Article: J. Hoitz

Simulation in military medicine: More than just skill training

History of simulation training in military

In the military world, „simulation“ as learning in a model of situations probably to be confronted with in the future has been used traditionally for a very long time. Already the famous Prussian general Clausewitz stated that “no military leader can get the army really used to war combat situations. Therefore exercises in peace must be established in a manner to show typical frictions in combat situations at least partially to train every leader in judgement, prudence, and even firmness could be trained…..It is very important for every soldier may he be of high or low rank not to be confronted with a situation in combat at very first time, that leaves him astonished and embarrassed. If he only had experienced this situation once before, he is familiar with it at least halfway”. In addition to field and table exercises being used for a long period of times, in modern times highly sophisticated simulation techniques have been developed to train technical and team performance skills as it is true e.g. for flight or tank simulators for combat training. In the world of medicine, highly sophisticated simulation techniques also have step by step been used since the last decades of 20th century and are now increasingly established for training in military medical services as well.

The “training dilemma”

There is a training dilemma for the military medical services well known throughout the world of military medical services: The training of the military medical service members must achieve a thorough mastery of caring for combat casualties with injuries not well known in the civilian world. This training must be accomplished in a veryshort time period in preparation of military missions and doesn’t allow for gaining expertise over many years. In addition, the training must be accomplished by large numbers of medical service members outranging the numbers of training opportunities in real life civilian facilities. Next to technical skills, also non-technical skills in terms of crew resource management must be trained in a manner, that deployed teams can safely accomplish their task even in life threatening combat stress situations even with repeated replacing of team members. Moreover, medical teams in combat situations must perform their medical tasks taking into account tactical necessities and the need of close cooperation with the troops, items to be included in pre deployment training as well. To resolve this training dilemma at least in major parts, the application of different simulation techniques is clearly a very useful tool. 

Several simulation methods 

Emanating from anatomic models used for centuries all over the world, in the 19th century first partial task trainers had been developed in parallel to the rising of modern medicine to train a special skill or a set of skills, e.g. anatomic model of parturient to train medical personal how to deliver a baby. Nowadays, modern partial task trainer cover e.g. training opportunities for airway management, intraosseous injection, invasive vascular access, handling endoscopic instruments to improve eye-hand-coordination and so on. Training goal is development of psychomotor competence in performing special skills or simple procedures. These modern partial task trainers are widely common also in training of military medical service members, can easily be used anywhere without big installation efforts and are applicable to train large numbers of trainees in short time. Repeated training of a particular set of skills can easily be performed up to drill exercises under stress. In this sense their application is very useful to resolve some of the items of the above-mentioned training dilemma. 

More complex procedures and application of treatment algorithms like life support measures can be trained with mannequins technically more advanced than simple partial task trainiers. This technique gives the opportunity to perform several different tasks in one mannequin either as a single person or as a medical team. It can be used as well anywhere without special requirements regarding space and time and allows also for training of large numbers of trainees. 

However, high sophisticated patient simulators are needed for a more advanced training. This high fidelity trainers allow for training of complex procedures and scenes of typical situations to be confronted with in the future, in that the instructor is able to let the simulator “respond” to the measures of the trainees. The training setting not only consists of the patient simulator but also on video-recording techniques to enable a thorough debriefing of the performance after finishing the simulation scene. This debriefing, in many cases taking much more time than the simulation scene itself, enables the trainees to watch their own performance, to get feedback from peers and instructors and to develop ideas for further development of own competency. This training setting allows not only for monitoring and improvement of technical competence as a single person or as a team but notably for monitoring and improvement of the very important non-technical skills in acting in a team, because the result of a team performance especially in medical emergency situations not only depends on the medical competence of the team members but especially on the crew resource management within the team. Topics as communication, situational awareness, shared mental model, decision-making, coping with stress and team management can be addressed by this simulation setting. 

To complete simulation techniques important to military medical service, three additional methods should be mentioned. Especially in surgical pre-deployment training, it is very difficult to train the surgical treatment of typical complex combat injuries because of the lack of sufficient numbers of patients with comparable injuries in the civilian world to get enough experience. For that reason, in some countries (e.g. France, Norway) live tissue training has been established to give surgeons the opportunity to perform life saving surgical procedures. This training can be rated high-end training, is laborious and must not be performed without strict observance of the regulations of the Protection of Animal Acts of the country concerned. 

Not only somatic combat injuries are typical for combat situations, the same is true for psychical disorders. To cope with those clients in acute, medical service members should be trained accordingly. Not only for specialists in psychiatry and posttraumatic stress disorder, role-play can be the adequate simulation method to train coping with affected soldiers. In role-play, actors behave as instructed by the trainer and have to be dealt with by the trainees. In this setting too, profound debriefing is one of the major elements in the training. 

