Joint Base San Antonio, Texas -A new Directorate of Simulation (DOS) was established at the Health Readiness Center of Excellence (HRCoE). The directorate is charged with coordinating and incorporating all medical simulation efforts across the full spectrum of medical and military operations. Last week, key stakeholders were brought together for a Strategic Medical Simulation Synchronization Summit to begin developing relationships and unity of effort.

At the summit, Maj. Gen. Patrick D. Sargent, the HRCoE Commander, provided a vision of the future and likened the challenge before them as our "go to the moon" opportunity. He told the audience that the audacious goal wasn't ensuring a person made it into space and back alive. The audacious goal was to ensure every soldier, sailor, airmen and marine makes it into combat and back alive. Simply put, the goal is zero preventable deaths on the battlefield.

INTRODUCING DOS
Since it was assembled on February 12, DOS leadership has worked hard to establish themselves as the central focal point for Army Medical Modeling and Simulation (MMS) initiatives with the responsibility for the development and execution of medical simulation (MEDSIM) training and the emerging medical simulated training environment (mSTE).

They have already begun to leverage internal stakeholders like Program Executive Officer for Simulation, Training and Instrumentation (PEO-STRI), STE Cross Functional Team (CFT), U.S. Army Futures Command and the Defense Medicine Modeling and Simulation Office (DMMSO) to help outline medical requirements. Col. Wes Clarkson, HRCoE's DOS Director said some early, quick wins include working with PEO-STRI to add medical scenarios and vignettes to the Maneuver Center of Excellence's Soldier, Squad Virtual Trainer and Integrated Visual Augmentation System (SSVT IVAS). DOS also provided specifications, contents, functions and usages for the Individual First Aid Kit and Combat Lifesaver Bag for modeling use in the SSVT IVAS project.

Within just 93 days of formation, having already made those and other significant contributions to the seemingly small world of medical simulations, HRCoE DOS brought together nearly 50 medical, simulation, training, and educations experts during a working session called the Strategic Medical Simulation Synchronization Summit (SMS3). There were subject matter experts in attendance from PEO-STRI, DMMSO, Brooke Army Medical Center, U.S. Army Futures Command and many other relevant external and HRCoE internal organizations.

The two-day event, hosted by the HRCoE on Joint Base San Antonio-Fort Sam Houston May 15 and 16, was the first of many future synchronization events that will grow in both size and scope. The overall purpose of the event was to ensure representation from as many subject matter experts as possible, orient DOS to the stakeholders' missions and vice versa, to clearly outline and define the goals set by the command, and to solicit the collaboration and cooperation that is needed to be successful in this arduous endeavor.

CHALLENGE ISSUED
Sargent noted a relative parallel with President John F. Kennedy's desire to have a man land on the moon, with some of the lofty goals and marked sense of urgency he set for DOS.

May 25th, 1961, nearly 58 years to the day of this first summit hosted by HRCoE's DOS, President John F. Kennedy announced, before a special joint session of Congress, his ambitious goal of sending an American safely to the Moon before the end of the decade.

Later, in his "We choose to go to the Moon" speech at Rice University in 1962, Kennedy said:
We choose to go to the Moon in this decade and do the other things, not because they are easy, but because they are hard; because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one we intend to win, and the others, too.

Sargent told attendees, "Today, May 16, 2019, is the day the Health Readiness Center of Excellence announces our audacious goal: we are unwilling to postpone our strategic pivot to fundamentally transform and exponentially improve the way we train to save lives on the battlefield through better use of 21st century technology. This is our shot at the moon, and we want to take all of you with us."

THE PROBLEM
During comments to open the event, James Aplin, Deputy Director, DOS, highlighted some of the challenges DOS faces as they forge ahead with this audacious plan. He said, "Having a centralized directorate will mitigate the current Army medical simulation environment that consists of fragmented, independent and isolated pockets of non-standardized training scattered across the operational Army; this will allow us to move further, faster." The summit was to be an initial step in that effort.

Aplin, who also served as the 12th MEDCOM Command Sergeant Major, leads the US Army Emergency Medical Services Program Management Division (EMS). They serve as the project management division for the Medical Simulation Training Centers (MSTCs).

MSTCs are a relevant example to highlight the complex environment DOS must operate in if they want to standardize medical sustainment training. There are 21 MSTC locations inside and outside of the continental US.

Though the MSTC program of record is the responsibility of EMS, and now DOS, the MSTC facility, as a physical structure, falls under the Installation Management Command per AR 350-52. MSTC funding is also accomplished through various entities at the operational and installation level as well as through PEO-STRI contracts and EMS.

Another point of friction with the MSTC is that the program of record does not include manning the MSTCs, so responsibility falls to garrison-level units to ensure the centers are properly staffed. Additionally, MSTC set-up and training scenarios are not standardized among locations, nor is MSTC sustainment training required across the enterprise; how much the MSTC is staffed and used depends heavily on the operational unit commander's priorities. Consequently, there are vast differences in training outcomes between each facility.

