Group Editor Marty Kauchak interviews Colonel Daniel Irizarry, MD.

MEdSim had the opportunity to gain far-ranging insights on medical learning technologies and military medicine from Colonel Daniel Irizarry, MD., US Army, the Clinical Advisor for the Joint Project Office for Medical Modeling and Simulation (JPO-MMS) at US Army’s Program Executive Office Simulation Training and Instrumentation (PEO STRI) in Orlando, Florida.

MEdSim: Tell us about your assignment as Clinical Advisor for the Joint Project Office for Medical Modeling and Simulation (JPO-MMS).

Colonel Dan Irizarry: In 2012, then PEO STRI Jim Blake, PhD, Assistant Product Manager MEDSIM Lieutenant Colonel (LTC) Wilson Ariza, senior Army medical acquisition leadership and the Assistant Secretary for Defense for Health Affairs ASD(HA), Dr. Jonathan Woodson, saw value in creating an office that would apply acquisition rigor to the Military Health Care systems Medical Modeling and Simulation (MM&S) portfolio. At the time, I was the NATO Special Operations Headquarters Command Surgeon at Supreme Headquarter Allied Powers Europe (SHAPE), Belgium, and we were working closely with PEO STRI to create a MSTC-like entity, the SOF Allied Centre for Medical Education (ACME), to support NATO special operations medical training.

At ITEC [2013] in Rome, Italy, Dr. Blake, LTC Ariza and I discussed the Joint Project Office for Medical Modeling and Simulation (JPO MMS) concept as a means to conduct advance development and lifecycle management of the prehospital and hospital based MM&S that underpins today’s Military Health System (MHS) medical training. As you know, most medical simulation centers have a clinical director and when speaking about future JPO MMS personnel, we discussed the need for a clinical advisor to advise the JPO MMS Program Manager and liaise with medical simulation center clinical directors. In 2013, Dr. Woodson signed the memorandum requesting PEO STRI, in conjunction with the then Tricare Management Agency, to establish the JPO MMS.

In June 2014, with NSHQ’s SOF ACME fully operational providing medical simulation for point of injury through advanced austere surgical care, it was time for me to move to my next assignment. Dr. Blake, with the support of senior Army medical leadership, identified me as someone with the appropriate medical and simulation experience to help build the JPO MMS and serve PEO STRI and PM MEDSIM as the clinical advisor. Thus, I was assigned to PEO STRI.

MEdSim: To follow up, comment on your previous interest and achievements in medical S&T - which led to your current assignment.

CDI: I have always had an interest in technology and simulation because I was a huge NASA fan as a kid. My childhood dream was to be a physician astronaut. As I progressed through medical school at the Uniformed Services University of the Health Sciences and Family Medicine residency at Womack Army Medical Center [Fort Bragg, NC] in the mid- to late 1990s, medical simulation was just being born.

My first assignment after residency was as a brigade surgeon in the 82D Airborne Division. Responsible for the brigade medical systems medical preparedness, I learned three lessons. First, the systems healthcare quality was wholly dependent on the brigade’s medical training capability. Second, if you do not have patients, it is impossible to train realistically. Third, quality training is a team effort that requires command support, expert instructors, motivated students and the resources to bring those elements together in a cohesive manner to create training outcomes that would save lives.

My next job as a battalion surgeon in a special operations battalion built on my previous experience, but now I was training highly skilled operators to provide quality healthcare in challenging and remote environments. In special operations, the medic’s and operator’s introductory training is extraordinary, but that skill and knowledge must be maintained if they are to be successful accomplishing their strategic missions in austere environments. At the time and still today, realistic training relied on hospital rotations, which provided spotty clinical opportunities and had little to do with the combat environment they faced. Then, the only reliable tactical alternative was live tissue training which allowed for a highly realistic trauma treatment experience in an appropriate austere environment commensurate with the mission. But being curious by nature, I started experimenting with adding available trauma partial task trainers into training missions to allow medics to do Advance Trauma Life Support procedures like chest tube thorocotomy and cricothyroidotomy. While these devices lacked realism of life, they did provide the benefit of improved correlative anatomy to a human, and reduced political and logistical requirements. Where they failed, and I believe where trainers still fail today, is realistically portraying critical tissue properties required for some types of training and eliciting the emotive experience that only biology provides which are critical to learning medical procedures in a complex stressful environment.