A completely different simulation method deals with virtual reality. Service members of medical services have typically grown up with computer games and are familiar with entering into a completely virtual world. Using this experience and translating it into training exercises has forced the development of serious games. Using this method, cognitive skills can be trained as in the “virtual military hospital” of the medical service of the German Bundeswehr e.g. for tropical diseases that are very rare in Germany. However, not only cognitive skills are in the focus of the training with serious games, decision making on different levels of complexity in combat situations and other items of management and leadership can also be trained. Using World Wide Web as the platform and in future even apps for smart phones, this training can be performed by the trainee anywhere and at any time. Serious games have also the potential to be interactive so as to react to the inputs of several “players” in the same game session and to resemble the sometimes-unforeseeable development of a given situation. Just being in the initial developmental phase, serious games training has the potential to grow up to one of the major simulation methods addressing the preferences of the younger generation. 

Integration of simulation methods into training courses

Above presented simulation methods should be integrated into the training course from novice to combat ready military medical service member. In the beginning, there is the individual training, starting with basic and advanced knowledge of medical subjects as well as basic skills and simple procedures. In this growth state, serious games can be used to teach medical subjects not available in real patients in the every day experience. Virtual realities can assist in fixation of and “playing” with necessary knowledge in an environment felt as “just playing a game”. Basic and advanced technical skills can be trained with partial task trainers even with increasing levels of difficulties and different challenges of surrounding conditions. After completing this level, technical skills and acquired knowledge must be composed to correctly handling more complex procedures by using mannequinst still under the perspective of individual performance. 

In the next step team training with team members of different medical professions comes into consideration. Initially, medical team performance in handling patients according to proposed algorithms like ACLS or ATLS may be trained with mannequins allowing for application of the proposed measurements according to the algorithms. However, additionally to the medical technical skills, in this training state reaction of the “simulator” to the applied measures come into focus as well as above mentioned non-technical skills regarding crew resource management. For this reason, high fidelity patient simulators with profound debriefing capabilities are essential. For surgical teams, live tissue training can be suitable to handle complex injuries under the stress of real pathophysiologic developments as well as to train a surgical team or even an interprofessional team of surgeons and anaesthesiologists in respect of crew resource management, highly important for the fate of injured combat casualties in the field. 

Finally training courses must be completed by situational training. In this training stage, trainees must be enabled to integrate their acquired knowledge and competence into typical situation to come in consideration of all surrounding conditions including stress factors. Those can be the need of bearing in mind tactical considerations interfering with the application of the regular treatment algorithms, lack of personnel or material in respect of the numbers of injured to be cared of, bad weather or light conditions (e.g. working in extreme temperature or at night) and so on. In this stage mobile high fidelity patient simulators can be integrated into field exercises for training of medical service members as well as troops in handling with combat casualties under described conditions. However, also serious games are a very useful tool in dealing with the subjects of how to manage greater numbers of combat casualties in preparation of military field exercises. 

Further perspectives

Integration of simulation methods into training courses could be further developed in several important directions. As mentioned above, military medical service members don´t work isolated but are integral part of military entity with members of other branch of services, may it be a within an army platoon or as part of the crew of an Forward Airmedevac helicopter. Especially in the latter situation, simulation techniques could be combined to train cockpit crew as well as medical crew in the back in regard of mutual understanding the rules of operations in each branch and the need of shared decisions in favour of best performance of a given task. Those simulation trainings possibilities combining military medical service with several branches of services can easily be identified for many situations. 

The last years have shown us that in military medical service there is a tendency to multinational cooperation. Even with the idea of sharing common roots of culture e.g. for european and american nations and performing in respect of the same scientific basis of modern medicine, there are differences in every day culture not least in military based on different socialisation processes during education and training. Working together on a combat casualty in an emergency situation using English as common but mostly foreign language, the “minor” cultural differences often unaware to persons involved may be the source of major trouble with unfavourable outcome. To address these intercultural problems, NATO Centre of Excellence for Military Medicine has inaugurated a multinational training program (NATO Emergency Medical Predeployment Team Training (EMPT)) held at the Bundeswehr hospital in Hamburg, Germany. In the pilot training in January 2012, multinational trainees highly appreciated this simulation training and felt to be more sensitive to differences in working together with multinational peers. This training will be held twice a year in Hamburg.

At last, not only medical performance or integration of medical objectives into military scenarios may be the aim of training. On every level of medical service entities from battalion physician troops to field hospitals and medical task forces, there are always officers in charge as leaders and managers. Confronted with many challenges they have to decide precisely and manage as well major medical incidents or unfavourable conditions as problems with subordinates or awkward persons. Even for this individual training of leaders, simulation methods could be useful. Serious games are suitable to simulate difficult situations in respect of dealing with military medical tasks and can be used to integrate the inputs from other branches of services in real time simulation. Role-play on the other hand can be a very useful tool to confront a leader to negotiate with awkward persons and train him how to manage those situations. 


Simulation methods have already developed as integral part of training in military medical service. They cannot resolve all problems of the training dilemma but can be an essential part of hybrid training combining real life experience with simulated situations. Simulation methods have a high potential to further development and should be expanded into additional training areas. 


Dr. Joachim Hoitz,
Colonel MC

Address of the author:
CO Dep. Anaesthesiology
GER Military Hospital Hamburg
Lesserstr. 180

22049 Hamburg, Germany
Tel.: +49 (0) 40 6947 2000

Date: 10/10/2012

Source: MCIF 3/12