Crossings

by Jon Kerstetter

  During the four weeks of “train-up,” every imaginable form of training took place: weapons qualification, self-defense, rescue operations, medical emergencies, patient evacuation, map reading, land navigation, equipment maintenance, radio communications, and convoy tactics. The training checklist also contained elements of combat strategy, team leadership, intelligence operations, and enemy tactics. Training did not end. Soldiers trained in the morning, at night, in the dark, in the cold—indoors and outdoors. We did portions of our desert warfare training in the snow that still lay in the heavily wooded acres of Fort McCoy.

  Other preparations included mandatory briefings and lectures on sexual assault, military sexual trauma, and suicide prevention. Army staffers flown in from active Army bases disseminated hours upon hours of information on rules of engagement, the law of war, and the Geneva Conventions. Additional briefings included deadpan PowerPoint presentations about soldier ethos, and command concepts. The Code of Conduct briefings seemed the most serious and laid out the rules that governed a soldier’s behavior in case they became a prisoner of war. The briefings were particularly troubling because they featured outdated video clips from the 1960s that showed overly dramatic actors providing only their name, rank, and identification numbers while being physically and psychologically tortured. Everybody knew that most soldiers eventually broke under torture, regardless of their personal ethics. Overtly, I gave assent to the Code. Internally, I feared becoming a prisoner of war and being tortured by an enemy or beheaded. In private discussions with other officers, I learned I was not alone in my fear. I held that fear close, as if it were a secret message I was dispatched to carry throughout the war, to be disclosed only to a covert operative in the dark of night when the war was over, and maybe not even then.

  Later in the week the docs mustered all company medical personnel for a training exercise on carrying and loading injured patients. Medics parked their ambulances in various positions in the snow and rigged the litter stanchions to carry four patients. The medics and docs all took turns trying to rig the ambulances. Most had never done an ambulance rigging in their Reserve or National Guard training; and the ones who had were rusty and out of practice.

  We planned the loading exercise as a fifteen-minute block for each team of four to six. When teams actually ran the exercise, they needed closer to a half hour. During the delays and restarts, the mock patients waited conveniently on nearby patient litters. Nobody bled actual blood or lost real limbs. Our pretend patients wrapped themselves in drab-green Army blankets to keep warm. A few sipped hot coffee from oversize travel mugs.

  The teams loaded patients with the same difficulty they encountered in rigging the stanchions. The weight of the patients and the litter averaged 170 pounds; a few topped 200. Medics struggled to angle the litters into position and lock them in place. Their feet kept slipping. Team members jammed fingers, pinched hands, and bruised their arms. They fell down, dropped litters, and yelled in frustration. The mock patients moaned and complained. A few of them were dumped in the snow. They brushed themselves off and climbed back onto their litters while mumbling about their mock injuries and their mock pain. As I watched, I shook my head and silently scoffed at the performance. Bullshit.

  When it was my turn to load patients, I resolved to do better than the other teams. As my team proceeded to lift our patient, I forgot the coordinating step to turn the litter for loading. We stalled trying to figure out which way to turn. One of the medics slipped in the snow and dropped his corner of the litter, nearly dumping our patient. The team hollered in unison, which was about the only thing we did in unison. We struggled to maintain a coordinated lift to the ambulance. I pinched my hand between the litter and the stanchion. I bungled the loading. I wanted to show leadership and skill. Instead, I showed ineptitude. I felt tiny and limited and flawed—as if perhaps I was not a soldier at all, or at least not a very capable one. I got a vague feeling in my gut that I might never be ready for war, that perhaps the entire 109th might never be ready.

  To make training more realistic, we enlisted the Army’s newest medical acquisition, a first-generation training simulator called SimMan. SimMans were the descendants of the Resusci Anne mannequins commonly used for CPR training. The concept was enticing: train with a computer-operated simulator, essentially a semi-robotic patient that provided real-time, lifelike feedback. Perform the appropriate steps of a trauma protocol, the fake patient survived; do the opposite, the patient died. The bonus for instructors and trainees alike was that the simulator closely mimicked real biological responses to interventions. That was not a small thing. Realistic training in medicine, especially in trauma, was hard to attain short of doing medical training in a trauma center where staff doctors monitored a trainee’s every move. That was the kind of training I had done to prepare for my career, and it was not easy to get.

