Combat Trauma Medicine (CTM) Student Reference Manual "These materials may be used only for Educational and Training Purposes. They include extracts of copyright works copied under copyright licenses. You may not copy or distribute any part of this material to any other person. Where the material is provided to you in electronic format you may download or print from it for your own use. You may not download or make a further copy for any other purpose. Failure to comply with the terms of this warning may expose you to legal action for copyright infringement." Deployment Medicine International 2 THIS PAGE LEFT INTENTIONALLY BLANK Deployment Medicine International 3 COURSE INTENT Combat Trauma Medicine (CTM) 1. We are medical trainers; we do not establish policy or protocol. We contribute to these processes through our individual and collective experience on the field of battle. We are educators and trainers devoted to the transformation of warriors into warrior healers; the ultimate Warfighter – trained to save lives as well as take them. 2. This course of instruction is designed to address the medical theory and science behind the special needs of providers in a theatre of war. Our goal is to augment the skills already given you through your service schools and other training—to present you with innovative lessons learned from the battlefield—to give you additional confidence and knowledge. Our mission it to train you to be your best when you’re best is needed in combat. Our mission is to train you to save the life of the operator sitting next to you. 3. The DMI CTM (with Live Tissue Training) course addresses the mission of the operational emergency medical care, remote medical care, prolonged transport times, unique military wounding and the pre-hospital environment. In this course we stress both the “How” and “Why” of every combat trauma medical task. 4. We provide a course based on current science and actual experience specific to the unique environments and resources of operational units to build on previous non-medical training to specify and train to the treatment options available to you, the “Warfighter”, in the combat environment based on the best academic medical consensus (as a minimum, Tactical Combat Casualty Care; Basic and Advanced Pre-hospital Trauma Life Support—Current Version), real casualty data, and actual combat experience to include (as a minimum): • Managing Blood Loss • Airway Management (Non Surgical) • Respiratory Injury Management • Circulation Shock Management • Head Injury and Hypothermia Deployment Medicine International 4 M H A C R • Casualty Assessment • Medical Ramifications of Blast Injury • Operational Burn Injury Management • Prolonged Care • Advanced Wound Care Management • Pain Management • Maximizing Operational Performance • Field Exercises and Tactically Relevant Scenarios Deployment Medicine International 5 5. Training for today’s warrior healer (Warfighter) has changed tremendously in the past decade. Lessons learned in previous conflicts and requirements for military transformation have been incorporated into this training. The warrior healer of today is the most technically advanced, highest trained, and best equipped ever produced by the United States Military—our mission is to take your training to the next level. 6. We account for every minute of your training time to maximize your training experience. 7. Your missions – ask questions, contribute, and remain present and focused. Everything you learn over the next several days will save your life, or the lives of your comrades should you have to apply what is taught in this course – pay attention. 8. We believe that proper, detailed, and current medical science taught in the classroom, and reinforced in the Live Tissue Training will bring together the students performance, knowledge and skills. Therefore, we stress critical points of operational medicine and lessons learned through case studies and experience in austere operational environments. We are dedicated to giving our students the time, training, and experience necessary for them to remain this Nation’s vanguard. 9. Classroom didactic lecture, simulator training, and practical exercise (mini labs) will incorporate the following (as a minimum) course criteria – DMI will add to this the curriculum and include a much broader spectrum to training for the non-medical operator or combat lifesaver. Deployment Medicine International 6 COURSE METHOD The Hybrid Training Model 1. Although not new to the military training regime, performance oriented training (Task, Condition & Standard) developed in the 1970’s and 1980’s was adopted years ago as the teaching mechanism of choice by Deployment Medicine International (DMI). DMI accepts performance- oriented training as the baseline standard for all of its training programs. However, training has evolved in the decades following the inception of service wide performance oriented training programs—especially in the field of operational medicine. Therefore, DMI has adopted a four-phased hybrid-training model, which expands the students learning experience in two functional areas (performance and retention). We do this to ensure a definitive result where it is needed most—in battle. 2. The four-phases of the hybrid-training model are: a. The Classroom Didactic. This will be the lecture portion of your class, each day, wherein the theory, science, and case studies of each learning objective are discussed. b. Practical Exercise, Lab and Simulator training (mannequin, FAST-1, others). This portion of the training model involves the (in class) use of simulators, practical demonstrations, videos, hands on applications and practice using mannequins and other simulators, as well as the experience of performing (permitted) medical procedures on each other and on harvested animal tissues (swine tracheas and ears). c. Live Tissue Procedures (a half day of medical procedures on anesthetized animals). The field training exercise training is divided into two-phases (procedures and scenarios). Phase 1 of the live tissue portion of your training involves the intensive focus of performing life-saving battlefield trauma procedures on fully anesthetized animals. DMI instructors monitor and train you— Deployment Medicine International 7 walking you through each procedure, demonstrating, and then allowing you and your team to perform the procedure under their tutelage. DMI’s veterinary staff and instructors constantly monitor your patients (anesthetized swine). Students will assist in this attention. d. Live Tissue Scenarios (a half day of hyper-realistic, tactically relevant scenario based training using anesthetized animals). The term tactically relevant in Phase II of live tissue training is critical. You are expected to respond to scenarios that template OIF/OEF battlefield conditions, and you will be likely to provide care to the wounded in all three phases of Tactical Combat Casualty Care, (1) Care Under Fire, (2) Tactical Field Care, and (3) Prolonged Field Care conditions. 3. Why do we employ the hybrid-training model; why not just teach medicine? This is a very good question; however, the training mission of DMI is not only to teach medicine, it is to teach medicine employed in high-threat environments. This is medicine to save life while all around you; the enemy will be trying to take your life. To function in this environment requires the convergence of two elements of the human performance model: the performance curve, and the retention curve. 4. The performance curve defines your ability to do just that, perform, to see the patient, access the patient, decide the optimum course of action to treat the patient and then treat—save life. Many of your colleagues/operators have adopted the adage, “Minutes equal blood, and blood equals life”. The performance curve must peak at the point of wounding, often under fire (care under fire) or facing imminent danger as you treat (tactical field care), or during prolonged field care. History demonstrates that performance curves are high in low stress environments and markedly low in high stress environments. Therefore, how do you ensure that your performance curve peaks at the point of wounding? In addition, what other mechanisms drive this peak performance? Deployment Medicine International 8 5. The other element of measurement in training is the retention curve—the ability to recall all of the decision variables related to a life saving task at the speed of thought, during the worst of circumstances—at the point of wounding. The classroom didactic, the practical labs and Phase I of the live tissue training are all designed to build muscle memory, to reinforce analysis, decision, and right action. Through decades of educational science, it has been determined that the retention curve is affected differently than the performance curve in high stress learning environments. In this instance, the stressors of the classroom environment build and embed neural patterns affecting muscle memory. These patterns are called upon in battle; what you know must coalesce at precisely the right moment as action (performance) if you are to be effective in battle. Deployment Medicine International 9 The illustration above (first figure) shows the retention curve and performance curve coming together past the point of wounding—this equates to lives lost. The illustration below (second figure) demonstrates the desired outcome of the emergence of the performance and retention curves at the point of wounding—a condition