Commentary

Military ‘live tissue trauma training’ using animals in the U.S. – its purpose, importance and commentary on military medical research and the debate on use of animals in military training

G. Martinic, MSc(Hons), DipAppSci, DipAnTech, MAIBiol

Introduction There has been a significant change in the types of injuries sustained on the modern battlefield due to the use of improvised explosive devices (IEDs) which are designed to cause severe penetrating injuries to limbs and torso, often resulting in massive haemorrhage in injured soldiers. Massive haemorrhage is the most common preventable cause of death for soldiers wounded in combat1. Hence life saving training techniques and practices are being used by US military medical personnel in an effort to reduce this incidence. ‘Live tissue trauma training’ (LTTT), or ‘combat medic training’2, as it is referred Sourced from: ‘Medic Training’ by Alexander Hunter to in the US, involves the use of animals (mostly for the Washington Times (2010). B1_nu_helmet_base_ goats and pigs) for the purposes of direct surgical s640x413.jpg /washingtontimes.com intervention in which physicians and paramedical personnel (military and civilian) obtain surgical He also highlights opinions and recent examples of skills by treating severe traumatic injuries. Once the animal research/training debate from both the animals are deeply anaesthetized, wounds of the pro- and anti- points of view and provides examples type army paramedics and doctors are likely to see of alternative types of LTTT tuition. He hopes that in combat situations are inflicted. Such wounds are this article will encourage wider discussion within then appropriately treated in order to gain valuable respective scientific, defence and animal welfare ‘trauma care’ experience not likely to be offered in circles, leading to further refinements in the welfare any other form. Upon completion of LTTT, animals and protection of animals used for these important, are humanely euthanased without ever regaining although often controversial, purposes. consciousness. Despite the understandable highly emotive and sensitive nature of LTTT, by pr oviding Why LTTT needs to continue new combat medics with methods in how to manage Jim Hanson2, a former member of a US Special critically-injured soldiers within the first few hours Forces unit, writes in the Washington Times (‘Save post-event, and where there is no local access to people, not pets’), that in his view animal use should doctors or medical facilities, military personnel assert continue for LTTT because ‘banning medic training that such realistic training programs are necessary using live animals could kill US troops’. Interestingly, and have facilitated the saving of countless lives of this publication was intentionally timely and was in soldiers who have sustained life-threatening injuries direct response to a bill before the US Senate at the 2,7,8,9 on the battlefield. In this ‘opinion’ article the time. This bill, known as the ‘Battlefield Excellence author explains how and why animals are used for Through Superior Training Practices Act’3, sought LTTT and in some areas of military medical research to amend the US Defense Appropriations Act which (MMR), as well as why he feels that the continued aimed to phase in human-based training methods use of animals for LTTT is justified at this time.

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and replace the current use of live animals for LTTT. rapidly apply surgical airways. Hence, ‘the spectrum If passed, this bill will require the US Department of care they are expected to provide at any given of Defense, no later than 1st October 2014, ‘to use moment exceeds what an entire civilian trauma only human-based methods for training members of centre might encounter in a week or month’.7 the Armed Forces in the treatment of severe combat While most LTTT tuition involves the infliction of and chemical and biological injuries’. It will also wounds using surgical instruments, some select US prohibit the use of animals in such training.3 One of special operations units8,9,10 have conducted LTTT the main groups that are seeking this change is the using various ‘projectile’ methods such as gunshot U.S. Physicians Committee for Responsible Medicine wounds, (bayonet) stab wounds, (napalm) burns, (PCRM), who strongly oppose the use of animals for and amputations. Such courses, known as ‘Combat research and training in any arena. Many believe Trauma Management’, are ‘designed to test and that this bill (known as the ‘BEST Practices Act’) will reinforce the application of knowledge with regard likely end up costing the lives of US troops in order to patient stabilization and treatment on an injured to save the lives of some animals simply because US animal-patient. The use of ballistic wounding in these military medics will no longer have access to vital courses is used to create a variation of wounds and and realistic LTTT. environments to complicate patient management and The PCRM, and other groups that oppose vivisection increase training realism’.7 It should be stressed that (surgery used for experimental purposes on during such procedures, animals are always deeply living organisms4) such as People for the Ethical anaesthetised (at a surgical plane of anaesthesia) for Treatment of Animals (PETA) seek an expanded the entire period, given appropriate analgesia, and use of simulators and other training aids so as to humanely euthanased post-training. completely replace LTTT, despite the fact that such The