TY - JOUR
AU - PhD, Kenneth G. Proctor,
AB - 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). TABLE I. Didactic Curriculum at the ATTC Day 1   1. Introduction/Agenda/Prerotation Survey   2. ATTC Overview/Safety Brief   3. Training Area/Facility Tour   4. Books/Equipment Issue   5. Command Brief   6. Preservation of Remains   7. Intro to Tactical Combat Casualty Care   8. Hypothermia Prevention   9. Patient Transportation Concepts   10. Wound Packing and Hemostatic Agents   11. Limb Tourniquets and Junctional Tourniquets   12. History of U.S. Army FST and ATTC   13. Intro to Clinical Practice Guidelines  Day 2   1. Critical Team Concepts   2. Critical Team Concepts Laboratory   3. Trauma Teamwork System   4. Trauma Triage   5. STX Prebrief/Orientation   6. Trauma OR Seminar   7. Trauma Simulation Laboratory   8. Surgical Airway/Chest Trauma   9. Airway Management/Military Ventilators   10. Splinting, Pelvic Binders, Field Traction Splints  Day 3   1. Physiologic Access and Exposure (Laboratory)   2. Combat Anesthesia Techniques and Concepts   3. Trauma Resuscitation Unit and OR Orientation   4. Combat Extremity Surgery Course (Part I)   5. Staff Roles/Evacuation/Detainee Operations/Med Plans   6. ASSET Course/Ocular and Cranial Trauma  Day 4   1. Combat Extremity Surgery Course (Part II)   2. OR/TRU Orientation   3. Physiology Laboratory   4. Operative Orthopedics (Laboratory)   5. STX Mission Brief   6. STX Prebrief/Orientation   7. Orientation to Facility/Setup   8. STX Session 1  Day 5   1. STX Session 2   2. STX After Action Review  Day 1   1. Introduction/Agenda/Prerotation Survey   2. ATTC Overview/Safety Brief   3. Training Area/Facility Tour   4. Books/Equipment Issue   5. Command Brief   6. Preservation of Remains   7. Intro to Tactical Combat Casualty Care   8. Hypothermia Prevention   9. Patient Transportation Concepts   10. Wound Packing and Hemostatic Agents   11. Limb Tourniquets and Junctional Tourniquets   12. History of U.S. Army FST and ATTC   13. Intro to Clinical Practice Guidelines  Day 2   1. Critical Team Concepts   2. Critical Team Concepts Laboratory   3. Trauma Teamwork System   4. Trauma Triage   5. STX Prebrief/Orientation   6. Trauma OR Seminar   7. Trauma Simulation Laboratory   8. Surgical Airway/Chest Trauma   9. Airway Management/Military Ventilators   10. Splinting, Pelvic Binders, Field Traction Splints  Day 3   1. Physiologic Access and Exposure (Laboratory)   2. Combat Anesthesia Techniques and Concepts   3. Trauma Resuscitation Unit and OR Orientation   4. Combat Extremity Surgery Course (Part I)   5. Staff Roles/Evacuation/Detainee Operations/Med Plans   6. ASSET Course/Ocular and Cranial Trauma  Day 4   1. Combat Extremity Surgery Course (Part II)   2. OR/TRU Orientation   3. Physiology Laboratory   4. Operative Orthopedics (Laboratory)   5. STX Mission Brief   6. STX Prebrief/Orientation   7. Orientation to Facility/Setup   8. STX Session 1  Day 5   1. STX Session 2   2. STX After Action Review  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. View Large TABLE I. Didactic Curriculum at the ATTC Day 1   1. Introduction/Agenda/Prerotation Survey   2. ATTC Overview/Safety Brief   3. Training Area/Facility Tour   4. Books/Equipment Issue   5. Command Brief   6. Preservation of Remains   7. Intro to Tactical Combat Casualty Care   8. Hypothermia Prevention   9. Patient Transportation Concepts   10. Wound Packing and Hemostatic Agents   11. Limb Tourniquets and Junctional Tourniquets   12. History of U.S. Army FST and ATTC   13. Intro to Clinical Practice Guidelines  Day 2   1. Critical Team Concepts   2. Critical Team Concepts Laboratory   3. Trauma Teamwork System   4. Trauma Triage   5. STX Prebrief/Orientation   6. Trauma OR Seminar   7. Trauma Simulation Laboratory   8. Surgical Airway/Chest Trauma   9. Airway Management/Military Ventilators   