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Changing landscapes of military conflicts require rethinking of casualty care.

U.S. Military soldiers assisting injured soldier
Bag-mask ventilation performed by United States Air Force soldier on simulation manikin

Author: LTC(Ret) Walter Engle, PA-C. Medical Consultant/Medical Trainer

“To secure peace, prepare for war.” – Carl Von Clausewitz

It’s been said that “Combat medics don’t study to pass the test. They study to prepare for the day when they are the only thing that stands between the patient and the grave.”

Thanks to the laser-focused efforts of professionals in the modeling and simulation industry, the military men and women rendering life-saving casualty care on the battlefield are more prepared today to be that solid barrier between “the patient and the grave.”

A major player in ensuring a continually increasing survival rate on the battlefield has been Operative Experience, Inc. (OEI). An innovator in healthcare simulation and tactical medicine, OEI fielded the Tactical Casualty Care Simulator (TCCS) for all combatant Tactical Combat Casualty Care (TCCC) training in 2017.

It quickly became the go-to technology for TCCC training among nearly all branches of the military because OEI designed its simulator for the sole purpose of complying with guidelines designed by Department of Defense (DoD) to save lives in short-term casualty care situations.

But on the field of battle, time is not a friend of those faced with the unenviable task of sustaining the lives of critically wounded warriors.

Care providers have what is called a “golden hour’ to apply their life-saving skills at the point of injury before handing off to a fully equipped military field hospital.

Unfortunately, that golden hour may turn into days in future conflicts in a Large Scale Combat Operation environments that make evacuation of the wounded even more difficult.

Senior Military leadership are warning that future conflicts with near-peer adversaries such as China, Russia, North Korea, Iran and others will create a “tyranny of distance” that will impair the quick evacuation of wounded combatants to a higher level of medical care. This creates a Prolonged Casualty Care (PCC) situation for Service Members.

In an online article posted by Health.mil, titled How Military Medicine is Preparing for the Next Conflict, Air Force Col. Stacy Shackleford, Trauma Medical Director for the Defense Health Agency (DHA), Colorado Springs Market, drives home the need for a new kind of training, new equipment and a new approach to casualty care.

“We’re worried about future casualties because those distances [to hospitals] are so great,” she warned. “If wounded warriors are unable to get that care within the golden hour window of time, Service Combat Medics, Special Operations Medics, and Independent Duty Corpsmen will need a lot of skills, such as administering pain medications, long-term pain control, advanced airway management, and nursing skills like changing dressings, even things like rolling the patient.”

The requirement for smaller combat units will pose another challenge to survival on the battlefield.

“It is entirely conceivable to me that a future force will need to be lots of small entities, small organizations that are in constant states of movement in order to survive on a highly lethal battlefield,” a top U.S. military leader said during a recent podcast to a foreign affairs audience.

Those smaller fighting units, four-person fire teams and nine-person squads, will rely on extensive, realistic combat medical training to prolong the lives of their team members until the next tier of medical care becomes available.

This task fell on all senior military leaders, including the DHA Director, LTG Telita Crosland. LTG Crosland recently challenged deployable Forces to prepare for PCC and to increase “return to duty” (RTD) rates on the battlefield as all logistics will be contested in a LSCO environment where there is decreased air superiority for medical evacuation.

Continuing with the proven successes of TCCS, the professionals at OEI, Inc. have worked together in partnership with the Department of Defense to meet its new challenge of caring for the wounded during longer, more isolated periods of conflict.

OEI answered the call to take its life-like medical mannequin, the TCCS, to the next level of realism and intensity with its new Prolonged Casualty Care Simulator Pro (PCCS Pro).

Male TCS simulator in training exercise in an ambulance

The company upgraded the simulator technology and introduced the only mannequin simulator on the market to meet all 13 guidelines established by the PCC Working Group (WG) for casualty management over a prolonged amount of time in austere, remote or expeditionary settings, and/or during long-distance movements. Prolonged Casualty Care (PCC) provides a seamless transition from the initial triage and treatment of Tactical Combat Casualty Care to those longer-term care goals essential to increasing survival rates.

