MS&T’s Chuck Weirauch interviewed Col. Meletios Fotinos.

Col Fotinos is the Chief, Medical Modernization Division, Directorate of Medical Services and Training, Headquarters Air Education and Training Command (AETC), Randolph Air Force Base, Tx. He is also Chief of the AFMMAST (Air Force Medical Modeling and Simulation Training) program, providing strategic direction for over $40 million in Air Force Medical Service simulation contracts and assets.

The AFMMAST program was established in 2008 to promote and manage simulation training across the Air Force Medical Service.

MS&T: As Chief of Medical Modernization for AFMMAST, could you please fill us in on just what that title implies for Air Force medical training and education?

In this position, it is my responsibility to guide the service on medical modeling and simulation training, research opportunities and acquisition initiatives. Ultimately, AFMMAST is the linchpin in helping to coordinate a standardized approach to align curriculum, logistical support, and assessment capabilities to enhance training for our medics. We function along the full continuum from basic to advanced training, using a wide variety of modeling and simulation platforms in an effort to develop life-like virtual environments to immerse our medics in, and to obtain more realistic training. The key to this whole process is standardizing our operations to ensure we capitalize on efforts and build critical curriculum for our customers (simulation operators and medics). This approach allows our medics to train to enhance their ability to provide “Trusted Care Anywhere”.

MS&T: What are some of the most critical needs for advanced medical training and education that have emerged at Air Force medical centers?

The slowdown of operations in Afghanistan has raised a major concern for how to sustain critical skills gained in the last decade plus of conflict. On-the-job training is not an option, since there is no real civilian analog to combat trauma care. Simulation is trying to capture the lessons and develop strategies and tools to help keep the medical forces ready for future engagements. Simulation technologies provide an avenue for augmenting current training curriculum by practicing hands on skill assessment and/or enhancing cognitive function and critical thinking prior to real patient care.

MS&T: How are simulation-based training devices being developed and implemented to meet those most critical needs?

There are several different development methods, beginning with basic research. We have a Joint Theater Trauma Registry (JTTR) that includes details of each patient case that flows through the system. We query this registry to look for patterns that present opportunities for training. We then develop training objectives that we need to meet the opportunities and try to match devices with these objectives. We use multiple methods and equipment depending on the requirements.

Implementation is through a multi-tiered structure that includes formal training sites (Medical Education Training Campus-METC, Center for Sustainment of Trauma and Readiness Skills, C-STARS, etc.) and medical treatment facilities from hospitals to clinics. The further down the tier structure the process is, the less complex the material. We have more than 80 sites that provide medical simulation training, including civilian partnerships. We are beginning to execute standardized training through our AFMMAST Portal, which allows us to leverage expertise from the larger sites to benefit the smaller sites and save development time.

Additionally, every research study is linked to assessing Bloom’s Taxonomy of Learning Domains (psychomotor, cognitive, and affective). The affective domain can be assessed across the majority of studies. The psychomotor and cognitive domains are assessed depending upon the capability of the simulation technology. For example, gaming cannot assess psychomotor. However, high-fidelity simulators, if utilized to their full potential, could assess all three learning domains.

MS&T: Would you please provide some examples of some of the most current training devices and those under development?

Some of the latest simulation technologies available are the Syndaver Synthetic Human, Cut Suit, serious medical gaming, train the trainer web-based training (WBT), virtual reality with haptics, virtual environments, and numerous other task trainers. Additionally, high-fidelity simulators are constantly being upgraded from multiple vendors as technology advances.

MS&T: How is AFMMAST looking to enhance curricula development, and would that include such technologies as virtual worlds?

One of the major projects on the plate for curriculum is the development of simulation operator’s courses. We don’t have the luxury of a stable staff that we can train and keep in one place like other civilian systems. As a result, we need a pipeline for training new operators that is repeatable, and cost-effective. We have developed a basic operator’s course that takes a novice with limited knowledge to operating a simulator with a pre-programmed scenario and template in about 2 hours (Sim 101). The second part of this training that is now in development is a more advanced operator course that will give the learner the ability to develop scenarios on their own and contribute them to the overall program.