production of extensive injuries in animals simulators and training aids cannot adequately used for LTTT is important so that medics, when mimic bodily functions or recreate the reality of faced with a real combat situation are unlikely to a wounded living being. In contrast, it is widely ‘freeze’ due to emotional shock and they are able to accepted in US defence circles that, were it not for quickly identify what they need to do, and apply it training programs such as LTTT, most medics would immediately and confidently. Such is the reality of be sent into combat situations never having had the LTTT that even hardened military personnel, when experience of treating a real traumatic injury. The observing a gunshot wound for the first time, cannot viewpoint of most medics is that the visceral reaction remain unaffected by the experience. LTTT training that a living animal can invoke, being similar to also provides clinical and psychological ‘conditioning that which each medic must face when a (human) for the horrors and chaos of war.’ Indeed there are life is in danger, is something that no simulator or many medics belonging to Special Forces (elite) units training aid can provide. According to the PCRM, who would gladly provide testimonials in support the US Department of Defense currently uses of the fact that such training, albeit graphic, has approximately 9,000 pigs and goats, and 20 vervet saved the lives of their colleagues who had sustained monkeys annually to teach Army medics, Navy severe wounds in actual combat.2,8,9,10 Despite corpsmen and Air Force personnel to respond to numerous advances in modern military technology, the most common causes of preventable battlefield such as personal body armour and armour-plating fatalities.1 Others claim that these figures are more of vehicles, it cannot be disputed that a confident than fifty-fold higher5, though these claims appear and well-trained combat medic is probably the most unsupported by any firm evidence. This is put into likely ‘instrument’ to save a wounded soldier on the perspective when one considers that in just one week battlefield. Furthermore, a military spokesman for in the month of February 2009 in the U.S., 2,236,000 the US Army in Europe recently announced that hogs were slaughtered for meat consumption.6 In effective combat trauma training, such as LTTT, LTTT sessions, military trainees practice procedures had contributed to the lowest ‘killed-in-action rate including tourniquet application, emergency in military history’.11 Thus, as LTTT actually saves management of haemorrhage, blocked airway lives, military personnel believe that this vindicates emergency techniques (such as cricothyroidotomy) their position, and that LTTT should continue. The and chest tube placement. This is because combat author, who also believes that priority should be medics are ‘trained and prepared to save life, and given to human life over that of animals, concurs to keep the casualty alive in austere high-threat with this view. Indeed, it would seem that others are conditions for hours on end’. Faces are often also of this view. David Hull, in his review of ‘Animal destroyed due to blast and burns injuries caused Liberation’,12 wrote that “if a choice has to be made by IEDs used by insurgents, and there is a need to between saving a human being and saving a pig,

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we would be morally obligated to save the human requirements at the cellular level regardless of the being because human beings are capable of greater state of consciousness. If successful, this area of sentience (possession of feelings such as pain and MMR is likely to have applications within the civilian emotional states such as fear) than pigs. One must world as well, for example in assisting victims of be careful when drawing such conclusions however motor transport accidents. as the degree of pain experienced by an organism Another significant part of MMR is the issue of cannot be assumed to be proportionate to its level of chemical weapons defense research (CWDR; as sentience.13 opposed to chemical weapons offence research - banned in US for decades). This is another area where Military Medical Research animals are used for military purposes.1,2,4,5 In order In the area of MMR numerous devices (for example, to find cures for soldiers exposed to deadly chemical tourniquets), procedures (damage control surgery) attacks on the battlefield, vervet monkeys are used and clinical practice guidelines (use of balanced as a model for CWDR. In this work, the monkeys are plasma to packed cell ratios) have been promulgated anaesthetized and administered a non-lethal dose in the military through initial animal studies and of a drug that mimics the symptoms of a chemical subsequent clinical studies. Subsequently, training weapon, and then given an appropriate treatment. procedures employing the use of animals have been The efficacy and safety of chemical warfare antidotes modified to reduce the use of animals, refined to and vaccines must be screened on animals prior to maximize their use and where possible, replaced their use in humans. This methodology has to date by the introduction of wide and varied techniques become standard practise in this area of MMR. including simulators. Combat-experienced soldiers, having first-hand Another major factor within the battlefield scenario, experience with regard to the types of injuries often is the issue dealing with blood loss. Uncontrolled sustained in modern military conflicts as well as