems indicates the U.S. military branches' full endorsement of a team approach to combat casualty care. 6 Team Strategies and Tools to Enhance Performance and Patient Safety is heavily stressed at the ATTD. Integrations of team development and learning concepts (like Kolb's experiential learning cycle, 7 Miller's prism of clinical competence, 8 and other theories) have also been incorporated. This has led to changes in our approach to training our students that have unique learning styles and modalities as individuals, sections and as a whole team.

Review of the postrotational surveys and standardized self-assessments before and after revision of the program shows promising results. In the postrotational surveys, 99% of students reported that their knowledge of combat trauma increased, 100% agreed that they understood their roles in the team's care of acutely injured patients, and 97% agreed that the team goals at the ATTD were met. The clinical rotations and the MASCAL exercise were each indicated as the most valuable of 10 different components of the course by 33% of students. Students graduating from the program are confident in both themselves and the rest of their FST. In addition, students realize the absolute necessity of good leadership, communication, situational monitoring, and mutual support. They are able to move forward with this knowledge and continue working on improving team performance in the future.

SITUATIONAL TRAINING EXERCISE (STX)

Phase 1 culminates with a MASCAL STX using live tissue, moulage standardized “patients”, trauma manikins, and high-fidelity human trauma simulators. The FST is simultaneously presented with increasing numbers of “patients” with multiple traumatic injuries, and then finally a MASCAL, to evaluate their implementation of Advanced Trauma Life Support protocols, use of current DoD TCCC and CPG, the proper triaging and management of patients to the OR, intensive care unit, or stabilization for transport to the closest combat support hospital, while managing other tactical, logistical, and administrative activities. The details and effectiveness of the MASCAL have been previously reported by our group. 2 , 3

The STX has undergone extensive restructuring since the previous reviews, and the major changes are shown in Table II. The STX is now split into two sessions over about 8 hours. The first now serves as a practice run, with instructors pointing out areas for improvement and complications not previously considered. The second session serves as the true test in which the students must perform above a certain standard for successful completion of Phase 1 of the course. During the first session, students have the option to approach instructors with any inquiries they may have and instructors have the option to interject at teaching moments as they present during the ongoing event. This critical real-time evaluation immediately affords students the ability to correct mistakes before the second session, which occurs the following morning. During the second session, students must successfully handle the patient load and any adverse situations. Instructors remain silent and solely observant, grading the students on their performance.

Expansion of the MASCAL into two sessions has provided an increased number of “patients” in both sessions. Depending on the size and caliber of the rotating team, the first session consists of two or three swine patients, and the second consists of four or five. In both sessions, additional moulage patients, mannikins, and simulators are used to probe the limits of FST skill and performance. At the beginning of the ATTC, the MASCAL injuries were strictly standardized and only live tissue was used. As the program progressed, injuries became variable from month to month. Current restructuring of the MASCAL STX includes transitioning back to the previous strictly standardized set of injuries administered to live tissue and the variability in the simulators, mannikins, and/or moulage patients. This allows for a consistent evaluation of each individual rotating FST, as well as the effectiveness of the program as a whole. Additional equipment, combat environment simulation, and scenarios also add to the realism of the STX.

Novel trauma equipment like tourniquets, junctional devices, hemostatic dressings, and others are now implemented in the procedural training exercises, as well as MASCAL, giving students the opportunity to become competent in utilization of these new techniques. Examples of the most recent incorporations are indicated in Table II. Improvements in tourniquets have resulted in a significant reduction in mortality in the combat setting. 9 Following the universal implementation of modern tourniquets in the armed forces in 2007, there has been an 85% decrease in mortality resulting from peripheral extremity hemorrhage in the battlefield setting. 9

Simulators serve as additional patients during each session. A comparison of the advantages and disadvantages of live tissue vs. the body suit simulators is presented in Table III. Currently used simulators include the Crash Kelly low-fidelity simulator (item no. 201-10001, Laerdal Medical, http://www.laerdal.com/us/item/201-10001)), the Advanced Life Support (ALS) high-fidelity simulator (item no. 205-05050, Laerdal Medical, http://www.laerdal.com/us/item/205-05050), and the Surgical Cut Suit-Partial Task Trainer (Strategic Operations 4705 Ruffin Road, San Diego, California, http://www.strategic-operations.com/products/surgical-cut-suit). Different simulators are currently being added to provide variety to the students and assess for appropriateness to replace live tissue in the future. Additionally, volunteers participate as standardized patients in the MASCAL STX. Moulage is applied for standardized fake injuries. The lack of actual injury is masked by the authentic human element as well as real communication between victim and caregiver. The ATTD currently uses both swine and simulators and both offer distinct advantages. The ATTD continues to evolve as DoD needs change; the balanced use of swine and simulators will evolve as well. Altogether, the swine, the simulators, the moulaged standardized patients, combined with real-life sights, sounds, and smells synergize to suspend disbelief and add to the STX.

Live Tissue vs. Body Suit Simulators

Live Tissue vs. Body Suit Simulators

Students are evaluated by ATTD instructors after both sessions. The first session AAR is informal, comprised of discussions covering satisfactory outcomes and improvements that could be made. The AAR following the first session is a quick debriefing, comprised of discussions covering clinical, administrative, logistical, and teamwork findings and recommendations to improve their overall performance. The AAR following the second session is more formal and involves an updated standardized performance metric completed by the instructors based on the team's performance. Each instructor evaluates FST performances in a specific area of the STX as well as critical team concepts. This extensive reconfiguration of the AAR performance metric allows for a more thorough evaluation of the team's competency in the MASCAL STX. Review of these metrics with the team highlights aspects of their performance that still need to be addressed in future training. Compilation and analysis of the evaluations of all rotating FSTs by instructors indicates deficits in the training program, and these deficits are addressed by the ATTD to provide the most effective training possible.