Both of these are web-based training platforms, which are available 24/7 at locations with Internet connectivity. Without skilled operators, the simulators will sit unused in closets and we won’t be able to share the lessons learned that were discussed above. AFMMAST is also working on a Small Business Innovation Research (SIBR) project with a vendor to develop a serious medical game to support Expeditionary Medical Support Emergency Department (EMEDS ED) and National Registry Emergency Medical Technician (NREMT) training for point of injury scenario care.

This has been taken a couple of steps further to placing these same patients in human simulators and also in separate self-paced learning modules. This way, we can hit all three levels of learning: cognitive, psychomotor, and affective using the same exact patient scenarios. We are also immersed in a 3D environment (the Wide Area Virtual Environment, or WAVE) that puts the learner in a realistic setting where they will need to apply a variety of skills. These skills include both medical and defensive skills on casualties in a combat arena. Using these types of scenarios helps to expose our medics to what they might experience while deployed.

MS&T: In what specialty areas has simulation-based training emerged to be an effective training tool?

Graduate medical education (GME) is using simulation-based training for things such as laparoscopic surgery, endoscopy, etc. We are also using simulation effectively in complex areas such as Critical Care Air Transport Teams (CCATT). The CCATT is in effect a flying critical care unit where there is high risk and mission rehearsal is critical. Nursing is using it to shore up training for novice staff where there are limited patient encounters.

MS&T: Has AFMMAST conducted any studies of the effectiveness of simulation-based medical education and training, and would furthering this work be a part of your office's responsibilities?

AFMMAST has conducted several different studies involving effectiveness. The Holy Grail is patient outcomes, which is a difficult item to grasp. We recently purchased several different simulators under the Military Utility Assessment (MUA) process and have implemented them at several sites. One, which is quite far along, is in the Obstetrics specialty. We identified the need to train OB staff (docs, nurses, techs) on instrument deliveries. Using a simple task trainer built in Australia (OB Lucy and her Mum), we trained approximately 80 percent of the AFMS OB staff on instrument delivery techniques and prevention of complications. We are waiting on the results from the hospitals that provide delivery services to see if our interventions reduced the rates of 3rd and 4th degree lacerations post delivery.

Also, AFMMAST was awarded over $600K from the Defense Health Program (DHP) to assess the training effectiveness of the WAVE. It currently resides at Camp Bullis, TX and the subjects involved in the study are students participating in the Expeditionary Medical Support (EMEDS) course. The Multiple Amputation Trauma Trainer (MATT) is immersed within the 3D virtual environment in a point of injury scenario where students have to triage and assess the patient and prep them for transport.

AFMMAST continues to develop research protocols for execution. Some other topics currently in the works are a live tissue vs. synthetic tissue assessment, performance metrics validation study on high-fidelity simulation mannequins, various patient outcomes studies, and a serious medical game validation study. The live tissue versus synthetic tissue assessment will compare the Syndaver synthetic tissue model to live tissue with hopes to validate an alternative for current live tissue training. The serious medical game validation study will include a point of injury scenario that will be implemented at METC to assess performance improvement on NREMT scores for basic EMT students.

MS&T: What emphasis are you placing on gaming technology-based and mobile applications?

We are looking at multiple different media to see which are the most effective. In our Sim 101 course, we have mobile applications as job aids for specific simulators, which can be downloaded from the AFMMAST Portal. The issue with gaming is cost. It is very expensive to develop and maintain/host games that continue to meet the changing medical knowledge and standards of care.

The vision for the serious medical game SBIR project is to provide seamless patient transition throughout the entire continuum of care (including point of injury, EMEDS, AE/CCATT, and definitive care). Gaming may become an important augmentation tool to enhance student cognitive ability. Today’s “digital learners” attention spans are short for traditional didactic learning. Preliminary results of games have shown that they encourage critical thinking, promote active learning, replicate real-life scenarios, and make learning more exciting.

MS&T: Along with the WAVE immersive medic combat training environment, is AFMMAST involved in R&D for any other kinds of virtual operating room environments for clinical team training?

In the SIBR game, a multiplayer environment will allow for teams across the globe to engage in training at the same time. Geographically separated medical teams scheduled to deploy together will be able to log on to a serious medical game online and train together virtually prior to arriving in-theater.

Editor’s Note: Visit the AFMMAST online portal for more information.