haemorrhage is by far the major cause of death for seeing the benefits of LTTT, haemostatic training and wounded soldiers.2,7,8,9,10 Blood loss accounts for CWDR, are strong advocates of LTTT and MMR for 40% of all combat deaths in Iraq and Afghanistan, the purposes of saving human lives (lives of soldiers according to the Army Institute of Surgical Research sent to war) over animals. They feel that LTTT Joint Trauma System, but 79% of ‘potentially should not be considered as a ‘callous disregard survivable’ deaths.14 Medics in the field are restricted of animals. It is the careful and thoughtful regard in their ability to maintain blood pressure and to for the survivability of the men and women that are ensure that there is enough circulating blood as sent to war’ by giving them (medics) all the tools and possible within the body. Mostly the only tools a training that can help them save lives.2 medic has in order to achieve these aims include the use of compression bandages, various bandaging The LTTT situation in Australia techniques, the use of thrombotic drugs to assist in LTTT has been similarly practised in Australia slowing the loss of blood and the knowledge and to aid in the training of both civilian doctors and experience gained from LTTT in dealing with complex Australian Defence Force (ADF) personnel in the traumatic injuries. Through their experience on the initial assessment and management of the trauma battlefield, medics have found that soldiers can often victim. This training essentially concentrates on the recover relatively well if haemorrhage and potential first hour of emergency care post-event, and does not massive blood loss has been arrested.7,14 include the infliction of firearm/projectile injuries The Pentagon has recently invested approximately (ie. gunshot, grenade wounds) as is practised by $10 million dollars in MMR to investigate strategies select US military groups conducting LTTT. In to increase the survival rate of soldiers through Australia, LTTT is known as Early Management of induction of a hibernation-like state.14 The medical Severe Trauma (EMST)15 and since 1988, training research arm of the US military has commissioned programs have been regularly provided for civilian Texas A & M University to undertake studies which and ADF medical and paramedical personnel across initially have shown that hydrogen sulphide can the country. It is important to note that EMST put rodents into a state of ‘induced hibernation’. training, when it is conducted, is carried out in full An extension of this work will seek to find scientific compliance with National Health & Medical Research solutions that could potentially allow human Council Guidelines, NHMRC (2009). Guidelines on cells to survive with less oxygen carried in the the use of animals for training interventional medical bloodstream and able to keep soldiers alive for up to practitioners and demonstrating medical equipment six hours despite massive blood loss.14 Essentially, and techniques.16 The EMST focus is purely on the such research is aimed at reducing the body’s ‘trauma’ patient, regardless of whether that is within a

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civilian casualty or a military casualty context. EMST kind. Effectively they believe it is ‘inhumane’ and training was essentially ‘imported’ into Australia in claim that those biomedical research organisations the early 1980s when the Royal Australian College of who conduct animal research, do so in a totally Surgeons (RACS) liaised with its equivalent body in unregulated environment which is fraught with the United States, the American College of Surgeons, animal cruelty. Recently, these groups have been to seek support and permission in setting up the very active on a world-wide scale by protesting 19,20,21,22 Advanced Trauma Life Support (ATLS) training (PETA and ALF, violently) against any form programme for the Australasian region. As a result, of animal-based research or training. PETA, ALF the first EMST course, made available by the RACS, and recently PCRM, seem to have realised that if was offered to potential trainees in 1988, and has to they can’t force a change to their views on various date been providing this type of training as well as industry and government bodies, they can certainly refresher training (normally undertaken if not done be more effective by using official processes to file within four years of the initial EMST training) ever complaints against major US research institutions. since. This results in the delay or cessation of research progress, the waste of much-needed resources The LTTT situation in the United Kingdom and results in frustrating delays while complaints are investigated, many of which usually result in In an article supporting the use of LTTT, Reeds ‘non-event’ outcomes. It seems that their collective (2010) states that ‘it would be prudent to clarify influence is spreading, for example, one just has that the Royal College of Surgeons of England to take note of the ever-increasing, official filed (RCSE) neither supports nor objects to the use of complaints to animal welfare regulatory bodies live animals for trauma training’.17 In a document such as the US Department of Agriculture (USDA) published by the RCSE in 1999, titled ‘Surgical and Animal and Plant Health Inspection Service Competence Challenges of Assessment in Training (APHIS). These obstructive tactics have had, at least and Practice’, the RCSE remained ‘neutral’ by in some cases, their desired effect, with a few major providing information