Medical Education- Courses

Military Contingency Medicine
 
LTC Clifford Lutz, MC, USA, Course Director
 
Military Contingency Medicine (MCM) is the capstone course of the four-year, integrated, medical-school education in military medicine at the Uniformed Services University (USU) and is the first half of the Military Studies IV (MS-IV) curriculum. Always taken after Military Preventive Medicine (MPM) through the Department of Preventive Medicine and Biometrics, MCM is four weeks in length and is offered to approximately one-third of the senior medical-student class during each of three iterations.
 
The MCM course consists of several modules designed to build on prior experiences in medical school to focus on application in a deployed military setting. This includes support of all military services in joint and multi-national roles. It is considered a clinical clerkship, which draws on knowledge from the basic medical sciences, clinical sciences experienced in the junior and early senior years, and prior courses in military medicine taught by the Department of Military & Emergency Medicine. The educational goals of MCM are:
 
Goal 1: Provide additional clinical, procedural, and administrative skills necessary to the practice of military medicine, such that following an active-duty, hospital-based internship, USU students will be able to function as a General Medical Officer (GMO) in the air, on land, or at sea; if called upon to do so prior to specialty training in residency. The focus remains on the elements that make military medicine unique: 1) environmental medicine, both personnel exposure causing casualties and delivery of care outside the hospital environment; 2) trauma management from basic life-saving skills to advanced interventions prior to definitive care; 3) preventive medicine and mitigation of other threats to mission accomplishment; 4) identification and management of global infectious diseases; and 5) behavioral sciences related to unique stressors such as combat, low-intensity conflict, and humanitarian assistance.
 
Goal 2: Initiate students to the concept of approaching problems with expedient management in mind, much in the way that emergency physicians approach patients in hospitals. Concepts related to this new method of thinking include: 1) while caring for any individual, the provider may not know what's coming in next, and there are few if any systematic processes to divert patient flow; 2) access to time-consuming ancillary tests will be absent or limited; 3) some patients will have serious problems masquerading as benign processes; 4) intervention is often necessary before the cause of the problem is identified or diagnosed; and 5) many external factors (both medical and non-medical) force adjust to what providers have been taught in hospitals and what they think is "ideal" care.
 
Individual topics are taught in lectures, small-group discussions, laboratories, patient simulations, and a week-long field training exercise (FTX) called Operation Bushmaster. The modular sections are:
 
Module 1: The course begins with introductions by department faculty and guest speakers who have significant real-world experience in the field supporting war-fighting, peace-keeping, and humanitarian-assistance operations. Topics center on environments in which military medicine is practiced in deployed settings. Historical and contemporary missions, political considerations, international laws of armed conflict, and rules of engagement are some of the issues discussed. Specific learning objectives include:
 
Restate the key tenets of international laws of armed conflict as they pertain to the protected status conferred on medical personnel.
 
Appraise possible responses to any ethical dilemmas represented and the consequences of each course of action proposed using examples drawn from actual personal involvement.
 
Develop solutions to potential problematic political, military, or administrative situations in the future by extrapolating from lessons learned during previous deployment experiences.
 
Create a plan for providing health services support and combat health support to a unit with up to 1000 personnel within the constraints of strategic, operational, and tactical scenarios with defined rules of engagement.
 
Module 2: Because all students need a common framework from which to develop skills in combat casualty management, the second module includes the Advanced Trauma Life Support Course for Doctors® (ATLS®) as designed by the American College of Surgeons. Trauma is one of the few core subjects to which most students have little exposure during their clinical years prior to MCM. USU is one of only a few medical schools in the United States that offer ATLS® to their students during the normal curriculum. However, the focus of ATLS® is necessarily on initial management of trauma victims in established hospitals in the United States. Subsequent MCM presentations discuss differences between injuries in the civilian setting and military combat trauma in the potentially resource-limited and medically austere setting of a deployment. Presentations on high-velocity terminal ballistics, primary blast-overpressure injuries, military triage, and combat wound infections are given by national experts in their fields. Specific learning objectives include:
 
Compare and contrast the most common and most serious mechanisms of injury in combat, otherwise deployed, garrison, and off-duty civilian settings.
 
Match the most appropriate emergency intervention to a list of presenting signs and symptoms indicative of life-, limb-, and sight-threatening conditions.
 
Perform endotracheal intubation, cricothyroidostomy, needle thoracentesis, tube thoracostomy, and needle pericardiocentesis on a model.
 
Assess for life-threatening problems and simulate interventions necessary to stabilize for transportation to definitive care; given a model with simulated blunt, penetrating, or thermal injuries in a community hospital setting without immediate surgical availability.
 
Outline the clinical features of open wounds that necessitate referral for evaluation and management by a specialist.
 