  Our physicians were of the first nationwide cohort of military doctors trained for combat medicine using computerized patient simulators. I thought it sort of cutting-edge to be using computerized patients that cost more than an Army doctor’s annual salary. Practicing on SimMan was far better than using a Resusci Anne mannequin whose hard plastic skin didn’t feel anything like real skin and whose chest felt like a stiff mattress spring when compressed during CPR.

  SimMans were different. Each simulator measured about six feet tall and weighed 170 pounds, the presumed height and weight of an average soldier-patient. They were all dressed out in Army DCUs (desert camouflage uniforms), including desert boots and Kevlar helmets. They had audible heartbeats and breathing sounds as well as palpable pulses. Their pupils reacted to light or stayed wide open and fixed in response to a computer command. When I first saw our five SimMans on gurneys I was suspicious; I thought they looked too much like static Resusci Annes. But as I worked with them and their variety of detachable body parts, I began to appreciate how realistic simulator training could become. These were more than rubber and plastic; they felt and acted real and added a deeper level of seriousness to our role-playing trauma scenarios.

  Training oversight was assigned to Gibbons, Brown, and me. We trained in collaboration with an Army Reserve Combat Support Hospital (CSH) from Wisconsin. The first day of my training, I spent a half day with simulator technicians learning about the computer programs and the interchangeable body parts. The training software included a menu of preconfigured scenarios that provided the full gamut of combat injuries. There was no lack of wounds from which to choose. A trauma instructor simply picked a set of injuries from the pull-down menu on a laptop computer and pressed the start button. The software then took control, and SimMan displayed the appropriate physical signs that corresponded to the selected trauma. His pulse galloped or stuttered. Simulated blood squirted from simulated wounds. His breathing would become slow and sporadic and agonal. A cardiac monitor provided critical vital-signs data. When the instructor had a scenario ready, he provided a brief one-line medical history and told the trainee to begin. The medic or physician trainees then began their initial trauma assessment and practiced their interventions. As they proceeded, the computer tracked their performance and kept a timed log of everything they did. The instructor could modify the physical responses by adjusting the computer controls. A tweak here or there could push SimMan from manageable, to critical, to dead—all within minutes.

  If I needed to show more tissue damage or a more critical scenario, I simply interchanged one body part for another and chose an appropriate computer algorithm. SimMan mimicked the appropriate responses that corresponded to human injury and treatment, but unlike real soldiers he didn’t moan or writhe in pain. He didn’t ask if he was “going to make it” or ask his doctor to tell his parents that he loved them.

  Brown, Gibbons, and I taught mandatory training scenarios that included ballistic wounds to the chest and abdomen, open and closed head injuries, traumatic amputations, and extensive full-thickness burns that covered over 50 percent of SimMan’s body surface area. I reg
arded the simulated burns as a bit too artificial, because the burned plastic skin didn’t look anything like real full-thickness burns with their char and oily soot. Other scenarios included multiple broken bones, a fractured pelvis, and various states of cardiac and respiratory arrest. To make things more challenging and push the trainees a bit, I severed both legs. I left the detached legs on the gurney and rigged a pump to squirt fake blood from the stumps; then I grabbed a green Army blanket and covered SimMan from the waist down. When trainees lifted the blanket I hit a computer button. Red water squirted onto the gurney and dripped on the floor. Trainees always got a stunned look on their faces and hesitated as they collected their thoughts.

  I pushed the soldiers hard because I wanted everybody to run the simulations perfectly. I viewed their performance as an extension of my teaching and leadership. If they weren’t perfect, I wasn’t perfect, and in front of Brown and Gibbons and the other docs, anything less than perfection was simply not good enough.