as to the benefits of LTTT, internationally-respected research institutions very but also emphasizing the disadvantages relating to recently having ceased using live animals.23 animal welfare considerations. Rather than outlining the formal policy of the RCSE on LTTT, this document This has occurred not due to the institutions in was simply a discussion of issues relating to surgical question having breached any federal animal welfare training and LTTT, which was collated as a summary laws but rather because it simply was easier for the of various conference presentations. As such, the institutions to avoid the time-consuming nature document ‘has confirmed that it does not hold any of such USDA investigations and the associated formal opinion or policy (on LTTT) nor has it ever disruption to research, teaching and training. considered the same.’18 The two Canadian hospitals in question, namely Hamilton Health Sciences in Ontario and Saint John Regional in New Brunswick Canada, have indeed halted their Advanced Trauma Treatment Courses (ATTC) using live pigs, and have commenced using patient simulators.23 Despite being accused of ‘caving in’ to external pressure exerted by the PCRM by some commentators, there was resistance by the Hamilton institution staff to the loss of the ATTC. Surgical residents at Hamilton openly expressed their opposition to the changes, as they considered the new simulators as poor replacements Anti-animal testing protesters marching through the in their training when compared to their previous streets of London (sourced from an anonymous internet experience using live pigs. The medical students source) 3518089112_6a7198e73f.jpg/flickr.com repeatedly demanded the return of the pigs for this type of training, because they felt that the ‘tissue’ Anti-vivisectionist groups also oppose civil on the mannequins simply was neither lifelike nor medical research realistic.23 Anti-vivisection groups such as PCRM, PETA and the Citing stark factual differences, a university more militant group Animal Liberation Front (ALF) veterinarian at Hamilton made it clear that some of the UK have traditionally been strongly opposed (anti-vivisectionist) groups often deliberately used to the use of animals for research purposes of any misinformation to get their point across.23 For

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example, in this very situation, the pigs used in paediatric training sessions per year. He reported the ATTC were cared for by well-trained, dedicated species was a good model for such training as they staff who would ensure that they were housed in a were a hardy animal which, when anaesthetized, comfortable environment, were well-fed and treated could easily tolerate between six to eight intubation with the utmost care and respect. Pre-delivery to attempts with minimal airway irritation. Recovery the institution, the pigs would be transported in is rapid and they could be used again within a an air-conditioned van and given a period in which few weeks.25 The Professor said that this training to acclimatize to their new surroundings. The pigs was important as it helped train medical students would be carefully anaesthetized before undergoing to insert breathing tubes in very low birth weight the ATTC procedure, and prior to the conclusion of babies, where medical simulators (mostly plastic the training, they would be humanely euthanased models which contain semi-realistic anatomical with an overdose of anaesthetic while still features, and unable to adequately duplicate the unconscious. This entire protocol certainly does not airway passage in extremely small infants) simply reflect a portrait of inhumane treatment of animals, weren’t at the level of sophistication required for as claimed by some anti-vivisectionist groups. these tiny infants. PETA filed a complaint in 2010 to the USDA against the University of Michigan (UM), which conducts Anatomical and physiological differences Survival Flight Training using animals.24 It claimed Anti-vivisection groups often cite the anatomical that the UM had violated the US Animal Welfare and physiological differences between animals Act because it used cats and pigs in an emergency and humans as one of their main arguments in training course for its Survival Flight nurses opposing LTTT. In a brief prepared by the PCRM for (personnel providing emergency air transportation consideration by the US Senate in relation to the BEST service for patients in critical care). PETA stated Practices Act30 the PCRM states that ‘the use of pigs that the UM should use human simulators instead and goats for combat casualty care training (another of live animals to practise common emergency name for LTTT) is suboptimal due to, among other procedures such as endotracheal intubation, which issues, the animals’ anatomical and physiological involves inserting a breathing tube into the trachea differences from humans. Compared with humans, to ventilate the lungs. pigs and goats have smaller torsos and limbs, thicker skin, different responses to anaesthesia and Responding to the PETA complaint, the UM analgesia, and important differences in anatomy of veterinarian and director for laboratory animal the head and neck, internal organs, limbs, blood medicine stated that ‘the work of the Survival vessels and airway’. Flight nurses required that such procedures were performed on living tissue’, and that there was no The same report also seems to recognise however substitute for this type of training, claiming that that the most important elements