In addition to the instructors' assessments, FST personnel complete standardized self-assessments. Table IV shows the self-evaluations before and after the institutional changes implemented in July 2013. Of particular importance, the team's perception of their communication increased from 24% as “done well” and 6% “needs improvement” to 44% as “done well,” and 4% “needs improvement.” In addition, students perceived that disagreements were resolved to a greater extent after the institutional changes with 83% “in agreement” prior and 99% “in agreement” post.

Team Improvement Promotes Success (TIPS) Scores

Team Improvement Promotes Success (TIPS) Scores

Communication is a major aspect of FST functionality and success in the combat setting. This type of dynamic learning has numerous advantages beyond the main goal of teaching students how to deal with a real MASCAL situation. Critical evaluation of the FST as a whole allows the students to determine the strengths and weaknesses within their group. Group dynamics revealed during the ATTD course will promote effective and cohesive FST function in future combat and other stressful environments.

MOBILE LEARNING MODULES

E-learning (electronic or World Wide Web-based) technology delivers an array of solutions that enhances knowledge and performance. Mobile learning is a subtype of e-learning that uses personal digital assistants to bring the latest information to the point of care, with or without internet access, and allows students to access the information according to their own schedules. Mobile learning presents unique opportunities and challenges in a variety of health care settings, including hospitals, field response, and austere environments.

The use of mobile learning for trauma can provide a solution that standardizes education, and replaces traditional didactic lectures. For units without time to fully train because of short notice, this learning can facilitate just-in-time training before or during movement and communication at the point of care. We demonstrated statistical equivalence between mobile learning modules and less traditional didactic lectures in trauma and critical care for FST members, 10 suggesting that mobile learning modules are an effective means of providing the same knowledge in less time. In addition, the training can be done anytime and anywhere, allowing flexibility in training schedules. Currently, the FSTs have access to a complete trauma mobile learning curriculum, which has replaced many of the previous didactic lectures, freeing time for other training. Each module includes an assessment that is completed to ensure mastery of the material. FST trainees can appropriately use information provided via mobile learning to achieve a higher standard of care. 10 Mobile learning modules, coupled with a structured assessment, have the potential to improve educational experiences in military settings. This includes their use in predeployment training, point-of-care reference in deployed austere environments, and maintenance of competence in-between deployments.

OVERVIEW AND MOVING FORWARD

The FST program at the ATTD has been continuously evolving since 2001. Ranging at times from 1 to 4 weeks in length, the current 2 week program has been stable for the past 10 years. The changes in the Phase 1 didactic and laboratory exercises are discussed above. Other changes in the skills laboratories, anatomy laboratories, and equipment training have also occurred recently with positive feedback from students and staff. Phases 2 and 3 are entirely clinical. Each FST is divided into two teams, consisting of day and night shifts that work for 3 days, have a day off, and then switch shifts. The different teams are integrated with university faculty, house staff, medical students, and nurses to provide care for all incoming patients at the Ryder Trauma Center. During each shift, the clinical performances of the FST personnel are evaluated by ATTD staff. Phase 3 is the culmination of the clinical training at the Ryder Trauma Center. The entire 20–30 person FST is on site together for a 24-hour period and assumes control of all patients arriving at the trauma center with oversight from the hospital and ATTD staff. Although the FST is prepared in 20–30 person groups, their actual deployment time and location may vary from person to person.

Development of a new system that tracks the arrival time of patients to the Ryder Trauma Center and compares it with the completion time of primary and secondary surveys by the FST is ongoing. Incorporation of this system into the program will allow objective evaluation into the efficiency of each rotating team when placed in a trauma situation. Inefficiencies can be identified, and solutions can be proposed. This will be used alongside the current subjective evaluation for a more complete assessment of FST progress and overall performance. Future evaluation as more teams rotate through will also provide new opportunities for further improvement of the curriculum. Further studies focusing on program improvement in the areas of live tissue replacement models, student learning styles and modalities, and integration of various additional classes into the curriculum are also ongoing. Altogether, this ensures that the program remains current on combat clinical knowledge, that it teaches the latest in trauma team theory and in medical education concepts and that U.S. Army FSTs continued to provide the highest quality of combat casualty care for our nation's injured heroes.

Lastly, the future of predeployment trauma training should be a world of the flipped classroom, where the learning occurs before the team arrives, and the time here is all spent on assessment and advanced training. Improved technology-based learning in the hospital stage of training would allow for better real-time evaluation and can be achieved via a web-based system of didactics, videos, examinations, etc. This would be followed by mobile or online sustainment training even while deployed. The dream is that this program can be replicated and used by all services and units of the military, both foreign and domestic partners, and developing nations.

ACKNOWLEDGMENTS

The successful operation of the FST training at the ATTD described in this article has literally involved hundreds of faculty, staff, students, and volunteers. We thank them for their continued efforts for the betterment of the program. This study was supported by the grants no. N140610670 from the Office of Naval Research and no. 09078015 from U.S. Army Medical Research and Materiel Command.