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An Argument for Non-Medic Combat Arms

Soldiers Conducting Live Tissue Training as a

Pre-Deployment RequirementByLouis H. Smith IV, MSJournal Article |Aug 22 2012 - 4:30am

The wars in Iraq and Afghanistan have seen US Soldiers surviving injuries that as recently as the late

1990s were certain to be fatal. This is the result of implementing lessons learned, improved realistic

training and the amazing work done at the Combat Support Hospitals (CSH). With all the improvements

to point of injury (POI) care, no one has addressed how to prepare the average combat soldier with the

most realistic medical training possible. This paper will discuss the effects that pre-deployment live tissue

training had for the Paratroopers of the 4thSquadron, 73rdCavalry Regiment (ABN) during an eight

month deployment to the Maiwand and Zharay Districts of Afghanistan.

In order to better prepare the warfighter for the upcoming deployment the Commander of 4thBCT,

82ndABN DIV, COL Brian Mennes, directed the implementation of a more advanced Medical training

course based on the Ranger First Responder program. The result was Fury First Responder (FFR). The

premise of FFR was to teach the common soldier basic and advanced trauma skills and then reinforcethose skills using hip-pocket training, outcomes based training, and scenarios during Intensive Training

Cycles (ITC). As a BCT program, FFR was able to be easily resourced and conducted without the

administrative processes associated with Combat Lifesaver (CLS).

FFR took from the tenants of Tactical Combat Casualty Care (TCCC) and applied them using the

MARCH Principals (MARCH is a TCCC centric acronym that stands for Massive hemorrhage, Airway, R

espirations, Circulation, Head injury and hypothermia. It replaced the old civilian ABC acronym). The

initial phase of the course was a quick didactic portion that was meant to act as an introduction to the

basics of TCCC. The next phase was a round robin training event that initially focused on deliberate

hands-on instruction. The areas covered consisted of application of a tourniquet, packing a wound and

pressure dressings, inserting the nasal pharyngeal airway (NPA) and King LT airway adjuncts, applicationof an occlusive dressing and needle thoracentesis. Initially training was done in ACUs with the focus on

enforcing correct techniques. On day two the round robin continued but this time with tactical vests and

combat gear. Simple scenarios were also added to make the students think about the injury and problem

solve in order to develop a solution. On the third and final day the students conducted multiple Situational

Training Exercise (STX) lanes. The scenarios were developed to be as realistic as possible. The basic

premise revolved around a mounted or dismounted patrol and a casualty producing event. Soldiers closest

to the POI provided initial care while everyone else returned fire and/or pulled security.

Immediately after the introduction of the FFR program the squadron began to incorporate casualties into

every training event making them a key component to success or failure. This allowed the troop

commanders to get a basic sense of their soldiers medical skill level. The introduction of casualties
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during a training event is a huge win for any medical planner. The issue is that medical training, while

important, is usually an afterthought. The primary focus is always the combat centric mission essential

tasks while the medical tasks are factored in but without the same level of realism. Also it is not practical

to pre-moulage a soldier prior to a training event as it would interfere with the primary training objective.

The result is often a casualty with notional wounds and no visual references to work with.

During the squadrons National Training Center (NTC) rotation there were multiple mass casualty events

(MASCAL) that required non-medic soldiers to augment and, in some cases, assume the role of the

medic. While the squadron received kudos for having combat soldiers that were more proficient at

medical skills than the average unit, it was felt that our soldiers were not at the level they needed to be.

Returning from the NTC rotation the problem set we identified was how do we as a squadron solidify the

medical skills we have been training. Finding a solution to the problem became more critical as the unit

that the squadron was relieving in Afghanistan began sending casualty reports as part of their regular

updates.

The ideas that were tossed around included using the Fort Bragg Medical Skills Training Center (MSTC),

conducting a comprehensive medical field problem or contracting a private company to facilitate live

tissue training for the entire squadron. We decided on live tissue training because nothing else can come

close to replicating the experience of treating traumatic injuries. It was important for us to choose a

civilian medical education company that had a good reputation within the military community for

providing a quality realistic product. With the potential for negative reactions from certain advocacy

groups it was equally important that we use a company that had a good track record for following all DoD

and Department of the Army regulations regarding live tissue. All live tissue models that were used were

completely anesthetized for the duration of this training and euthanized in a humane manner upon

completion.

Once we decided on the company to use it was necessary to establish guidelines for what skills the non-

medic soldiers would be allowed to practice. The tasks allowed for the non-medics were based on FFR.

Additionally, medics would be allowed to conduct a supervised cricothyroidotomy. The use of an off post

site came with the added benefit of ballistic wounding. Ballistic wounding would allow the instructors to

create wounds that closely resemble the blast injuries that the squadron would face in Afghanistan. The

method of instruction was based on each troop conducting the training for one day, approximately 12

hours total. The morning would be dedicated to a quick PowerPoint instruction on MARCH followed by

two hours of hands on live tissue training with an instructor. The afternoon was dedicated to an

unannounced MASCAL event and mission type scenarios that incorporated actions on the objective, point

of injury care, and quick evacuation to a Casualty Collection Point (CCP). In all each platoon ran through

four scenarios over the course of the afternoon.