of LTTT for both simulators and associated teaching aids simply practitioners is realism, human-specific injuries and weren’t adequate.24 This training was designed for treatments, volume of trauma exposure and ‘team- practising various essential life- saving techniques, building’.30 In essence, they recommend combined which ultimately would be used for helping young use of simulators, human cadaver use and access children. The clinicians felt that because of the to civilian trauma centres. While in theory this anatomical similarities between some animals and combination of training elements does sound ideal humans, they were simply the best learning models for LTTT, and in fact they are used by the military available for this training,24 and importantly, the wherever and whenever possible, all of these separate animals were under anaesthesia when such training elements do have their own inherent problems. was being conducted. In addressing the first argument above, it needs to be In another separate animal welfare complaint, stated that it is the reaction or response of living tissue filed by the PCRM to the USDAs APHIS against to injury or irritation, rather than the anatomical or the University of Washington (UW) School of physiological species differences which is the main Paediatrics,25 the PCRM claimed that this institution issue in question. Live tissue appears to be the most was breaking federal animal welfare laws because it suitable element in training combat medics. ‘Most used live (anaesthetized) ferrets as a model to train patient simulators do not bleed, and those that paediatric medical residents to insert breathing can, do not respond in the same biological way that tubes, as would be used for emergency procedures bleeding patients do in clinical practice’.31 Using the in premature babies. Responding to the complaint, example of physician training, real vascular injuries a UW Medical Director and Professor of paediatrics allow trainees opportunities to perform various stated that up to ten ferrets (maximum) were used for techniques that respond authentically to injuries

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that they realistically encounter during clinical Major General Pollock made the following statement practice; this is a distinct advantage of the Advanced in 2007, “On any given day more than 12,000 Army Trauma Operative Management course (or LTTT) that medics - physicians, dentists, veterinarians, nurses, uses the live tissue porcine model and which has allied health professionals, administrators, and been shown to be of great benefit to trainees.32,33 ‘An combat medics - are deployed around the world additional benefit is the pathophysiological response supporting the (US) Army in combat, participating to traumatic injuries that live tissue provides and in humanitarian assistance missions and training the appropriate physiologic response of the patient throughout the world”.36 Furthermore, he added that is observed to the trainees interventions/clinical that “to date, more than 17,800 Combat Medics have management’.17,31 Simulators and human cadavers received training in Medical Simulation Training cannot produce this same effect. Endoscopy and Centers which use computerized mannequins that other associated training techniques have also been stimulate human response to trauma. (Only) use of used as part of LTTT. Some operators, Barthet et live tissue best simulates the challenges and stress al (2007), also have ‘demonstrated significantly inherent in stopping actual bleeding”.36 From the increased competence using live liver tissue in above statements, it should be obvious to the reader performing diagnostic procedures with regard to that LTTT is the optimal method of training delivery visualizing anatomic structures, performance of fine and that the ‘through-put’ of hospital trauma centres needle aspiration, and, to a lesser extent, endoscopic cannot provide pre-deployment training requirements ultrasound-guided celiac neurolysis (endoluminal for combat medics, especially in adequate emergency ultrasound)’.34 case management experience. Other problems with the use of civilian trauma centres for combat medics With respect to the use of human cadavers and is that the types of injury encountered in hospital simulators as an alternative to LTTT, another trauma centres are quite different to the spectrum distinct advantage of live tissue is that organ texture of injuries that service members often encounter and tissue handling characteristics are optimal, both on the battlefield. Lastly, putting combat medics in of which are limited in cadavers and simulators. civilian trauma centres for the purposes of training Although cadavers and simulators have their uses in also removes them from their daily duties and thus certain applications, neither respond authentically to reduces their capacity to provide healthcare for other surgical procedures and other medical interventions military personnel. in the same way that living patients do in everyday trauma practice.31 There are various (human) In terms of military medical preparation for the simulators on the market, most of which have been treatment of combat casualties, advocates strongly developed to meet certain requirements for training. believe that LTTT is the current solution because it One of them, ‘Trauma Man’ (Simulab Corporation) is effective (it saves lives) and is the most advanced was constructed specifically for advanced trauma kind of training available. It trains its participants surgical skills