10. Splinting, Pelvic Binders, Field Traction Splints  Day 3   1. Physiologic Access and Exposure (Laboratory)   2. Combat Anesthesia Techniques and Concepts   3. Trauma Resuscitation Unit and OR Orientation   4. Combat Extremity Surgery Course (Part I)   5. Staff Roles/Evacuation/Detainee Operations/Med Plans   6. ASSET Course/Ocular and Cranial Trauma  Day 4   1. Combat Extremity Surgery Course (Part II)   2. OR/TRU Orientation   3. Physiology Laboratory   4. Operative Orthopedics (Laboratory)   5. STX Mission Brief   6. STX Prebrief/Orientation   7. Orientation to Facility/Setup   8. STX Session 1  Day 5   1. STX Session 2   2. STX After Action Review  Day 1   1. Introduction/Agenda/Prerotation Survey   2. ATTC Overview/Safety Brief   3. Training Area/Facility Tour   4. Books/Equipment Issue   5. Command Brief   6. Preservation of Remains   7. Intro to Tactical Combat Casualty Care   8. Hypothermia Prevention   9. Patient Transportation Concepts   10. Wound Packing and Hemostatic Agents   11. Limb Tourniquets and Junctional Tourniquets   12. History of U.S. Army FST and ATTC   13. Intro to Clinical Practice Guidelines  Day 2   1. Critical Team Concepts   2. Critical Team Concepts Laboratory   3. Trauma Teamwork System   4. Trauma Triage   5. STX Prebrief/Orientation   6. Trauma OR Seminar   7. Trauma Simulation Laboratory   8. Surgical Airway/Chest Trauma   9. Airway Management/Military Ventilators   10. Splinting, Pelvic Binders, Field Traction Splints  Day 3   1. Physiologic Access and Exposure (Laboratory)   2. Combat Anesthesia Techniques and Concepts   3. Trauma Resuscitation Unit and OR Orientation   4. Combat Extremity Surgery Course (Part I)   5. Staff Roles/Evacuation/Detainee Operations/Med Plans   6. ASSET Course/Ocular and Cranial Trauma  Day 4   1. Combat Extremity Surgery Course (Part II)   2. OR/TRU Orientation   3. Physiology Laboratory   4. Operative Orthopedics (Laboratory)   5. STX Mission Brief   6. STX Prebrief/Orientation   7. Orientation to Facility/Setup   8. STX Session 1  Day 5   1. STX Session 2   2. STX After Action Review  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. View Large 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. TABLE II. Phase 1 Before and After Institutional Changes Preinstitutional Change (Before June, 2013)  Postinstitutional Change (After June, 2013)  Lectures  Lectures Using Current DoD CPGs and TCCC Guidelines; FST Tactical Mission Briefs  Single Team-Building Exercise  Multiple Team-Building Exercises and Leadership-Building Opportunities Built Into Curriculum  Clinical Skills Exercises  Updated Clinical Skills Exercises Using Current Hemostatic Agents, Limb Tourniquets, Junctional Tourniquets, Current FST Equipment and Supplies, and Enhancement to Previous Cadaver Laboratories  Standard ACS ASSET Course  Enhanced ASSET Course With Lateral Canthotomy, Burr Holes, and Carniotomoy  Abbreviated Combat Extremity Surgery Course  Updated-Abbreviated Combat Extremity Surgery Course  MASCAL—1 Session, 6 Live Tissue Supplemented With Medical Manikins or Patient Actors  MASCAL—2 Sessions, Up to 8 Live Tissue Supplemented With Manikins, Low-Fidelity Simulators, High-Fidelity Simulators, Surgical Bodysuits, and Standardized Patients  MASCAL Live Tissue Injuries Varied From Each Rotation  MASCAL Live Tissue Injuries Strictly Adhere to Standardized Injury Protocol  Traditional MASCAL Evaluation Metric  Updated MASCAL Evaluation Metric  No Ultrasound Training in Curriculum  FAST and eFAST Refresher Class; Intro to FATE Class  Preinstitutional Change (Before June, 2013)  Postinstitutional Change (After June, 2013)  Lectures  Lectures Using Current DoD CPGs and TCCC Guidelines; FST Tactical Mission Briefs  Single Team-Building Exercise  Multiple Team-Building Exercises and Leadership-Building Opportunities Built Into Curriculum  Clinical