Similar to the MSTCs, the Army's Central Simulation Committee (CSC) is a MEDSIM capability that is currently fielded at ten Army medical treatment facilities (MTFs). These CSC sites are accredited and strategically aligned with the Army's Graduate Medical Education (GME) training programs and work parallel to MTF education departments. Though the primary mission of the CSC is to support GME MEDSIM training needs, they have expanded their mission to training non-GME students and medical professionals within the MTFs.

Lt. Col. Maria Molina, Chief of the CSC, discussed the Army simulation structure and how she sees DOS fitting into that. She also provided attendees with a CSC overview and included an explanation of the overlapping training mission and deviation to non-GME related training. Molina, an obstetrics and gynecology physician assigned to Brooke Army Medical Center at JBSA, said, "It would be ideal if DOS could be the centralized button to help Army medical simulation be a little more efficient and less disjointed than it has been."

Funded by MEDCOM until October 2019 when their funding will come from the Defense Health Agency (DHA), there are 10 Army GME hospitals with applicable simulators, which also perform non-GME training that overlap with sustainment training done at the CoE, the MSTCs and the units. "We have been trying to standardize GME curriculum so that we can start looking at accreditation as a whole instead of seeking accreditation for each individual site," explained Molina.

In contrast to the MSTC program, the CSC has its own budget and funds all 10 GME locations to include equipment, consumables, an administrator and a simulator operator for each site.

FORGING THE WAY AHEAD
In addition to receiving formal presentations on overlapping functions, the working group allowed the diverse group of medical simulation experts to network, connect names with faces and begin the cooperation that will be needed to navigate the complicated process of standardizing training of existing capabilities, acquiring new, more advanced STE capabilities and eliminating duplication of effort and inefficiencies that has plagued the field to date.

Clarkson, a cardiologist by trade said, "This is why we wanted to conduct this summit. Everyone in this room can help us determine how we can rehearse relevant medical functions and tasks in a simulated environment, with opportunity for repetition, to ensure a Ready Medical Force and increase survivability."

On day two of the event, Sargent, who has commanded the HRCoE since June 2018, told the audience that it is not enough for doctors to be fully trained because eliminating preventable deaths on the battlefield depends on ensuring the entire medical team, across the continuum of care, is fully trained. He reiterated that proficiency is assured through standard Individual Critical Task Lists (ICTLs) which lead to a capable team proficient in supported collective tasks.

Sargent, a medical evacuation pilot, described his vision for ICTLs and the ability to effectively evaluate the proficiency of medical soldiers upon arrival to each operational assignment. The concept, similar to an aircrew training program, would evaluate readiness through a series of written, oral and practical evaluations upon arrival to an operational assignment.

"It's not enough to call Soldiers and providers well trained if we do not ensure they maintain their proficiency when they go to their follow-on assignment or MTF," he said.

Sargent sees the opportunity to gain true proficiencies in medical competencies through advances in STE, as a vital element in any future operational medicine training program. Currently, pre-deploying individuals or medical teams are provided optional hands-on Tactical Combat Casualty Care (TC3) training as a three to five-day immersive refresher before they are considered trained and prepared for the rigor of combat medicine.

These courses, like Tactical Combat Medical Care (TCMC) or the Brigade Combat Team Trauma Training (BCT3), are classified by graduates as some of the most relevant training they could receive prior to a deployment. Still, he says, Army medicine should go further.

"Can you imagine allowing a new pilot to spend a few days in a helicopter trying to maintain a steady, 10-foot hover and then check them off as fully trained and ready for flight on day five?" asked Sargent. "Let's stop justifying what we had to do in the past, purely out of necessity, and focus on establishing new standards through innovative methods to accomplish standardized, effective training methods and standards with an operational medicine focus that yields proficiency over familiarization."

CHALLENGE ACCEPTED
To close out the summit, Jay Harmon, Deputy to the Commanding General, HRCoE, who has direct oversight over the DOS program, thanked attendees for contributing their valuable time, being transparent and sharing their knowledge and skills with the team.

Harmon continued, "The CG laid out his vision to the CoE and his challenge to you today. It's now our job, together, to operationalize that vision."

Harmon outlined how the next steps after the SMS3 are to formalize the team and add anyone else who should be in the room, establish a timeline and then create a plan of action complete with milestones and priorities. He said the CG believes DOS is starting out behind the power curve and has lost the strategic advantage when it comes to medical simulations.

"As the boss said, we missed the train at the first station, but we are going to catch up and get on the train at the next station," said Harmon.

Subject matter experts at this first SMS3 were encouraged to submit after action review comments complete with names or entities who should be included in any future assembly. Many in the group committed to come together during at least two more synchronization events in May: the May 22-23 Military Simulation Summit hosted by STE CFT and the May 29-30 Medical Industry Day hosted by PEO STRI.

Ruben Garza, Chief, Defense Medical Modeling and Simulation Office (DMMSO), Education and Training J7, Defense Health Agency, believes seeking buy-in from MMS Stakeholders is key to this team concept and was the best thing about the summit.

Garza said, "The summit was perfect. Together we can leverage best practices across the Army, Navy, Air Force and Marines to improve communication, collaboration, and coordination for cost efficiencies and improve medical training at all levels."

The next Strategic Medical Simulation Synchronization Summit is scheduled for September 25 and 26, 2019. Contact the Directorate of Simulations at 210-221-0837 for more information.