Module 3: The next three days are spent discussing the approaches to specific patient presentations common to many deployments. Students are challenged to develop management plans in medically austere settings ranging from situations where all equipment must be improvised to those with only basic or limited resources to mobile medical treatment facilities. MCM provides students their most extensive exposure to basic dentistry, dermatology, ophthalmology, and podiatry exclusive of elective rotations. Additional emphasis is placed on environmental problems such as extremes of temperature, altitude effects on casualties, reptile and arthropod envenomations, and lightning injuries. Problems unique to the marine environment are also included. Specific learning objectives include:
 
Demonstrate the ability to perform a comprehensive oromaxillofacial examination following blunt trauma.
 
Choose an effective temporary management for each of the most common acute dental problems.
 
Perform bridging of an alveolar fracture, aspiration of a simulated dental abscess, and extraction of a tooth on a model.
 
Match a list of common dermatological conditions found in deployed personnel to their initial treatment modalities.
 
Categorize sets of ocular symptoms and signs into groups that are more or less likely to be manifestations of sight-threatening pathology.
 
Perform foreign-body removal from the lids or cornea of a model.
 
Complete an examination of each major adult joint to ensure that there is no ligamentous laxity or instability.
 
List several field-expedient methods each of passive and active, external and internal rewarming of a hypothermic casualty.
 
Differentiate the symptoms and signs of heat exhaustion and heat stroke.
 
State the precautions that must be taken before evacuating a patient by air given a list of specific problems encountered in sick and injured personnel in combat and other deployed environments.
 
Describe the procedure for partial or complete removal of a toenail.
 
Write specific steps to and not to take when managing victims of venomous bites and stings in an out-of-hospital environment.
 
Outline the field management of decompression injury and arterial air embolism.
 
Module 4: This module combines clinical and administrative responsibilities surrounding mass-casualty planning, humanitarian assistance for displaced populations, support of deployed female personnel, and intervention for combat stress. Reviews of the management of chemical, biological, and radiological casualties are also conducted by current or former personnel assigned to the United States Army Medical Research Institute for Chemical Defense (USAMRICD), the United States Army Medical Research Institute for Infectious Diseases (USAMRIID), and the Armed Forces Radiobiology Research Institute (AFRRI). Specific learning objectives include:
 
Write the definition and purpose of geographical triage.
 
Outline a rapid decision-making algorithm or process for assigning triage categories when the number of casualties exceeds the resources available to care for them all.
 
Name the four most frequent causes of death in a population of victims of forced migration, other than intentional trauma.
 
State the physiological basis for oral fluid-replacement therapy for most cases of dehydration, as opposed to intravenous fluid administration.
 
Estimate the likelihood that an unconventional weapon could be the cause of a given set of symptoms and signs in a simulated patient.
 
List the administrative actions to be taken when use of a chemical, biological, or radiological is suspected.
 
Module 5: The third week is devoted to FTX Bushmaster, a supervised educational exercise using a peace-enforcing scenario to help students understand and overcome problems more common in a field environment. They are graded in leadership abilities, medical skills, and management of combat stress. Specific learning objectives include:
 
Analyze both rapidly and slowly evolving problems to create mission-oriented solutions with limited information and resources.
 
Establish vehicle traffic, casualty flow, and evacuation methodology to, through, and out of a medical treatment facility in the field.
 
Organize a small medical unit into functional teams with clear and concise directions.
 
Create plans and allocate resources to quickly respond to requests for casualty transportation.
 
Communicate plans and important information to subordinates and higher authorities in a timely manner.
 
Assess available resources to protect unit personnel, supplies, and equipment from heat or cold, inclement weather, disease transmission, unintentional injury, and simulated attack.
 
Formulate the best management option for a series of simulated sick-call patients.
 
Appropriately adjust learned triage and trauma-management skills to an environment with limited medical and surgical resources and relatively long transportation times; presented with one or more simulated combat casualties.
 
Consistently practice and enforce preventive medicine measures to mitigate the threat of water- and food-borne diseases.
 
Obtain sufficient information from a role-playing patient with abnormal behavior to differentiate combat stress from organic or functional neuropsychiatric disorders.
 
Develop a system of accountability for equipment and supplies in a field environment without electronic storage media.
 
Integrate all treatment and disposition decisions into any current tactical situation, available resources, distance and terrain, weather, and orders from higher authorities.
 
Effectively supervise implementation of any directions given to subordinate personnel when in a leadership role.
 
Module 6: Following their return from the field, students begin two days of instruction on how to function in a deployed equivalent of an emergency department (ED), which may or may not have sophisticated diagnostic tests available for use. This module directly prepares them to learn more and perform better in actual EDs during Military Emergency Medicine (MEM), the other required MS-IV course under the Medical Education Division of the Department of Military & Emergency Medicine.
 
Selected military applicants from other medical schools have taken MCM as space allows. Recent international attendees have come from France, Japan, Russia, and the United Kingdom. International faculty observers have come from France, Mexico, Thailand, and the United Kingdom.
 
