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Trial by (Simulated) Fire
Military Doctors Learn to Practice Wartime Medicine on Mock Battlefield

By Philip Rucker
Washington Post Staff Writer
Friday, August 8, 2008

FORT INDIANTOWN GAP, Pa. -- After four years of medical school and 700 hours of military training, the final two weeks for students at Bethesda's Uniformed Services University of the Health Sciences come down to this:

Smoke fills the dark sky in the woods of Pennsylvania, as piercingly loud bombs and gunfire stir chaos on a mock battlefield. Terrorists, in the make-believe country of Pandakar, drive a hijacked van into a tent inside a U.S. military camp, wounding more than 30 troops in the ensuing explosion.

"Doc, you've got to help me," cries a student acting as a wounded soldier.

"My hands! You're going to make me lose my hands," another shrieks.

"Grab his legs. One, two, three, lift," orders a student acting as a medic, pulling a dying soldier onto a green canvas gurney.

In a two-week simulation, which culminates in a mock evening battle with catastrophic casualties, the medical students learn to treat combat wounds and ailments, from the traumatic (severed limbs and blast wounds) to the mundane (diarrhea, aches and foreign diseases). They also learn to cope with the psychological wounds of war, including watching a fellow student acting as a medic become so depressed he pretends to commit suicide. And through it all, the doctors-in-training play dual roles as military officers, fending off sniper attacks on their medic camps from the fictional enemy.

Lt. Gen. James G. Roudebush, the Air Force's highest-ranking medical officer, flew from the Pentagon to Fort Indiantown Gap, about 25 miles northeast of Harrisburg, to watch the evening simulation last month. The exercise, known as Operation Bushmaster, teaches students to practice good medicine in a demanding environment, he said.

"This helps build skills, it helps build confidence and it helps build awareness of how to work in a very challenging environment," Roudebush said. "In any mass casualty event, there's always going to be the fog and friction of war, the element of the unknown. It could be a jungle, it could be an urban environment, it could be a desert, but these skills persevere."

The students agreed. Ensign Stephen Lewis held an M-16 rifle to his torso as he stood guard along the perimeter of a medic camp.

"You can talk about it in the classroom, but until you get out here and have all the variables in place you just can't simulate it -- the stress level, so many things in your head," said Lewis, 35, a former Navy flier from Blacksburg and a fourth-year medical student.

"Even though we know in the backs of our minds that this is artificial and a mock experiment, it prepares us for the real thing," said his classmate, Army 2nd Lt. Corey Mossop, 25, of Pennsauken, N.J. "It takes out the 'Oh my Gods' of seeing these battle injuries for the first time."

Operation Bushmaster is an elaborate dramatization of war. While fourth-year students work as medics, first-year medical students play patients. Makeup, or "moulage," artists use wax, stage blood and other material to create realistic trauma injuries on uniformed first-years. Those students act as wounded soldiers, some limping, coughing or crawling. Others squeeze bags of fake blood from inside their uniforms to simulate bleeding.

Moulage artist Shyla Glynn said her favorite creation is an open wound fracture. To create the faux broken bone, Glynn broke off a piece of a plastic laboratory skeleton and secured it to a student's arm with wax, cotton balls and stage blood.

"It is like Halloween, actually," she said. "You can make it gruesome. You can make it as dirty as you want. Some like extra blood and like to be really messy and others whine about it."

Lt. Eric Bishop, 30, a first-year student and Army veteran, said the realism makes the exercise exciting.

"I've been in the Army 10 years and this is by far the most realistic moulage I've ever seen," said Bishop, of Gainesville, Fla. "They're making it so a doctor for the first time sees the open chest wound and amputations and can get over that fear to do the job."

The university's professors and the military's medical officers from bases around the world converge on Fort Indiantown Gap, where they devise and implement scenarios based on actual war events.

"These are all real problems that we've extracted here," said retired Navy Capt. Eric McDonald, who was a combat surgeon in Anbar Province, Iraq, and now works as an emergency physician at Naval Medical Center San Diego.

The students are evaluated on their medical aptitude and leadership skills. To graduate, each student must pass Operation Bushmaster, and the standards are high.

"It's not just taking a test and circling the right answer, but it's doing the right thing when you're tired, you're hurt and it's dark," said Army Lt. Col. Cliff Lutz, who helped develop the program.

In Bethesda, the medical students undergo the same rigorous curriculum as their peers at standard U.S. medical schools, but they have an additional 700 hours of instruction on military leadership, war trauma and field exercises.

Some of the university's students are combat veterans, but others are fresh out of college with no military experience. About 10 percent of the military's doctors have attended the university, as many graduates of traditional medical schools serve stints in the armed services, Navy Capt. Trueman Sharp said. But most of those who serve long careers as military doctors are Bethesda campus alumni.

"You can't just put a uniform on a doctor and say, 'Now practice in the military,' " said Sharp, who chairs the military and emergency medicine department. "It clearly does not work in the operational environment. We are supposed to be creating the Colonel Potters, like from 'M*A*S*H,' the career docs."

At Fort Indiantown Gap, the mass casualty came as a surprise to the fourth-year students. They rushed to the scene of the van explosion. It was pitch dark and smoke filled the air, with the thick forest illuminated only by little lights on the students' helmets and glow sticks in their hands. They raced through the trees, dodging rocks on the uneven ground, to find the 30 to 35 wounded soldiers.

In just 30 minutes, they had to bring order out of chaos. They recovered the soldiers and performed triage on each. They separated the troops by severity of injury. And they evacuated the most seriously hurt in ambulances.

Their commanders, who were evaluating them, were shouting at them.

"Let's go! Too much time on the scene."

"Let's go! Make a decision."

"Why is this taking so long? Let's go!"

But by the end, the chaos subsided.

"The students transform before our eyes," Sharp said. "They seem reticent at first to play the role . . . and at the end we practically need to hand out Academy Awards."

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