OEI’s PCCS is true to lifesaving critical-care criteria for injuries that result in the highest casualty rates when rapid and effective treatment is not available, MARC2H3-PAWS-L, standing for massive hemorrhage, airway respirations, circulation, communication, hypothermia/ hyperthermia, head injury (traumatic brain injury), pain control, antibiotics, wounds (+nursing/burns), splinting and logistics. By strictly following PCCC’s MARC2H3-PAWS-L, OEI has produced a simulator that is unrivalled in its training of PCC care and examples of training scenarios in which PCCS training excels include:

  • Stage 2,3 or 4 hypothermia,* and hyperthermia
  • Massive hemorrhage extensively aligned with the proper clinical queues, and drug and treatment response
  • Pain management supported by correct drugs and drug response
  • Burn treatment that replicates the correct physiologic queues associated with the required support to antibiotics, sepsis, and other drugs
Soldiers performing medical training simulation on a manikin

As established by the PCC WG, the PCC principles* are all executable in training sessions with OEI’s PCCS Pro through the proposed PCC roles of care at Point-of-Injury/Need (RUCK), transportation platform (TRUCK), support site (HOUSE) and evacuation (PLANE). The principles include:

  1. Perform initial lifesaving care and continue resuscitation.
  2. Delineate roles and responsibilities, including naming a team leader.
  3. Perform comprehensive physical exam and detailed history with problem list and care plan.
  4. Record and trend vital signs.
  5. Perform a teleconsultation as soon as feasible.
  6. Create a nursing care plan.
  7. Implement team wake, rest, chow plan to take care of the medic and each first responder.
  8. Anticipate resupply and electrical issues
  9. Perform periodic mini rounds assessments to recognize changes in the patient’s condition.
  10. Obtain and interpret lab studies.
  11. Perform necessary surgical procedures, while considering both risks and benefit to the patient’s overall outcome and not merely the immediate goal.
  12. Prepare for transportation or evacuation care while ensuring there are ample drugs, fluids, supplies needed for long distance movement.
  13. Prepare documentation for patient handover.

OEI’s unique, modular “Smart Limb” technology with interchangeable limbs and wounds instantly enables trainers to create different injury profiles allowing medical personnel to train correctly to handle some of the most critical and life-threatening injuries in combat: traumatic limb amputation, junctional hemorrhage, maxillofacial injuries, burns and others.

In further support of the PCC WG guidelines for prolonged care training, the PCCS Pro includes advanced physiology and conditions, drug library support, fully integrated patient monitoring, and all-new software capabilities and scenarios.

The simulator’s state-of-the-art technology uses real-time feedback to enhance learning. A smart tablet queues up human response based on the type and success of interventions a trainee administers.

As in a true medical emergency scenario, improper medical intervention will lead to increased patient morbidity and possible mortality. Fortunately, the trainees learn from mistakes made, discuss triage and treatment through the After Action Review process and continue simulated scenarios on the simulator until individual and collective medical-skills proficiency ratings progress from Untrained (U) to Trained (T).

PCCS Pro is available in models with varying skin tones to better represent today’s diverse military.

OEI is also the first company to produce a completely anatomically correct female simulator for use in casualty care training with the introduction of its Tactical Casualty Care Simulator Pro (TCCS Pro), the backbone of the new PCCS Pro.

Female mannequins designed for both the PCCS Pro and the TCCS are solely based on female anatomy, which is important for trainees in multiple scenarios, such as the triage of a gunshot wound to the chest and treatments of chest seal application and needle decompression. The ability to train with accurate anatomical representation is essential to saving lives and contributes to improved survival and RTD rates on and off the battlefield.

United States Air Force personnel performing an emergency trauma exercise with Operative Experience simulators

Historically, “female” mannequins used by the Department of Defense were male models using overlays of female anatomy. The modifications did not realistically represent women’s anatomy, body weight, or proportions.

That deficiency produced a negative training experience and ultimately lowered chances of survival for female service members during recent conflicts. Critical injuries to the chest area are often missed because of hesitancy by all Service Members to completely expose female patients during trauma assessment. Repetitive training on the female simulator will negate the delayed response in providing care to female casualties.

OEI modeled its design using data compiled about service women by the U.S. Army Research, Development and Engineering Command.

“At OEI, we are extremely passionate about exceeding in our mission to support such a critical medical need for our brave military men and women,” said Lou Oberndorf, OEI chairman and CEO. “Just knowing that the medical training products we put in their hands are having a profound impact on returning our wounded warriors to their loved ones is a satisfaction beyond belief.”

Part of the combat medics’ creed is “Combat Medics never stand taller than when they kneel to treat the wounded!  Saving lives in the midst of utter chaos!”

With sophisticated, cutting-edge training tools, like TCCS and the PCCS Pro, backed by well-researched medical guidelines from DoD, the U.S. military medical personnel can stand even taller in combat when the call of “Medic!” reverberates on the battlefield.



*Found on PCC Guideline (CPG ID: 91) on deployedmedicine.com

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