  I gave trainees only a minimal patient history or sometimes no history at all. I simply said “trauma patient—critical” or “patient—unknown injuries.” I always added more simulated bleeding as the scenario progressed. I dialed up the heart rate to two or three times normal or slowed it to a standstill. As a subtle test, I dropped SimMan’s core temperature to simulate a critical loss of body heat. I increased respirations to dangerous levels or simulated labored, agonal breathing. When the docs and medics tried to intubate SimMan in order to provide him with a “breathing tube,” I clicked a button on the laptop that inflated a small air bladder situated beneath his hard rubber trachea, making emergency intubation nearly impossible. Some treatment protocols required an emergency cricothyroidotomy, a variant of a tracheotomy also known in trauma care as a “cric.” Trainees had to make a midline surgical incision in SimMan’s neck, cut an opening in the underlying trachea without lacerating the carotid arteries, quickly insert an endotracheal tube, and then connect the tube to an emergency source of oxygen. If done incorrectly, the procedure could kill a patient.

  If a trainee bungled the “cric” by doing it too slowly or not at all, I clicked another computer button and pushed SimMan into an unrecoverable, two-minute slide to his death. The cardiac monitors sounded an alarm as his heart faltered in wild dysmorphic rhythms and a flat bright line finally signaled a failed resuscitation. If SimMan had had a computerized skin controller, his skin would have turned pallid and damp.

  Trainees got nervous, upset, and rattled. Most of them forgot to perform critical steps in the resuscitation. Some of them underdosed the simulator with critical medications. A few administered life-threatening overdoses. Several punctured SimMan’s lungs with a surgical trocar. One medic punctured SimMan’s heart—pushed a trocar right through the left ventricle. Some did not intervene fast enough and he bled to death. One trainee cried when she failed to resuscitate her patient. Almost all trainees developed an uncontrollable hand tremor, and when I saw them shake, I tweaked the computer to make the simulation even harder, as if I were moving in for the kill.

  The scenarios tested skill and speed. They usually ran for less than ten minutes, during which we tracked everything: procedural attempts and non-attempts, injections, incisions, every command, and every question. Each trial. Every error. We monitored adherence to trauma protocols and a trainee’s ability to develop an efficient and confident resuscitation rhythm—the ability to transition from patient assessment, to medical intervention, to treatment monitoring, and then to repeat the steps as necessary, without hesitation, and without succumbing to the typical chaos of trauma resuscitations.

  In the first week of simulator training, the training team tested about ninety medical personnel. SimMan survived very few scenarios. After two weeks of training, the plastic patient had a survival rate of 90 percent. He always died in about 10 percent of the cases, simulating an expected reality of trauma resuscitation.

  Brown and I were fiercely competitive in a friendly sort of way. We tried to outperform each other on the SimMan. When it was my turn to test him, I dialed up the toughest cases. I set the starting point as a burned patient with hemorrhagic shock, an open chest wound, and agonal breathing—essentially three breaths away from dead. Brown responded rapidly and systematically. As the scenario required, he tried to perform an emergency intubation, and when he did, I tweaked the computer to make SimMan’s trachea collapse or become obscured with simulated blood—anything to make intubation impossible.

  “What the hell you doing?” he screeched.

  I yelled back, “What the hell you doing?” Then I told him he had thirty seconds left and gave him a devilish grin.

  He scurried to perform an emergency cric. I hid the scalpels so he had to use his pocketknife. “What did you do with the scalpels?” he barked in a squeaky high-pitched voice. I usually shrugged my shoulders or said they were destroyed in transit or hit by a bomb. When he finally cut SimMan’s throat and put a tube in his trachea, he proceeded to correct the other life-threatening injuries. Insert a chest tube—done. CPR—check. Ligate a bleeding artery—a breeze. Technically, Brown’s SimMan always survived, but I found ways to kill him off anyway—too much blood loss, hypothermia, or cardiac arrest.

  When it was Brown’s turn to test me, he pulled the same crap. “Okay, Doc, let’s see what you’ve got,” he chortled. He always killed my SimMan in retaliation.

  When we were done with our scenarios, we simply hit the reset button on the computer. SimMan would be instantly and electronically resuscitated—alive and ready for another round.

