Chief of Medical ModernizationAir Education Training Command

Colonel Storms was interviewed by Group Editor Marty Kauchak. The interview addressed a wide range of simulation and training topics pertaining to the U.S. Air Force.

Interview

MedSIM: Colonel, good afternoon and thanks for taking time to speak with MEdSIM. Let’s first discuss your responsibilities at AETC.

Colonel Storms: Our responsibilities are both for Air Education Training Command and in the medical modeling and simulation world. AETC actually has Air Force-wide responsibility for medical M&S activity. The Air Force medical M&S training program falls within the purview of the AETC Surgeon [Colonel Margaret B. Matarese] and I am her action officer for that..

MEdSIM: Describe how Air Force medical training has responded to lessons learned from the wars in Iraq and Afghanistan.

CS: There are two aspects to that.

First, are the overall changes in medical training at large. With the advent of our Tri-Care partners coming to offer some portion of the care previously provided in military treatment facilities (MTFs), what we have seen in the last two decades is a decline in the total number of patients, particularly a decline in the number of acutely ill patients that are seen in our MTFs.

Having a large number of very sick people is a remarkably effective training resource for a staff in training, be that medical residents, nurse training or medical technicians in training. A loss of some of that volume of extraordinarily sick people in the era of downsizing of some of our MTFs has left us with the opportunity to look for other training avenues to get that same intensity in level of training that we had previously seen based purely on patient volume.

Part two is when we turn to a war environment. I’ll be quite frank with you and say the nature of injuries and woundings we see in a wartime environment are unlike anything we see in the civilian or military treatment facilities.

MEdSIM: As a follow-up, do even some inner city, civilian emergency facilities treat cases that approach the wartime level of injuries you and your colleagues have seen?

CS: To some extent that is true. In terms of high caliber or highest projectile speeds of arms and armaments that is probably accurate. And certainly the Air Force utilizes civilian training platforms in our C-STARS [Center for Sustainment of Trauma and Readiness Skills] program that accomplish a lot of that familiarization and training.

Unfortunately, there’s another level of wounding that you don’t see in stateside medical facilities. IED injuries, for instance, really are not managed in even most of our high volume civilian trauma centers. So that’s an area where many of our folks can deploy without a tangible personal experience in that training.

I was the commander of a theater hospital in Southwest Asia and it was not unusual to see some of our new medics who had just arrived from their military bases and their common experience was, even if they had extensive training, they had never seen anything like the level of wounding that we encountered in those stations.

MEdSim: Tell us how the Air Force is using simulations and other learning technologies in its classrooms and other facilities.

CS: The basis is that the curriculum drives the learning tool that you use – it’s a curriculum-focused effort. It’s been very interesting in that I recently had an opportunity to chat with some of my colleagues from the Uniformed Services University of Health Sciences and the VA medical centers.

The commonality of approach is very striking – you identify a training need and then we look for the appropriate tool or technology to fill that need. Under some circumstances, training is best accomplished by live human actors.

So if you are practicing the history of physical examination techniques, this practice is probably best done on a live human actor rather than any mannequin.

If we are trying to look at cognitive mapping of a complex skill set, then the plastic mannequins offer a remarkable opportunity because the advances in technology with the plastic mannequins have come a long way.

If you think back several decades ago you would do your cardiac life support training on something called the Resusci Annie. There was limited ability to perform mouth-to-mouth resuscitation and some model of thumping on the chest.

Current high-fidelity, patient simulators have physiological responsiveness, can accept medication administration, can respond appropriately to the administration of that medication, they will appear to breathe and have pupillary responses and they will respond appropriately to positive encounters and good medical choices, and to bad encounters and bad medical choices. It gives us the opportunity to repeatedly “crash” without damaging or harming a patient.

MEdSIM: As a follow-up what is needed to advance from the state-of-the-art in medical simulators to more effectively replicate more serious injuries, wounds and illnesses?

CS: There’s a tremendous (amount or body of) work being done on that front now. First, what is needed is better synthetic tissue. While we can do extraordinarily effective cognitive mapping using the current generation of plastic mannequins, to get the real feel for a scalpel going into the skin, or the tissue planes that separates them, that is something the current technology is not quite there on yet.

We at AETC, have let some Small Business Innovative Research grants out specifically in the field of synthetic tissue research and development, as a model for that kind of hand skill training.

Mark Bowyer, a colonel (retired) M.D., mbowyer@usuhs.mil, the Director of Surgical Simulation at USUHS, would be a remarkable individual to talk to about what they are doing with synthetic tissue and tissue modeling.

MEdSIM: Are there any other ways your service is using simulators in its medical training?

CS: Absolutely. We have a tiered system of simulator training. Our largest and most experienced sites are identified as Tier 1 training sites. They are responsible for curriculum implementation, oversight of subordinate facilities and aggressive training activities for their larger populations. They also are responsible for the larger view simulation curriculum development for themselves and their subordinate location.