Skills Exercises  Updated Clinical Skills Exercises Using Current Hemostatic Agents, Limb Tourniquets, Junctional Tourniquets, Current FST Equipment and Supplies, and Enhancement to Previous Cadaver Laboratories  Standard ACS ASSET Course  Enhanced ASSET Course With Lateral Canthotomy, Burr Holes, and Carniotomoy  Abbreviated Combat Extremity Surgery Course  Updated-Abbreviated Combat Extremity Surgery Course  MASCAL—1 Session, 6 Live Tissue Supplemented With Medical Manikins or Patient Actors  MASCAL—2 Sessions, Up to 8 Live Tissue Supplemented With Manikins, Low-Fidelity Simulators, High-Fidelity Simulators, Surgical Bodysuits, and Standardized Patients  MASCAL Live Tissue Injuries Varied From Each Rotation  MASCAL Live Tissue Injuries Strictly Adhere to Standardized Injury Protocol  Traditional MASCAL Evaluation Metric  Updated MASCAL Evaluation Metric  No Ultrasound Training in Curriculum  FAST and eFAST Refresher Class; Intro to FATE Class  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. View Large TABLE II. Phase 1 Before and After Institutional Changes Preinstitutional Change (Before June, 2013)  Postinstitutional Change (After June, 2013)  Lectures  Lectures Using Current DoD CPGs and TCCC Guidelines; FST Tactical Mission Briefs  Single Team-Building Exercise  Multiple Team-Building Exercises and Leadership-Building Opportunities Built Into Curriculum  Clinical Skills Exercises  Updated Clinical Skills Exercises Using Current Hemostatic Agents, Limb Tourniquets, Junctional Tourniquets, Current FST Equipment and Supplies, and Enhancement to Previous Cadaver Laboratories  Standard ACS ASSET Course  Enhanced ASSET Course With Lateral Canthotomy, Burr Holes, and Carniotomoy  Abbreviated Combat Extremity Surgery Course  Updated-Abbreviated Combat Extremity Surgery Course  MASCAL—1 Session, 6 Live Tissue Supplemented With Medical Manikins or Patient Actors  MASCAL—2 Sessions, Up to 8 Live Tissue Supplemented With Manikins, Low-Fidelity Simulators, High-Fidelity Simulators, Surgical Bodysuits, and Standardized Patients  MASCAL Live Tissue Injuries Varied From Each Rotation  MASCAL Live Tissue Injuries Strictly Adhere to Standardized Injury Protocol  Traditional MASCAL Evaluation Metric  Updated MASCAL Evaluation Metric  No Ultrasound Training in Curriculum  FAST and eFAST Refresher Class; Intro to FATE Class  Preinstitutional Change (Before June, 2013)  Postinstitutional Change (After June, 2013)  Lectures  Lectures Using Current DoD CPGs and TCCC Guidelines; FST Tactical Mission Briefs  Single Team-Building Exercise  Multiple Team-Building Exercises and Leadership-Building Opportunities Built Into Curriculum  Clinical Skills Exercises  Updated Clinical Skills Exercises Using Current Hemostatic Agents, Limb Tourniquets, Junctional Tourniquets, Current FST Equipment and Supplies, and Enhancement to Previous Cadaver Laboratories  Standard ACS ASSET Course  Enhanced ASSET Course With Lateral Canthotomy, Burr Holes, and Carniotomoy  Abbreviated Combat Extremity Surgery Course  Updated-Abbreviated Combat Extremity Surgery Course  MASCAL—1 Session, 6 Live Tissue Supplemented With Medical Manikins or Patient Actors  MASCAL—2 Sessions, Up to 8 Live Tissue Supplemented With Manikins, Low-Fidelity Simulators, High-Fidelity Simulators, Surgical Bodysuits, and Standardized Patients  MASCAL Live Tissue Injuries Varied From Each Rotation  MASCAL Live Tissue Injuries Strictly Adhere to Standardized Injury Protocol  Traditional MASCAL Evaluation Metric  Updated MASCAL Evaluation Metric  No Ultrasound Training in Curriculum  FAST and eFAST Refresher Class; Intro to FATE Class  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. View Large 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. TABLE III. Live Tissue vs. Body Suit Simulators Live Tissue  Body Suits  Advantages  Disadvantages  Advantages  