training. According to the Surgeon to observe, assess, triage and treat based on the General of the US Army, Major General Gale S. severity of the penetrating trauma presented, and all Pollock, ‘use of this simulator is not applicable set within a ‘battlefield scenario’ where the need for for haemorrhage control, the largest, preventable rapid decision- making in a ‘high-stress’ environment killer of our Service members on the battlefield’.7 is a constant challenge for the course participants.7 Furthermore, in a study done at the US Army Base Participants in LTTT build an individual proficiency at Fort Lewis, a haemorrhage simulator was used to and a level of confidence in their ability to treat real training military medics. However the control group combat casualties.37 had received no exposure to the simulator. There The US military already uses a range of simulators was no comparison with live animal haemorrhage including Trauma Man, the Combat Trauma Patient training.35 It should be remembered that simulation Simulation System, and other training modalities as is a training step; it is not the end of the training described by Cherry and Ali.38 While these simulators process.7 are used where appropriate, and although they can The use of civilian trauma centres, as an alternative to enhance the experience of learning trauma training, LTTT and on the scale that the military requires it, is they are only at best a progression towards, rather also unrealistic and naïve. Hospital emergency rooms than a replacement for, LTTT, as they cannot replace simply do not have the capacity or the resources to all of the procedures used in training combat medics. accommodate the needs of the military. As a rough So, effectively, the use of live animals cannot be guide, their programmes can only provide training for eliminated altogether and this remains the reason approximately 24 men (only) every 6-8 weeks.7 To put that the US military uses the LTTT model for its the US military’s requirements into some perspective, troops pre-deployment.39 However, ‘hybrid’ courses

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have been developed by military training providers the life-saving benefits to human health have been which offer a combination of LTTT, use of simulators, enormous, as has the reduction of human suffering human cadavers and civilian trauma centres to aid caused by widespread, global infectious diseases.26 in the training of military medical personnel. Though This has only been possible, because of the far- the success of some of these programmes has been reaching implications of animal-based research variable,40,41,42 the use of live tissue has remained an and training. Interestingly, recent figures from the essential component of such training. US National Academy of Science confirm that world rankings on average life expectancy have shown One of the better developed hybrid courses is the that they have increased over the last 25 years, due US Army’s ‘Tactical Combat Casualty Course’ which mostly to the advances in medical research and consists of didactic sessions, interactive human training.27 There have also been immense direct surgical simulators, triage scenarios, use of animal benefits to veterinary medicine as a result of animal- tissues and LTTT. It would be interesting to see how based biomedical research. Unfortunately, many changing the relative proportions of such hybrid anti-vivisection groups continually dismiss these training may affect overall tuition, hence further enormous advances in human and animal medicine research in this area is needed. Currently, until a and continue to incorrectly propagate the view that simulation technique is developed that is documented these advances have been achieved at the expense of to equal the benefit of live tissue training in preparing ‘humane’ care of animals. medics to manage combat trauma, appropriately conducted LTTT should be supported as an essential Surely the ‘common denominator’ on both sides of this component of combat medic training.7,43 debate must primarily be the increased protection and safety of service personnel, together with enhanced There are a number of simulators available for generic humane welfare and protection of animals used for training which, although improved in their ability to LTTT, CWDR and MMR purposes. It should be noted provide useful training, they do not yet have the full that the US Animal Welfare Act28 does permit the use capability of encompassing all aspects of live tissue of live animals for research and training purposes training.44 It is for this reason that the American in both the civil and military arenas. However, it is College of Surgeons (ACS) “supports the use and the role of this Act to regulate whether animals are humane care and treatment of laboratory animals treated humanely. Violations of the Act are promptly used in research, education, teaching and product investigated. Routine monitoring of conduct often safety testing in accordance with applicable local, involves unannounced visits to research and training state, and federal animal welfare laws”. The ACS also establishments, aiming to ensure that animals are states that “wherever feasible, alternatives to the use being treated humanely and with the utmost care. of live animals should be developed and employed” Actions taken for non-compliance can be severe and but “believes that now and in the foreseeable future range from official warnings to fines being imposed it is not possible to completely replace the use of on the