Belize scenario, The

Sea Power, Nov 2000 by Howard, Patricia L

USNS Comfort-Full Speed Ahead to Innovative Medical Training

Hurricane Maria has devastated Belize. Amid the destruction, the Military Sealift Command (MSC) hospital ship USNS Comfort has arrived to provide assistance. Victims and casualties-men, women, and children-are many. Electrocutions, critical wounds, malaria, and psychological trauma are just a few of the problems keeping the ship's medical staff working at fever pitch. The triage and casualty-receiving areas are crowded to capacity with individuals and families affected by the damaging winds and waters of Maria and her aftermath.

cost of the sick and injured are carried in on stretchers, but some are able to come in on their own. Many are suffering from the effects of drinking contaminated water, some are bleeding profusely from a variety of wounds, and others are looking desperately for loved ones from whom they have become separated. Everywhere, emotions run high-sobbing, screams, moans, heated arguments, all can be heard-making the scene a tense and challenging one for the medical staff and ship's crew of the Comfort.

This was the scenario designed for a simulated but extremely realistic training exercise conducted aboard the ship while she was docked in her homeport, Baltimore, Md. The casualties were specially trained simulators, or "standardized patients," as they are called in the medical field. The exercise-conceived by Navy Medical Corps Capt. Richard E. Hawkins, medical director of the National Capital Area Medical Simulation Center (a component of the Uniformed Services University (USU) in Bethesda, Md.)was designed to give medical staff and crew members the experience (as close to authentic as possible) they need to prepare for similar "real-world" missions to which they might be called almost anywhere in the world.

Standardized Realism

The trend toward simulation in almost every area of military training has found a solid place in naval/military medical training as well. To provide a sense of realism to training, the Navy has begun to utilize the concept of the standardized patient, initiating a training concept now used in such prestigious university and teaching hospitals as Johns Hopkins.

The standardized patient is coached to present a set of symptoms to a physician while "staying in character" within a set of specific circumstances developed by the training staff. The purpose is to add the human element to training-- equipping doctors and medical staff not only to cope with the medical condition of the patient, but to prepare them as much as possible for the emotional curves that can be thrown at them when dealing with real people with real problems.

Among the goals of the "Belize" exercise, said Hawkins, were not only to hone the already considerable medical skills of the crew, but also to discover potential gaps and deficiencies, prior to the occurrence of a real-life disaster, that might not become apparent under traditional training methods.

"Although the Navy has already been making use of standardized patients on a one-on-one basis in our medical training, this is the first time to our knowledge it has been applied to a mass-casualty setting," said Capt. John Mitas, commanding officer of the MTF (medical treatment facility) aboard the Comfort.

The standardized patients participating in the Belize scenario maintained, over a period of several hours, their roles as believable characters who had been traumatized physically and/or psychologically by Hurricane Maria. These trained simulators, many of them actors with considerable improvisational skills at their disposal, were diagnosed and treated by the ship's medical personnel. The "casualties," made up onethird of professional actors and two-thirds of experienced standardized patients, provided the challenge necessary to test the skills of the medical staff.

Moulage and Mannequins

The exercise began with 48 casualties arriving on the flight deck. Moulage (realistic-looking special-effects makeup) had been applied to some patients to depict severe wounds or bruising. On the flight deck, patients were triaged by crew members and-except for those who were ambulatory-carried on stretchers to the casualty receiving area. There, doctors and nurses performed another triage or immediately began providing emergency treatment.

The simulation was carried through to the point of actual medical tests and even surgery, if called for; if actual surgery or a particularly invasive procedure was required, the standardized patient was replaced with a mannequin. In either event, the procedure was marked through in real time, using all of the medical equipment and supplies appropriate to the procedure.

Bleeding ulcers, respiratory failure, late-stage esophageal cancer, broken limbs, as well as maladies that would be expected in a tropical climate-e.g., malaria, meningitis, acute diarrhea, dengue fever, and insect bites-were among the broad spectrum of medical problems presented to the ship's medical staff. Some of the most difficult cases to cope with were presented not by patients suffering physical trauma, but by those going through psycho-social trauma. A prostitute in search of medication for HIV rudely attempted to distract doctors trying to provide care to the more seriously injured. Cries of a young wife on her honeymoon who became unhinged by her husband's fatal injuries reverberated throughout the treatment areas.