Disadvantages  Incomparable Authentic Injuries  Variable Porcine Physiology  Instructor Control of Outcomes  Lack of Actual and Realistic Injuries  Real tissue: Bleeds and Holds Sutures Like Human Tissue  Less Instructor Control of Encounter  Ability to Alter Complexity of Encounter  Less Variability in Injures  Instructors Have More Variability in Choices for Injury  Lack of Human Element  Human Authenticity via Microphones for Instructors  Does Not Behave Like Normal Tissue  Better Tactile Sensation  Less Standardization  Standardized Encounters  Poor Tactile Sensation  Injuries Appear More Realistic  Not Anatomically Accurate  Anatomically More Accurate  Less Emotionally Stressful Since Simulator is Synthetic  Physiology Auto Adjust to Real Condition  May Expire Before Training Goals Have Been Met  Only Expires When Instructors Decide to Do So    Element of Emotional Stress    Instructor Controlled Physiology    Live Tissue  Body Suits  Advantages  Disadvantages  Advantages  Disadvantages  Incomparable Authentic Injuries  Variable Porcine Physiology  Instructor Control of Outcomes  Lack of Actual and Realistic Injuries  Real tissue: Bleeds and Holds Sutures Like Human Tissue  Less Instructor Control of Encounter  Ability to Alter Complexity of Encounter  Less Variability in Injures  Instructors Have More Variability in Choices for Injury  Lack of Human Element  Human Authenticity via Microphones for Instructors  Does Not Behave Like Normal Tissue  Better Tactile Sensation  Less Standardization  Standardized Encounters  Poor Tactile Sensation  Injuries Appear More Realistic  Not Anatomically Accurate  Anatomically More Accurate  Less Emotionally Stressful Since Simulator is Synthetic  Physiology Auto Adjust to Real Condition  May Expire Before Training Goals Have Been Met  Only Expires When Instructors Decide to Do So    Element of Emotional Stress    Instructor Controlled Physiology    View Large TABLE III. Live Tissue vs. Body Suit Simulators Live Tissue  Body Suits  Advantages  Disadvantages  Advantages  Disadvantages  Incomparable Authentic Injuries  Variable Porcine Physiology  Instructor Control of Outcomes  Lack of Actual and Realistic Injuries  Real tissue: Bleeds and Holds Sutures Like Human Tissue  Less Instructor Control of Encounter  Ability to Alter Complexity of Encounter  Less Variability in Injures  Instructors Have More Variability in Choices for Injury  Lack of Human Element  Human Authenticity via Microphones for Instructors  Does Not Behave Like Normal Tissue  Better Tactile Sensation  Less Standardization  Standardized Encounters  Poor Tactile Sensation  Injuries Appear More Realistic  Not Anatomically Accurate  Anatomically More Accurate  Less Emotionally Stressful Since Simulator is Synthetic  Physiology Auto Adjust to Real Condition  May Expire Before Training Goals Have Been Met  Only Expires When Instructors Decide to Do So    Element of Emotional Stress    Instructor Controlled Physiology    Live Tissue  Body Suits  Advantages  Disadvantages  Advantages  Disadvantages  Incomparable Authentic Injuries  Variable Porcine Physiology  Instructor Control of Outcomes  Lack of Actual and Realistic Injuries  Real tissue: Bleeds and Holds Sutures Like Human Tissue  Less Instructor Control of Encounter  Ability to Alter Complexity of Encounter  Less Variability in Injures  Instructors Have More Variability in Choices for Injury  Lack of Human Element  Human Authenticity via Microphones for Instructors  Does Not Behave Like Normal Tissue  Better Tactile Sensation  Less Standardization  Standardized Encounters  Poor Tactile Sensation  Injuries Appear More Realistic  Not Anatomically Accurate  Anatomically More Accurate  Less Emotionally Stressful Since Simulator is Synthetic  Physiology Auto Adjust to Real Condition  May Expire Before Training Goals Have Been Met  Only