institution, with the possibility of suspension animals and that the study of whole living organisms, of work or the revocation of research licenses. tissues and cells is an indispensible element of biomedical research, education and teaching”.45 The majority, if not all, research and training institutions both military and civil, operate within a The benefits and controls of animal-based rigid environment of internal and external controls research and training governing their use of animals. This environment is highly regulated by the federal government, overseen Military medical personnel and researchers by federal agencies which mandate several layers of across most institutions acknowledge the use and review and involve a dedicated staff of caretakers usefulness of alternative approaches as being very and research animal veterinarians.26 Additionally, important. They do not use animals unnecessarily each institution has effective animal care and use or uncaringly. All personnel consider it a privilege to committees set up to provide internal controls. A use animals in research or training, and demonstrate requirement of these committees mandates that a this by treating them with the utmost level of care lay-person (an ordinary member of the community) and respect. serve as a member of its quorum. Indeed, the Military research groups often support their system on which this model is based is in place in argument by reminding us as to the many lives many western countries today. Taking all of these of soldiers saved directly, both in the past and factors into account, it should be evident that claims currently, as a consequence of LTTT, CWDR and such as ‘inhumane treatment’, ‘fraught with animal MMR. This has similarly been the case in the cruelty’ and the like, appear to be without foundation. civilian arena of medical research as well, where Nonetheless, there is no room for complacency as it

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is important that regulatory authorities continue to non-animal alternatives exist, every effort is made monitor the welfare of animals used for military and to promptly implement or adapt them for current civil research and training activities, and continue use. And although military and civil researchers will to maintain the high standards expected of such make use of new alternate technology and training institutions. Those ‘high standards’ have long been a methodologies wherever possible, at this point in tradition in the military services as ‘military medicine time, animals (along with other types of tuition) has always been at the forefront of research. remain vital in advancing medicine and for use in It spans everything from disease prevention to life-saving training techniques. rehabilitation’.29 Acknowledgments Summary This work is based on an article previously published This article highlights the importance of military in ‘Lab Animal’. training in life saving techniques and treatments developed through clinical research and now used The author would like to thank Dr. Julianne by physicians and combat medics operating in the Djordjevic and Dr. Julie Ferguson for their critical emergency arena of warfare. To this end, it should be review of the manuscript. remembered that such protocols have been refined Author’s affiliation: Westmead Millennium Institute to minimise pain and distress to animals, that the Contact author: Gary Martinic number of animals used is always reduced to the Email: [email protected] absolute minimum possible and that where effective

References 1. Physicians Committee for Responsible Medicine (2011). Improving Military Medicine. Frequently asked questions: Implementing non-animal training methods in US Military Medical courses. http://www.pcrm. org/resch/dod/faq.html 2. Hanson, J. (2010). Save people, not pets – Banning medic training with live animals could kill our troops. http://www.washingtontimes.com/news/2010/may/25/save-people-not-pets/print/ 3. Shalev, M. (2011). Regulation update – May/June 2011. ALN Magazine. http://www.alnmag.com/ print/5784 4. U.S. National Humane Education Society (2011). Vivisection may wane in military; still going strong at UW school of medicine. http://nhes.wordpress.com/2011/02/18/vivisection-may-wane-in-mili... 5. Budkie, M.A. (1997). Military animal research. Medical research modernization committee. http://www. mrmcmed.org/mar.html 6. United States Department of Agriculture Market News. Slaughter Report for the week of February 16th 2009. United States Government. 7. Morehouse, D. (2009). Live Tissue Training and Ballistic Wounding Point Paper. http://bloximages. chicago2.vip.townnews.com/nctimes.com/content/tncms/assets/editorial/2/0c/128/20c128fa-83ab- 11de-b0a8-001cc4c002e0.pdf.pdf 8. Chivers, C.J. Tending a fallen marine, with skill, prayer and fury. New York Times (http://nytimes. com/2006/11/02/world/middleeast/02medic.html) (2006) 9. Knudsen, P.J, Darre, E.M. (1996). Training in wound ballistics: operational exercises at the Defence Medical Training Centre. J Trauma Mar; 403 (3 Supplement): S6-9. 10. Walker, M. (2009). Military: Marine Corps lift the veil on ‘live tissue training’. http://www.nctimes.com/ news/local/military/article_9a50803f-b16c. 11. Robson, S and M. Kloeckner (2010). Army looking to conduct combat medic training on live animals in Germany. Stars and Stripes. http://www.stripes.com/news.europe/army-looking-to-conduct-comb... 12. Hull, D.L. (1976). The rights of animals. Science. 192: 679-680. 13. Silverman, J. (2008). Sentience and sensation. Lab Anim (NY). 37; 465-467. 14. Gomez, A. (2009). ‘Hibernation’ research could help on battlefield, at home. http://www.usatoday.com/ news/world/2009-12-20-bibernation-research_N.htm 15. Royal Australian College of Surgeons. (2010). EMST Training. http://www.surgeons.org/racs/education- trainees/skills-training/emst/