USU students who successfully complete the didactic portion MCM are qualified to take MEM during one of their subsequent rotations, which actually begins during the last three days of each MCM block.

Operation Bushmaster
 
LTC Clifford Lutz, MC, USA, Academic Director
 
CPT Jeffery Hogue, MS, USA, Exercise Director
 
Operation Bushmaster is a one-week practical field laboratory exercise (FLEX) that occurs during the last week of Military Contingency Medicine (MCM) course. The exercise is currently conducted at Camp Bullis TX.
 
The student detachment is a company of up to 72 individuals, which is further divided into three platoons and six squads [two per platoon]. A student chain of command operates throughout the operation. The established educational goals of Operation Bushmaster are:
 
1. Provide participants with an environment that simulates an overseas deployment, which can be used as a framework to achieve the specified learning objectives.
 
2. Allow senior medical students to make necessary decisions that affect mission accomplishment, casualty care, and a myriad of other actions without adverse consequences on actual operations or the health of real personnel.
 
3. Afford future military medical leaders with opportunities to see common and uncommon problems, try one or more solutions, and evaluate the consequences before they may be faced with similar real-world situations.
 
The overall learning objectives include:
 
Analyze both rapidly and slowly evolving problems to create mission-oriented solutions with limited information and resources.
 
Establish vehicle traffic, casualty flow, and evacuation methodology to, through, and out of a medical treatment facility in the field.
 
Organize a small medical unit into functional teams with clear and concise directions.
 
Create plans and allocate resources to quickly respond to requests for casualty transportation.
 
Communicate plans and important information to subordinates and higher authorities in a timely manner.
 
Assess available resources to protect unit personnel, supplies, and equipment from heat or cold, inclement weather, disease transmission, unintentional injury, and simulated attack.
 
Formulate the best management option for a series of simulated sick-call patients.
 
Appropriately adjust learned triage and trauma-management skills to an environment with limited medical and surgical resources and relatively long transportation times.
 
Consistently practice and enforce preventive medicine measures to mitigate the threat of water- and food-borne diseases.
 
Obtain sufficient information from a role-playing patient with abnormal behavior to differentiate combat stress from organic or functional neuropsychiatric disorders.
 
Develop a system of accountability for equipment and supplies in a field environment without electronic storage media.
 
Integrate all treatment and disposition decisions into any current tactical situation, available resources, distance and terrain, weather, and orders from higher authorities.
 
Effectively supervise implementation of any directions given to subordinate personnel when in a leadership role.
 
The Operation is executed in four phases:
 
Phase 1: During the third week of MCM, students receive briefings specific to Operation Bushmaster and process through a "mobility line" simulating preparation for an overseas deployment. The briefings are designed to familiarize the students with the physical environment of Camp Bullis, describe all phases of deployment from an operational perspective, and share the criteria by which the students will be evaluated. The mobility line ensures students' required documents (identification cards and tags) are current, financial and legal affairs are in order, medical qualifications for deployment (records, immunizations, etc.) are reviewed and updated. They are also introduced to the fictional country of Pandakar for which the operational scenario is based and pre-deployment resources (AFMIC, DIA/CIA reports) are made available to them.
 
Phase 2: Two days of training are allocated for review of specific field skills (land navigation, NBC decontamination), orientation to the site and as a transition/practice period from what they learned in the class room setting to what they will be graded on during the exercise (BAS set up, Triage).
 
Phase 3: The operational field problem begins on day 3. Students staff generic first- and second-echelon medical facilities in a simulated deployed setting for the next 72 hours. Students staff two Army Battalion aid stations, one Marine Corps Battalion aid station and one Army forward support medical company. This elaborate scenario involves strategic, operational, and tactical scenarios that develop over the course of 3 days. Solutions require knowledge of many aspects of the mission at many levels [including political], enemy intent and capabilities, friendly intent and capabilities [medical and non-medical], terrain and weather, time available, and considerations of how decisions affect noncombatants. Knowledge of all three service medical capabilities is essential to mission completion.
 
Phase 4: Recovery. At the conclusion of the field problem the students are allowed a rest period (6-8hrs) and then participate in the recovery operations. Formation on day 8 followed by redeployment to USUHS concludes the exercise.
 
A Tactical Operations Center (TOC) serves as the headquarters element and the communications center for both notional and real-world activities. All student communications pass through the TOC. The TOC issues all official directives and supplemental information to the students as the scenarios evolve. It is staffed 24 hours a day for the entire week by commissioned and non-commissioned officers.
 
USU graduates are exempt from the requirement that all medical officers participate in the Combat Casualty Care Course (C4) at the Defense Medical Readiness Training Institute (DMRTI). This exemption is secondary to Operation Bushmaster and the four-year, integrated, medical-school education in military medicine at USU.
 
In conclusion, Operation Bushmaster provides both an excellent multi-service educational tool and an outstanding initial operational experience in the tradition of our National Training Centers.
 
Downloads: (USUHS Access Only)

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