  Watching a patient simulator turn critical and die was strangely unnerving, even though everybody knew that SimMan could not be killed and would never actually be placed in a body bag. In the worst case, he might suffer a broken part or maybe some torn rubber skin—all of which we could replace from the parts warehouse within a matter of minutes. Everybody knew that SimMan’s manufacturer parents would never get a letter from some commanding officer telling them he was a good soldier—that he had distinguished himself in battle and had served his nation with honor. I think what made the simulator training so unnerving was the understanding that, within weeks to months, some real soldier’s life could very well depend upon how well resuscitation efforts were performed in the field and how quickly those efforts were put into play.

  That understanding made the simulator training intense. Medics and docs got angry with themselves for botching a scenario. Like me, they wanted to show themselves as the kind of soldiers who could save lives in the rush of combat. Sometimes they got upset with the instructors, or with the SimMan computer, or with the Army—but mostly, they got upset with themselves. I tried to remind everybody that the simulator was a tool. “Learn from it,” I said. “Make accurate observations, interpret the clinical findings, and then respond without hesitation.”

  I showed a PowerPoint presentation one night as sort of a relief valve from the SimMan training. It was a collection of photos I had taken during my work in Rwanda, Bosnia, and Kosovo. I assembled about seventy photos of patients from those war zones. I started the presentation by asking if everybody was confident from all the SimMan trauma training. A resounding Army “Hooah” filled the room. As each photo of a wounded patient hit the makeshift screen, the lighthearted banter of the classroom grew quieter.

  The first pictures showed a teenage boy in Bosnia with half his chest blown open by a grenade. A dozen photos highlighted traumatic amputations and bones sticking out of limbs. One photo showed a young patient from Kosovo with a post-op infection that left his abdomen gaping and his intestines exposed to the air. His physicians had sewn empty intravenous bags over his open abdomen to keep heat and moisture in and flies and other contaminants out. One picture showed the boy’s gaunt face. Several others showed various angles of his exposed and necrotic bowel. Another few showed the boy’s head flexed downward, eyes wide open, as he watched a surgeon remove the plastic abdominal covering. I kept those pictures up on the sc
reen longer than the others. I said nothing.

  A few pictures of collateral children showed eyes fixed in an upward gaze so that only their white sclera and a small crescent of iris were visible. The photos revealed distorted faces, massive swelling, and the periorbital bruising that resulted from concussive blasts or blows to the head. The classroom grew eerily quiet when I showed the children.

  The series of medical photos from Rwanda distressed everybody. They showed the Hutu woman I had treated who had been shot through the upper arm and breast. I explained her critical need for an amputation of her arm and breast. Soldiers, I explained, were not our only patients.

  When the presentation was finished, I asked if anybody had questions. At first there were none. Then a medic raised her hand and asked what happened to the woman with the bullet through her breast. “Dead,” I said. “It took three days. Her baby was taken to a pediatric camp.” Lots of questions followed. Everybody wanted to know what kinds of medicine the different patients needed and what kinds of medical procedures could have saved them from their various injuries. Everybody took a deeper interest in the issue of medical logistics and supply, and in how to perform medical procedures in the field. Everybody wanted more SimMan training.

  We continued to work on SimMan for a few more days, to the point where most of the trainees could manage all but the most complex of injuries. At times, after an intense training day, I wondered how the new simulator training would pan out in combat. In our training modules we tested a single scenario at a time. One medic or doctor stood at the ready, always leading a team of three or four well-equipped soldiers. The training objective focused on the rapid trauma resuscitation of complex injuries in a single patient. We ran other non-simulator exercises that trained soldiers in the assessment of multiple simultaneous patients. But in our simulator training, we never had the time or resources to use ten or twenty SimMans in a single scenario where half of them died of wounds, or where we had to drag them out of a kill zone before providing medical treatment. Our simulation training focused only on resuscitative algorithms. We did not simulate combat fatigue, or fear, or the risk of dying in a war zone. There were no wounded children or other collateral noncombatants. Missing from our simulations was agony and weeping and the real pain of a slow, torturous death.