By Fonda R. Bock, USARECApril 26, 2013
ROCHESTER, Minn. (April 26, 2013) -- The scene was chaotic.
On April 13, the Army Reserve's 865th Combat Support Hospital of the 3d Medical Command Deployment Support out of Utica, N.Y., was hit with their first round of casualties since deploying to Iraq. One woman was having a miscarriage, another an asthma attack, a third needed an appendectomy, and a young boy who'd swallowed a small toy was wheezing from a partially blocked airway.
Complicating matters, the medical team had difficulty explaining to the boy's frantic mother, who couldn't speak English and refused to leave her son's bedside, what was wrong with her child and getting her consent to treat him.
The medical team first tried putting a breathing mask on the child, which only shoved the object further down his throat totally blocking his airway causing his oxygen level and pulse to drop. They then initiated CPR and put in a breathing tube, at which time, his vitals rebounded.
This fictitious scenario actually played out at the Mayo Multidisciplinary Simulation Training Center, or MMSTC, in Rochester, Minn., where the 865th Combat Support Hospital, or CSH, was doing a training exercise. The child was actually a mannequin, and a Reserve Soldier played the part of the mother.
By partnering with the Mayo Clinic, the Army Reserve Medical Command, known as AR-MEDCOM, Medical Readiness and Training Command, or MRTC, which conducts premier combat training for medical forces, can now use the center's state-of-the-art simulation facilities to prepare CSH units to treat the kinds of injuries and patient flow found in combat zones.
The 10,000-foot center was set up to reflect a hospital with an emergency room, operating room, intensive care unit, pharmacy, laboratory and X-ray, and a patient administration and tactical operations center. The clinicians used all types of equipment, including anesthesia machines, mechanical ventilators, blood pressures cuffs, defibrillators, perfusion simulators and high-tech mannequins with a heartbeat and a pulse and that can breathe, cry and yell.
"With these patients, they can simulate any wound in the world, change the scenario and tempo and pace of the patients coming in," said Col. Kurt Vonfricken, a thoracic and general surgeon with the 865th CSH. "I had scenarios where I had to be in a couple of places at once. At one point, I had to take on another surgeon's patient. The patient had had a laparoscopy and colon resection, they were bleeding, and I had to come back and operate. Then there was a patient who had a traumatic amputation, one with a knife in his shoulder and one shot through the chest where we had to open the chest, fix the lung and do chest CPR."
He concluded, "Other than having live patients, this is how you train a team. I don't think you can do it any better."
Despite the vast range of medical scenarios the 865th practiced during the intense two-day exercise, this training wasn't designed to improve the clinicians' individual skills, but, rather, to improve their ability to work together as a team in diagnosing and managing patient care.
Col. Joaquin Cortiella, medical director for the MRTC, said good patient care is all about teamwork.
"We are interested in the clinical part, [but] our aim was not to teach trauma here," said Cortiella. "Our intent here is to look at team development in managing the patients' care."
Cortiella said correct medical decisions must be made within the first 15 minutes, because a patient can go from being in a relatively stable condition to an unstable one if decisions are not made quickly enough to prevent whatever is going on.
"It takes coordinated teamwork and good communication to diagnose the condition of not just one patient, but several at the same time, managing multiple patients' care and get them the appropriate treatment within a certain amount of time," expressed Cortiella.
Monitoring the training from observation rooms, expert Army Reserve observer controller/trainers, known as OC/Ts, communicated with Cortiella or computer operators in the control center through headsets, informing the OC/Ts of the type of injuries, related stressors and conditions the clinical teams of the 865th CSH were treating, often changing the status of a patient's condition to mimic the chaos of real-life combat situations.
Learning to deal with and manage the chaos and stressors often experienced in combat hospitals is what this exercise was designed to bring out, said Maj. Mike Harper with the 452nd CSH in Milwaukee and an OC/T for the exercise.
"What we're hoping to achieve, is that by exposing them to those types of [stressors] over and over, that those stressors will just becomes muscle memory in that they've done it so much, they just know what to do without even thinking -- because what they need to be thinking about is how to take care of the patient."
"To me doing this kind of medicine is like playing chess," said Vonfricken, who in his civilian life is a general and thoracic surgeon at Kaleida Health in Buffalo, N.Y. "You've got to think a couple of steps ahead and you have to put things in order. We had a couple of patients here that could have gone to the operating room and you have to put them in order -- who really needs to go now, who can wait an hour and who can wait a day. You have to keep them in your head like that and you have to keep all your colleagues informed."