Colonel (Dr.) Daniel Irizzary, US Army, the Clinical Advisor for the Joint Project Office for Medical Modeling and Simulation (JPO-MMS) at US Army's PEO STRI. Image Credit: U.S. Army

My next assignments as a family medicine clinic medical director and clinic commander required my focus to change to the challenge of clinic and hospital based education. In the clinic and hospital, there is a wide range of professionals to teach, from medics to nurses to physician extenders and physicians. Within the physician population, there is significant variability between specialties. It is very different from training for combat. Besides standard required training like basic life support, we had to develop critical skills required for extremely rare emergency situations in the clinic like cardiac arrest. Unable to obtain simulators for training purposes, I frequently relied on volunteer actors to portray patients, which provided a realistic experience, but of course, we could only practice some of the necessary procedures (opening code carts, moving patients, calling 911 and teamwork skills) required to be successful in these events.

My assignment just prior to PEO STRI was at the NATO Special Operation Headquarters (NSHQ). NSHQ was established to help coordinate NATO and partner nation’s special operations activities and our medical team was given the mission to improve interoperability and NATO SOF and partner medical capability. With the support of special operations commanders, national surgeon generals and national SOF command surgeon leadership, we launched the NATO Special Operation Medicine Development Initiative (NSMDI), at the heart of which, was the creation of a medical simulation capability, the SOF Allied Centre for Medical Education (ACME). PEO STRI, which is fielding similar capabilities to the Army through the Medical Simulation Training Center program of record, provided acquisition expertise to build the ACME. The combination of command support, resources, acquisition acumen and industry partner efforts resulted in a MSTC-like system able to support highly realistic initial point of injury trauma training through forward surgical resuscitation. Today, the nation’s SOF and conventional forces regularly train together enabled by the ACME’s medical simulation platform. They are not only developing medical skills, but also growing critical interoperability and relationships that can make the difference in failure or success on today’s battlefields.

MEdSim: The US military has experienced increased survival rates from injuries and wounds on the battlefields of Iraq and Afghanistan. How has simulation and training (S&T) supported our injured and wounded service men and women's survival processes, and ability to fight another day?

CDI: The US military has made significant progress in casualty survival rates over the past 10 years, unfortunately a product of knowledge learned on the battlefield with real casualties. We have clear data showing that tactical combat casualty care training and simulation have contributed greatly to survival. The US Army Rangers, who typically see more combat and have more critical casualties, have significantly better survival rates on the battlefield. The Rangers have a died of wounds rate of 1.7% compared to conventional forces whose died of wound rates were 5.8%. Perhaps more impressive is the KIA [killed in action] wound rate, which includes all casualties who die before reaching a medical treatment facility. For the Rangers, this rate was 10.7% compared to conventional forces rate of 16.4%. A primary difference between the Ranger Regiment and other forces is its aggressive commander-led casualty response system underpinned by all forms of simulation. The take home message is well prepared point of injury care training supported by realistic simulation is critical to saving battlefield casualties.

From left, Sgt. Raul Zepeda and Spc. Martin A. Cardenas of the 57th Expeditionary Signal Battalion along with Spc. Larry Harper of the 209th Aviation Support Battalion and Senior Airmen Jerome Williams, Jr. (right) of the Defense Contract Management Agency evaluate, treat and secure a simulated casualty during medical training at the Medical Simulation Training Center at Kandahar Airfield, June 14. Kandahar Airfield features one of only two Medical Simulation Training Centers in Afghanistan. Image Credit: Tyler Meister/ U.S. Army

I believe medical simulation has played a critical role in saving lives, but we still have plenty of work to do in both training and equipping our forces for mission success and survival. The recent study by Eastridge, et al. shows that 24% of our casualties who died from 2001-2011 were potentially savable. Now more than ever, with the reduced pace of combat operations creating fewer casualties and the loss of experience caused by personnel turnover, we will soon have a command cadre and force that has neither felt the motivating pull to train medical skills that losing a warrior in combat creates, nor the opportunities to gain critical experience actually treating casualties. Our only hope of sustaining current lifesaving success is through realistic simulation.

While much of the PEO STRI’s focus has been prehospital simulation, we cannot forget the importance of hospital based simulation. Sustaining capabilities of battlefield surgery, which is significantly different from the laparoscopic-based surgical procedures found in nondeployed settings, is critical to sustaining survival. Likewise, casualties are not just saved at the point of injury and the operating room, but they are sustained enroute between nodes of care by medics on helicopters and ambulances and critical care transport teams. Without the components of quality medical simulation, patient simulators, environment of care, instructor-operators and the computer based systems that underpin these elements, it will be very challenging to keep these critical elements in the chain of care sustained.

MEdSim: The Defense Medical Research and Development Program has a goal to discover and explore innovative approaches to accelerate the transition of technologies to ensure the most effective medical training systems for the DoD. Tell us about your efforts in the DMRDP, in particular with the Joint Program Committee-1 (JPC-1), which is responsible for medical simulation research.