The primary goal of the training was to reinforce critical medical skills with as realistic training aspossible. That goal was easily accomplished but there were several intangibles gained as well. Each

soldier took away differing lessons from the training. Several soldiers reported that they now truly

believed that the FFR medical training would save a life. They were also amazed at how much trauma

and blood loss the live tissue models could endure and still survive. The most important of these

intangibles was the confidence they gained in the trauma skills of their platoon Medics. A correlation can

easily be made between willingness of the average Soldier to place himself in harms way based on the

confidence he has in his medics capabilities to fix him should he get hurt.

Arguments can be made for or against the use of live tissue training for non-Medics. What cannot be

argued is that every single one of the 46 traumatic injuries that the squadron had a hand in treating or

evacuating during the first 115 days of the deployment was initially cared for by non-medics. Of those 46



casualties, one was the fourth quadruple amputee in the history of US Army Medicine to have survived his

wounds. Another person to have survived similar injuries within the last year is a Navy EOD technician

attached to a Naval Special Warfare unit. The medics assigned to those units must complete the US

Armys Special Operations Medic course, which conducts extensive live tissue training. The additional

training also factored in a 19-year-old PFC medics ability to perform a successful cricothyroidotomy.The current failure rate in theater for cricothyroidotomies performed by medics is over 30%. Of the

squadrons three KIAs, one was a high lower extremity double amputee that was talking as he entered the

CSHs trauma bay. The success rate at that CSH for casualties that arrive with a pulse is 98%. The fact

that the Soldier was alive when he arrived at the CSH is a testament to the abilities of the Medics and first

responders that were on the ground.

The Army Medical Department (AMEDD) has a pre-deployment training program called Brigade Combat

Team Trauma Training (BCT3) that is used to give medics a quick refresher on trauma skills prior to

deployment. FFR and BCT3 are very similar in how the courses are laid out. The BCT3 model could be

expanded and adapted to provide similar training for all deploying Soldiers within a BCT. There are

several key changes that should be made if BCT3 were to be expanded. First, there needs to be a selectionprocess to ensure that the medic instructors have credible combat medicine backgrounds. Emphasis

should be placed on medics that have multiple years of experience with either maneuver battalions or

brigade support medical companies. The credibility of the instructor will make or break any combat

medicine class. Soldiers are quick to pick up on competency and experience levels of their instructors.

Second, infantry, cavalry, or armor soldiers should be incorporated into the training cadre. We should not

expect realistic infantry STX lanes from medical personnel just as we would not expect realistic medical

scenarios from an infantryman. It is critical that this training be conducted while maintaining platoon or

company integrity.

There are many within the Army Medical community who are less than enthusiastic in supporting any

type of live tissue training, with the exception of medical professionals and special operations medicalpersonnel. Our squadron ran into these roadblocks as we planned our last live tissue training event.

Arguments ranged from the standard worries of pictures being taken to the belief that live tissue training

was solely within the realm of AMEDD and USASOC. The arguments invariably seem to fall into two

categories: wanting to protect the ability of established institutions to conduct live tissue training or

declaring that there is minimal value in providing live tissue training to non-medic conventional soldiers.

We have multiple documented incidents that clearly show that the live tissue training our paratroopers

received prior to deployment to Afghanistan was instrumental in lives being saved on the battlefield.

There are numerous documented cases where the tactical situation does not allow for the medic to reach

the casualty until 20 to 30 minutes post injury and sometimes not at all. If non-medic soldiers receive

prerequisite training beforehand and the event is conducted with the proper decorum then there is no

acceptable argument against not allowing them to participate in this course in preparation for deployment.

What many AMEDD leaders fail to realize is that the initial care provider is almost always the casualtys

buddy. The extra edge that live tissue training provides could be the difference that affects a non-medics

confidence in attempting a lifesaving intervention. The question we need to ask ourselves as an institution

is; do the sensibilities of a vocal minority of the population and the expense of the training outweigh the

loss of just one soldiers life. Those first 60 minutes are the golden hour of care. Having the best care that

military medicine has to offer at a Role 2/3 facility means nothing if the casualty cannot survive from the

point of injury to that facility. Great strides have been made in battlefield care during the past 9 years and

further measures need to be undertaken to ensure that we are doing everything possible to save lives in the

future.



About the Author

Louis H. Smith IV, MS

2LT Louis Smith enlisted in the Army in January 2002 as a Combat Medic. Upon

completion of training he was eventually assigned to the 1st BN 504th PIR, 82nd

ABN DIV. Over the next 9 years he deployed four times with the Red Devils to

locations such as Fallujah and Baghdad. He has served in every leadership position

within an Infantry Battalion medical platoon. In 2011 he commissioned into the

Medical Service Corps and is currently deployed to Afghanistan serving as the

Medical Officer for the 4th Squadron, 73rd Cavalry Regiment (ABN).

Available online at : http://smallwarsjournal.com/jrnl/art/an-argument-for-non-medic-combat-

arms-soldiers-conducting-live-tissue-training-as-a-pre-dep

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