Honing teamwork is especially important for Army Reserve combat support hospitals whose members don't work with each other on a daily basis and where some members of the team, who operate in support roles, don't work in the medical field in their civilian jobs.
When the MRTC offered Col. Kathie Clark, commander of the 865th CSH, the opportunity to train 50 of her 500 Soldiers at Mayo she jumped at the chance.
"The unique thing about our CSH that's different from the rest of the Army Reserve is that we're so dispersed throughout New York and Pennsylvania, and it's very uncommon that we collectively do exercises like this or in general. So to be able to pull the leaders of seven different locations into one place and have a collective event like this is a great opportunity.
"Through this exercise, we have seen a marked improvement in lessons learned and effective communication. The work now is to implement that in our weekend drills and collective field and annual training exercises."
Nurse anesthetist and 20-year Army Reserve Soldier, Maj. Todd Oller, found the experience extremely useful. Oller, who lives in Bowling Green, Ky., is assigned to the 865th CSH because there are no Reserve medical units anywhere near his home where he can use his medical specialty.
"Not only have I never trained with any of these people, but it's the first time I've actually been in a training environment with a hospital unit," Oller said. "I drill with my home hospital for clinical training. So for me to get an opportunity to train with this unit is great. Now we know who the providers are and who the support players are going to be in our department."
The first steps toward the development of this partnership between the Army Reserve and world renowned Mayo Clinic began in 2011 when Dr. Walter Franz, an Army Reserve colonel in the Medical Corps and a family medicine physician at Mayo, was looking for a place to train members of the 945th Forward Surgical Team, 807th Medical Command Deployment Support, from Fort Snelling, Minn.
"I had a pretty pragmatic mission. I'm commander of the 945th FST and I needed a place to train my Soldiers. So I asked Mayo if it would be okay for my Soldiers to use the simulation center on weekends and nights when no one else was using it, when it wouldn't interfere with the clinic's regular operations, and they said, 'OK.'"
Franz had already given a tour of the center to AR-MEDCOM commanding general, now retired Maj. Gen. Robert J. Kasulke. Impressed with what he observed, Kasulke talked to then MRTC commanding general, Brig. Gen. Bryan R. Kelly, and plans to form a partnership began taking shape.
The 856th became the first military unit to train at Mayo following Franz's experimental training with his FST team, and an Army Reserve pilot program in July.
Kelly, now a major general and commanding general of AR-MEDCOM, considers this type of training essential.
"There had been a gap in the opportunity for combat support hospitals to get this kind of training, the level of fidelity and the type of team cohesion training they're able to develop here," said Kelly, "compared to other opportunities they have across the ARFORGEN cycle."
ARFORGEN, which stands for Army Force Generation, is a cyclic model implemented by the Army to effectively man, equip, and train units to meet continued requirements of combatant commanders. ARFORGEN focuses on training, training support and other limited resources for units as they prepare for operational employment in a timely predictable manner.
Kelly stated that Mayo provides state-of- the-art training for Army Reserve combat support hospitals; the plan is to schedule combat support hospitals for training at Mayo just ahead of a unit's deployment tailoring their specific training to address whatever types of casualties they're likely to experience during their mission.
"Right now, that's where we see this fitting in, but we have the flexibility, once we get a better handle on the learning curve that occurs here, where it might be best to plug them in," said Kelly.
"When I was a combat support hospital commander, in 2008 to 2009, our training consisted of just putting a tag on a mannequin saying 'This person has a broken leg. Now how would you treat it?'" said Col. Danny C. Baldwin, who currently commands the MRTC and is on the brigadier general promotion list. This type of patient play where the simulation can be changed to reflect the outcome of negative patient care is the way-ahead being able to quickly change the patient's condition gives clinicians real perspective -- it's real world."
Baldwin stressed that the training at Mayo will have a significant impact on the outcome of wounded warriors down range.
"We will cut down the mistakes because of the teamwork and effort between the doctors, nurses, paramedics, X-ray and lab technicians. The smoother they work together, [the more] they save time, which cuts down on mistakes and saves lives," said Baldwin.
This exercise also provided the U.S. Army Recruiting Command with fertile ground for finding subject matter experts. Ten of the clinicians offered to work in the exhibit booths at medical conventions, telling their Army story and promoting careers in Army medicine to potential applicants and influencers.
Capt. Jeffrey Engle, officer in charge of the Bloomington, Minn., Medical Recruiting Center, plans to use future Army Reserve CSH training at Mayo as an outreach event, inviting distinguished guests, influencers and potential applicants interested in Army medicine to observe and interact with Army Reserve Soldiers.