The Tier 2 and 3 sites answer to their Tier 1 sites for both training and assistance in the day-by-day operations of their training laboratories. Those training opportunities focus on anything from readiness skills verification training, which is the wartime skills that every Air Force medic must be able to deploy and be utilized within his specialty, and the traditional training needs of a large facility because our graduate education sites have specific training requirements linked to their residency programs.

Almost all sites have needs for advanced cardiac life support training, specific nurse skills training, pediatric life support training and neonatal resuscitation training. A lot of our obstetrical sites utilize obstetrical simulators to go through obstetrical emergencies.

Particularly at some our lower volume sites, that is a very important thing because they can practice, for example, a hemorrhage case again and again and again, where they might have a hemorrhaging patient except once every two months otherwise.

MEdSIM: Can you discuss any other compelling reasons for the Air Force to invest in medical simulators and other learning technologies?

CS: The most compelling reason is that you can make a mistake and you can learn from the mistake without harming a patient. When I attended medical school in the late 1970s we learned on patients. And we still continue to practice our skills on patients, giving rise to the phrase “the practice of medicine”.

But in a simulated environment you can present atypical or unusual presentations of crises, and you can drill the student or trainee again and again and again. In addition, a simulator environment allows a much greater use of team-based healthcare. That benefits us in terms of team building and expertise, and it strengthens our ability to communicate within the members of the medical team.

I can’t begin to overestimate the value of that team-based training. And that falls very naturally into a simulation environment.

MEdSIM: Your forecast please on the new simulations and other learning technologies your medical community may see in its training programs in the next 24 months.

CS: Actually we are trying to remain engaged with our military partners in crafting that future for ourselves, particularly in the realm of trauma trainers. The current simulator models we use in most of our training arenas are built for general audiences at civilian or military hospitals. They are very good for physiologic modeling but not ideal for trauma modeling. We are working aggressively with our Army partners, our other sister service partners and with civilian development agencies to come up with higher fidelity trauma trainers.

In fact, our medics at Camp Bullis [San Antonio] are engaged in developing research projects to make those simulator products more life-like and realistic in a trauma environment. One of the technicians that works at Camp Bullis is developing “smell-o-vision” – in which he tries to incorporate the smells of a combat environment into their training scenarios. You don’t really think how much of a difference that makes until you have experienced that training with and without the smell-o-vision addition.

MEdSIM: So in your assessment, how is industry progressing with regard to developing increased smell and some of the other attributes needed to increase fidelity in these simulators?

CS: All of our partners are fully engaged. There are technological hurdles that have to be assessed – and I’ll tell you those technological hurdles are expensive. A Resusci Annie is a relatively cheap piece of plastic but it gives you very little in return. The higher fidelity patient simulators are quite expensive but in return you get much higher training fidelity and you escape the age old problem of having some trainer in the room tell you what is going on with the patient instead of visualizing that within the simulated patient sitting right in front of you. And it’s that suspension of disbelief that I think will mark the technological improvements in the future. The more we can step in and simply see the sim as the patient, the more effective that training will be.

MEdSIM: So what is the Air Force’s commitment to investing in simulators and other learning technologies in the classroom through the budget out years?

CS: I think you have seen a phenomenal investment on behalf of our own Air Force Surgeon General and the other services’ surgeons general in bringing simulation to the forefront – motivated by not only the desire to offer better training but the realization that with the development of these technologies we can make phenomenal strides that would not otherwise be available in the purely human dimension. And I don’t think we’re alone in the military in pursuing that strategy. My friends at the VA, in talking to them this past week, are very powerfully engaged in developing their own simulator presence and they are making tremendous strides in integrating curriculum into simulator training.

MEdSIM: Anything else to add?

CS: One area of interest is the area of virtual simulation – creating a 3-D environment on the computer that will allow you to interact and to engage. We have seen some very promising demonstrations and we are investing in that future ourselves.

Here’s where I think that brings value. When I would greet a new group at the Theater Hospital, it would take those individuals a while to learn the lay of the land and to get to know their other deployed teammates. We deploy people from any of several MTFs into that deployed theater. The person standing across the stretcher from you may come from another Air Force Base.

Virtual reality offers the opportunity to these individuals to train together prior to deployment – meaning I can have a person at Wright Patterson AFB, Nellis AFB and Wilford Hall all engaged simultaneously in the care of a virtual patient in a virtual environment, and that give them the opportunity to learn their communications skills and handoffs.

Second, if I had an emergency room modeled after an ER at a deployed location, you could save a lot of time in just learning the lay of the land – you go down this hall and take a left to get to the blood bank. That is something someone has to learn by walking the floor space when they arrive. If you could do that in a virtual environment prior to deployment that would save a tremendous amount of orientation time. And I’ll tell you the bad guys tend not to take days off and tend not to respect our hand offs and transitions.