CDI: PM MEDSIM works very closely with JPC-1 to establish capabilities and technologies that can be transitioned to programs of record. LTC Chris Todd the Product Manager at PM MEDSIM, has done a fantastic job providing acquisition expertise to the committee’s decision making processes. His ability to translate the complicated world and realities of acquisition, to often science and research heavy discussions, has injected an important level of practicality that is indispensable to transition developing technologies. Drs. Janet Harris and Kevin Kunkler, who lead the committee’s day-to-day activities, have created a highly collaborative environment that brings experts from the scientific community (ARL STTC), academic community (USUHS), operational community (US Special Operations Command) and acquisition, just to name a few, to make prudent investment decisions with the precious taxpayer dollars they have been entrusted to allocate. The team approach is good for PEO STRI, allowing us to see the art of the possible as it develops and plan for transition. I believe it helps the other team members, as well, in similar ways.

MEdSim: Staying on the topic of jointness, explain some of PEO STRI's efforts to increase medical S&T initiatives among the US services.

CDI: As I mentioned earlier, Dr. Woodson, ASD(HA), directed the establishment of the Joint Project Office for Medical Modeling and Simulation (JPO MMS) to synergize MHS simulation efforts, maximize efficiency and reduce costs. Major General (MG) [Jonathan A.] Maddux is fully committed to bringing this office into fruition in coordination with Mr. Mike Obar the Component Acquisition Executive, Defense Health Agency. MG Maddux and Mr. Obar recently signed a Memorandum of Agreement establishing the office and a charter designating Colonel Vince Malone as the Provisional JPO-MMS Program Manager. We have been working closely with Brigadier General Miller, DHA Director of Education and Training, to align our efforts with the strategic vision of the future shared services committee. Practically, PM MEDSIM has already created significant jointness through its support to the Air Force Medical Modeling and Simulation Training (AFMMAST) program and Navy Medical Modeling and Simulation Training (NMMAST) program establishing both foundational precedence and the necessary relationships at the Service MM&S action officer level to make a joint endeavor a success.

The ASD(HA)’s office has launched some recent initiatives to synergize the services’ efforts. Two capability based assessments have been initiated and near completion looking at how to develop and validate joint medical modeling and simulation requirements and technology requirements. The DHA Education and Training Directorate is working diligently to assess how it can support and synergize service requirements. Working in conjunction with DHA E&T and the service MMS action officers, the entire enterprise is looking carefully at how we can establish joint programs of record to better organize the MHS medical modeling and simulation program and in so doing, create a structure that can effectively engage in the programmatic budgeting process and our acquisition efforts. A very preliminary concept is to organize the system along the current distribution of simulation, Point of Injury Training, Enroute Care Training, Hospital Based Training and Military Medical Modeling. However this happens, the first step is improved cross talk and coordination between the Services, which is active and increasing.

MEdSim: As follow ups, are there any collaborative PEO STRI efforts with the VA and US friends and allies' medical services?

CDI: Yes. As you already probably know, LTC Todd has an amazing team of professionals that collectively accomplish PM MEDSIM’s daily mission. One element of this team is dedicated to support SIMLEARN, the VA’s monumental efforts in improving the quality and use of simulation for better healthcare outcomes. Guided by the vision of the VA’s, Mr. Harry Robinson and Dr. Haru Okuda, the PM MEDSIM team is supporting the establishment of the VA’s flagship simulation platform at Lake Nona [Orlando, Florida], and other SIMLEARN efforts. From a JPO MMS perspective, this is a win-win because outside our combat mission, the MHS and VA treatment facilities share many hospital education requirements like ACLS and BLS. Some of the VA’s unique program initiatives like women’s healthcare simulation align well with military graduate medical education requirements. As a bi-product, PM MEDSIM’s already stellar staff, is well trained and experienced in supporting hospital based simulation requirements for the MHS.

From an ally and partner perspective, we continue to work with NSHQ and are providing medical simulation expertise world-wide to partners and allies in support of the PEO STRI Foreign Military Sales program led by Mr. Dale Whittaker. It makes great strategic sense to assist our allies and partners in improving their medical capabilities. From an operational perspective, you are more likely to be confident in taking risk if you are confident you will survive. From a practical standpoint, the US military is rarely on the battlefield alone. In partnering missions, the person saving your life may be an ally.

MEdSim: Preview some new simulation and training systems the Army healthcare community will receive in its classrooms and other training venues in the next 12 or so months.