Expires When Instructors Decide to Do So    Element of Emotional Stress    Instructor Controlled Physiology    View Large 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. TABLE IV. Team Improvement Promotes Success (TIPS) Scores Standardized Self-Assessment Tool: TIPS Card Before June 2013 → After June 2013     Strongly Agree (%)  Agree (%)  Neutral (%)  Disagree (%)  Strongly Disagree (%)  1. The Patient Was the Most Important Person  74 → 69  19 → 24  3 → 0  0 → 1  4 → 6  2. The Team Planned and Rehearsed Effectively  32 → 26  58 → 70  7 → 2  3 → 1  0 → 1  3. The Team Worked in a Way That Indicated Individuals Knew and Executed Their Roles  42 → 41  53 → 54  2 → 3  3 → 2  0 → 0  4. Disagreements Between Team Members Were Resolved Respectfully Without Losing Patient Focus  57 → 57  26 → 42  14 → 0  3 → 1  0 → 0  5. There Was Effective Situational Monitoring (Overwatch) to Ensure Task Completion  31 → 26  57 → 62  11 → 4  0 → 8  1 → 0  6. Changes and Problems Throughout the Event Were Communicated to Team Members  27 → 25  57 → 52  12 → 7  4 → 16  0 → 0       Planning (%)  Rehearsal (%)  Communication (%)  Roles (%)  Leadership (%)  Overwatch (%)  Prioritization (%)  Handoffs (%)  Adaptability (%)  Safety (%)    7. List 3 Things We Did Well  4 → 3  25 → 9  24 → 44    8 → 4  3 → 4  5 → 6  3 → 4  12 → 14  9 → 10  7 → 2  8. List 3 Things We Need to Improve  3 → 9  0 → 1  6 → 4  30 → 24  10 → 10  2 → 3  20 → 14  1 → 3  27 → 24  1 → 8  Standardized Self-Assessment Tool: TIPS Card Before June 2013 → After June 2013     Strongly Agree (%)  Agree (%)  Neutral (%)  Disagree (%)  Strongly Disagree (%)  1. The Patient Was the Most Important Person  74 → 69  19 → 24  3 → 0  0 → 1  4 → 6  2. The Team Planned and Rehearsed Effectively  32 → 26  58 → 70  7 → 2  3 → 1  0 → 1  3. The Team Worked in a Way That Indicated Individuals Knew and Executed Their Roles  42 → 41  53 → 54  2 → 3  3 → 2  0 → 0  4. Disagreements Between Team Members Were Resolved Respectfully Without Losing Patient Focus  57 → 57  26 → 42  14 → 0  3 → 1  0 → 0  5. There Was Effective Situational Monitoring (Overwatch) to Ensure Task Completion  31 → 26  57 → 62  11 → 4  0 → 8  1 → 0  6. Changes and Problems Throughout the Event Were Communicated to Team Members  27 → 25  57 → 52  12 → 7  4 → 16  0 → 0       Planning (%)  Rehearsal (%)  Communication (%)  Roles (%)  Leadership (%)  Overwatch (%)  Prioritization (%)  Handoffs (%)  Adaptability (%)  Safety (%)    7. List 3 Things We Did Well  4 → 3  25 → 9  24 → 44    8 → 4  3 → 4  5 → 6  3 → 4  12 → 14  9 → 10  7 → 2  8. List 3 Things We Need to Improve  3 → 9  0 → 1  6 → 4  30 → 24  10 → 10  2 → 3  20 → 14  1 → 3  27 → 24  1 → 8  View Large TABLE IV. Team Improvement Promotes Success (TIPS) Scores Standardized Self-Assessment Tool: TIPS Card Before June 2013 → After June 2013     Strongly Agree (%)  Agree (%)  Neutral (%)  Disagree (%)  Strongly Disagree (%)  1. The Patient Was the Most Important Person  74 → 69  19 → 24  3 → 0  0 → 1  4 → 6  2. The Team Planned and Rehearsed Effectively  32 → 26  58 → 70  7 → 2  3 → 1  0 → 1  3. The Team Worked in a Way That Indicated Individuals Knew and Executed Their Roles  42 → 41  53 → 54  2 → 3  3 → 2  0 → 0  4. Disagreements Between Team Members Were Resolved Respectfully Without Losing Patient Focus  57 → 57  26 → 42  14 → 0  3 → 1  0 → 0  5. There Was Effective Situational Monitoring (Overwatch) to Ensure Task Completion  31 → 26  57 → 62  11 → 4  0 → 8  1 → 0  6. Changes and Problems Throughout the Event Were Communicated to Team Members  27 → 25  57 → 52  12 → 7  4 → 16  0 → 0       Planning (%)  Rehearsal (%)  Communication (%)  Roles (%)  Leadership (%)  Overwatch (%)  Prioritization (%)  Handoffs (%)  Adaptability (%)  Safety (%)    7. List 3 Things We Did Well  4 → 3  25 → 9  24 → 44    8 → 4  3 → 4  5 → 6  3 → 4  12 → 14  9 → 10  7 → 2  