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16. NHMRC (2009). Guidelines on the use of animals for training interventional medical practitioners and demonstrating medical equipment and techniques. Australian Government Publishers, Canberra. 17. Reeds, M.G. (2010). Trauma Training Using the Live Tissue Model. J.Trauma Vol.69(4); Oct. 999-1000. http://ovidsp.tx.ovid.com/sp-3.4.2a/ovidweb.cg?QS2=434f4e1a73... 18. The Royal College of Surgeons of England. Surgical Competence Challenges of Assessment in Training and Practice. Lincoln’s Inn Fields, London: RCSENG-Communications;1999. Available at: http://www.rcseng. ac.uk/publications/docs/surgical_competence.html 19. Conn, P.M. and F.T.Rantin. (2010). Ethical research as the target of animal extremism: an international problem. Brazilian J Med Biol Res. http://www.bjournal.com.br 20. Conn, PM, Parker, JV. (2008). Terrorizing Medical Research. The Washington Post. (syndicated by the LA Times-Washington Post) December 9, pg. a 19 op ed http://www.washingtonpost.com/wp-dyn/content/ article/2008/12/07/AR20081 21. Conn, PM. (2008). The War on Animal Research. The Scientist. 22(3): 40-46. http://www.the-scientist. com/article/display/54494/ 22. Newsweek, December 10, 2009, http://www.newsweek.com/id/226336. 23. Blackwell, T. (2011). Hospitals bow to US group, quit using pigs. http://nationalpost.com/news/ Hospitals%2Bgroup%2Bquit%... 24. Keeping, J. (2010). University of Michigan response to PETA complaint: ‘We have nothing to be ashamed of”. http://www.annarbor.com/news/university-of-michigan-to-peta-we-have-nothing-to-be-ashamed... 25. Cohn, M. (2011). Group faults UW use of ferrets in medical training. http://seattletimes.nwsource.com/ html/health/2014178603_uwanima... 26. Martin, B. (2010). Animal studies save lives, limit suffering. http://host.madison.com/wsj/news/opinion/ column/guest/article_c2ba866e-80c2-11df-... 27. Murphy, B. (2011). Understanding life expectancy in the US: analysis behind the numbers. http://notes. nap.edu/2011/07/05/understanding-life-expectancy-in-the-u-s-anaylsis-behind-the-numb... 28. Animal Welfare Act 9 CFR. United States Government. 29. Cressey, D. (2010). From battlefield to bedside. Nature. http://www.nature.com/news/2010/101217/ full/news.2010.684.html 30. Physicians Committee for Responsible Medicine. (2009). Saving troops: the implementation of non-animal training methods in US military medical courses. A Brief prepared by the PCRM. 31. Reeds, M.G. (2010). Live Tissue: Ideal for Trauma Training. J.Trauma. Vol. 68(5); May. 1268-1269. http:// ovidsp.tx.ovid.com/sp-3.4.2a/ovidweb.cg?QS2=434f4e1a73... 32. Jacobs, L.M., Burns, K.J. et al (2003). Development and evaluation of the advanced trauma operative management course. J. Trauma. 55: 471-479. 33. Jacobs, L.M., Burns, K.J, et al (2005). Follow-up survey of participants attending the advanced trauma operative management (ATOM) course. J.Trauma. 58: 1140-1143. 34. Barthet, M., Gasmi, M. et al (2007). EUS training in a live pig model : does it improve endoscope hands-on and trainee competence? Endoscopy.39: 535-539. 35. Mabry, R.L. (2005). Use of a haemorrhage simulator to train military medics. Mil Med. Nov; 170 (11):921-5 36. Pollock, Gale S. (2007) (Major General, Acting Surgeon General of the United States Army) Statement made to the 110th Congress, first session. March 27th. 37. Blumenfeld, A., Kluger, Y. et al (1997). Combat trauma life support training versus the original advanced trauma life support course: the impact of enhanced curriculum on final student scores. Mil Med. Jul; 162(7): 463-7. 38. Cherry, R.A. and Ali, J. (2008). Current concepts in simulation-based trauma education. J. Trauma. 65 : 1186-1193. 39. McManus, J.G., Eastridge, B.J. et al (2007). Combat trauma training for current casualty care. J. Trauma. 62: 513.

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40. Sohn, V.Y., Miller, J.P. et al (2007). From the combat medic to the forward surgical team : the Madigan model for improving trauma readiness of brigade combat teams fighting the Global War on Terror. J.Surg. Res. Mar; 138(1):25-31. Epub 2006 Dec29. http://www.ncbi.nlm.gov/pubmed/17196987 41. Gerhardt, R.T., Hermstad, E.L. et al (2008). An experimental pre-deployment training program improves self-reported patient treatment confidence and preparedness of Army combat medics. Prehosp. Emerg. Care. Jul-Sep; 12(3): 35965. http://www.ncbi.nlm.nih.gov/pubmed/18584505 42. Rubiano, A.M., Sanchez, A.I. et al (2010). Trauma care training for National Police nurses in Colombia. Prehosp. Emerg. Care. Jan-Mar; 14(1): 124-130. http://www.ncbi.nlm.nih.gov/pubmed/19947877.. 43. United States Army Institute of Surgical Research (2009).Tactical Combat Casualty Care (TCCC) Retreived Feb. 23rd. http://www.usaisr.amedd.army.mil/tccc.html 44. Moore, W.A. and Noonan, A.C. (2010). Using live tissue laboratories to promote clinical reasoning in doctor of physical therapy students.AdvPhysiolEduc.34:54-58 45. American College of Surgeons (2002). Statement on the use of animals in research, education, and teaching by the American College of Surgeons. Reprinted from Bull Am Coll Surg 87:16. http://www.facs.org/ fellows_info/statement/st-10.html

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