CDI: Army medical simulation acquisition is driven by requirements generated by user stakeholders so we will seek to respond to those requirements as they develop. Recently, the AMEDD Center and School identified a training capability manager for the MSTC program, who will also look at the wider Army medical simulation requirements. This is an important development in Army medical simulation because it establishes a senior leader to develop the necessary requirements documents that drive funding and acquisition. Since requirements precede fielding, this is an important development that will have positive impacts in future training system deployment.

One of the emerging requirements is the need to sustain the training of our flight medics. Based upon lessons learned in the war and anticipating longer transportation times in future conflicts, the Army recently established a flight paramedic program commensurate with civilian flight paramedics. This year, PM MEDSIM fielded an integrated simulation capability for initial flight paramedic training at the AMEDD C&S, the Transport Medical Training Lab (TMTL). TMTL integrates patient simulators into a mockup UH-60 cabin, outfitted with environmental controls and monitoring equipment, all controlled by a central control station. With TMTL, soldiers can realistically train patient hand over from point of injury, in flight transport care and hand off to a forward surgical team. Given the Army’s commitment to flight paramedic training, I think this will be an area where we see requirements generated.

MEdSim: Summarize the Army's commitment to medical S&T through the budget out years - recognizing the FY2016 president's budget has not been enacted.

CDI: I think the Army will remain committed to medical simulation and training. The US Army Special Operations Command has validated medical simulation as a capability gap. The Assistant Secretary of Defense for Health Affairs and Congress directed a reduction in live tissue training making man-made casualty simulators the only alternative. Civilian medicine is increasingly using medical simulation in hospitals and graduate medical education (GME) programs, which will drive sustaining and improving the fifteen GME based simulation centers in our medical treatment facilities. Medical simulation has the potential to save money through the improvement of health care outcomes, particularly if it is linked to risk reduction strategies.

However, I do think we will need to find ways in this fiscal environment to improve our return on investments. Presently, medical simulator procurement and funding primarily occur at the local level, creating a distributed and redundant procurement process, not infrequently, for the same items. Also, despite using the same curriculums, it is not uncommon for different simulators to be used to support the same curriculum. Finally, we really do not know how many simulation assets have been procured and fielded throughout the Army formation because of the grass roots evolution of medical simulation development in the Army. One of our short term goals is to establish what investment has been made to date in Army medical simulation and look at opportunities to maximize simulation use, centralize lifecycle management and establish strategic sourcing options. Essentially, we are looking at how we can apply Better Buying Power [ http://bbp.dau.mil/] initiatives to Army medical modeling and simulation. But, as important as it is to spend our investments wisely, we are also looking for ways to ensure our investments provide optimal training outcomes.

MEdSim: Looking at the current and near-term technology base for medical S&T, are there any technology focal points and thrusts we need to be attentive to for breakthroughs and similar developments?

CDI: I think the future for medical simulation science and technology is the ability to integrate simulators and simulation systems. To date, much of simulation has been focused around creating the stage for an individual or team to train at a point of care. For the military healthcare system in particular, our joint trauma system is a continuum of care, an integrated chain of compassionate, quality treatment reliant upon accurate information flow, which leads to optimal patient outcomes. The key is to be able to link the nodes of care and transport to create a cohesive simulated chain of care, one that ideally does not require every node to be active, but that can be linked live if possible from point of injury to enroute care to surgery.

Along the same lines, we need to be able to link multiple patient simulators to the same control systems. The reality is that some simulators are better at teaching certain skills than others. There is a mix of simulators presently found at any given simulation center, but proprietary software prevents linking these different simulators into an overarching simulation grid. Also, finding ways to upgrade already fielded simulators rather than purchasing new would be helpful to the community.

We still need a lot of work on developing simulators that are more realistic to life in the critical training elements such as tissue fidelity for surgery and other procedures. Finally, I would say that development of cognitive virtual training that can be inexpensively distributed to reduce the time required to conduct live training is a frontier technology.

MEdSim: Your follow on message to the S&T industry: how can it better respond to the dynamic learning requirements of your service's healthcare providers through the next five or so years?

CDI: I think the key for future success in responding to future requirements is developing a collaborative forum between the users, industry, academia and acquisition and then getting the requirements generated and validated through the Army system. A mechanism for this is already forming and we are seeing positive efforts to bring some organization and order to the processes so I think this will make it easier for all of us.

MEdSIM: Finally, anything else to add?

CDI: I am truly honored to have the opportunity to contribute to your publication. I am most honored to have the chance to work so closely with so many fantastic professionals from the great team at PEO STRI and PM MEDSIM to the many stakeholders we interact with daily. Since my earliest days in medicine, I was taught to always put my patients first. I think it is important for all of us in this industry to remember that what we do sets the conditions for saving lives. No cause is nobler than saving the lives of the Warriors who protect our nation every day.