8. List 3 Things We Need to Improve  3 → 9  0 → 1  6 → 4  30 → 24  10 → 10  2 → 3  20 → 14  1 → 3  27 → 24  1 → 8  Standardized Self-Assessment Tool: TIPS Card Before June 2013 → After June 2013     Strongly Agree (%)  Agree (%)  Neutral (%)  Disagree (%)  Strongly Disagree (%)  1. The Patient Was the Most Important Person  74 → 69  19 → 24  3 → 0  0 → 1  4 → 6  2. The Team Planned and Rehearsed Effectively  32 → 26  58 → 70  7 → 2  3 → 1  0 → 1  3. The Team Worked in a Way That Indicated Individuals Knew and Executed Their Roles  42 → 41  53 → 54  2 → 3  3 → 2  0 → 0  4. Disagreements Between Team Members Were Resolved Respectfully Without Losing Patient Focus  57 → 57  26 → 42  14 → 0  3 → 1  0 → 0  5. There Was Effective Situational Monitoring (Overwatch) to Ensure Task Completion  31 → 26  57 → 62  11 → 4  0 → 8  1 → 0  6. Changes and Problems Throughout the Event Were Communicated to Team Members  27 → 25  57 → 52  12 → 7  4 → 16  0 → 0       Planning (%)  Rehearsal (%)  Communication (%)  Roles (%)  Leadership (%)  Overwatch (%)  Prioritization (%)  Handoffs (%)  Adaptability (%)  Safety (%)    7. List 3 Things We Did Well  4 → 3  25 → 9  24 → 44    8 → 4  3 → 4  5 → 6  3 → 4  12 → 14  9 → 10  7 → 2  8. List 3 Things We Need to Improve  3 → 9  0 → 1  6 → 4  30 → 24  10 → 10  2 → 3  20 → 14  1 → 3  27 → 24  1 → 8  View Large 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. REFERENCES 1. Thorson CM, Dubose JJ, Rhee P, et al.   Military trauma training at civilian centers: a decade of advancements. J Trauma Acute Care Surg  2012; 73( 6 Suppl 5): S483– 9. Google Scholar CrossRef Search ADS PubMed  2. Pereira BM, Ryan ML, Ogilvie MP, et al.   Predeployment mass casualty and clinical trauma training for US Army forward surgical teams. J Craniofac Surg  2010; 21( 4): 982– 6. Google Scholar CrossRef Search ADS PubMed  3. King DR, Patel MB, Feinstein AJ, Earle SA, Topp RF, Proctor KG Simulation training for a mass casualty incident: two-year experience at the Army Trauma Training Center. J Trauma Acute Care Surg  2006; 61( 4): 943– 8. Google Scholar CrossRef Search ADS   4. Capella J, Smith S, Philp A, et al.   Teamwork training improves the clinical care of trauma patients. J Surg Educ  2010; 67( 6): 439– 43. Google Scholar CrossRef Search ADS PubMed  5. Steinemann S, Berg B, Skinner A, et al.   In situ, multidisciplinary, simulation-based teamwork training improves early trauma care. J Surg Res  2011; 68( 6): 472– 7. 6. Lineberry M, Bryan E, Brush T, et al.   Measurement and training of TeamSTEPPS dimensions using the Medical Team Performance Assessment Tool. Jt Comm J Qual Patient Saf  2013; 39( 2): 89– 95. Google Scholar CrossRef Search ADS PubMed  7. Kolb DA Experiential Learning: Experience as the Source of Learning and Development , xiii, 256 p. Englewood Cliffs, NJ, Prentice-Hall, 1984. 8. Norcini JJ Work based assessment. BMJ  2003; 326( 7392): 753– 5. Google Scholar CrossRef Search ADS PubMed  9. Eastridge BJ, Mabry RL, Seguin P, et al.   Death on the battlefield (2001–2011): implications for the future of combat casualty care. J Trauma Acute Care Surg  2012; 73( 6 Suppl 5): S431– 7. Google Scholar CrossRef Search ADS PubMed  10. Schulman CI, Garcia GD, Wyckoff MM, Duncan RC, Withum KF, Graygo J Mobile learning module improves knowledge of medical shock for forward surgical team members. Mil Med  2012; 177( 11): 1316– 21. Google Scholar CrossRef Search ADS PubMed  Reprint & Copyright © Association of Military Surgeons of the U.S.
TI - Recent Advances in Forward Surgical Team Training at the U.S. Army Trauma Training Department
JO - Military Medicine
DO - 10.7205/MILMED-D-15-00084
DA - 2016-06-01
UR - https://www.deepdyve.com/lp/oxford-university-press/recent-advances-in-forward-surgical-team-training-at-the-u-s-army-BUWoCI2JRF
SP - 553
EP - 559
VL - 181
IS - 6
DP - DeepDyve
ER -