Paramedics in Ottawa, Canada utilize a Cuit Suit to treat a simulated casualty.
Army Reserve Medical Command
FORT MCCOY, Wis., May 20, 2014 – Medical Readiness and Training Command members from San Antonio employed a special piece of equipment during a military medical exercise held here from April 26 through May 16.
Army Master Sgt. Tinamarie Reese, a combat medic, and Army Sgt. 1st Class Kristina Boettcher, a licensed practical nurse, are only two of the six personnel that were trained and certified to work with the cut suits during the exercise.
“The neat thing about these cut suits is we can ‘heal’ them,” Reese said. “This gives us the opportunity to have a 24-hour turnaround time on any one of the suits we have here. We prepare one to be worn on a live person with any type of wounds we choose, to create different scenarios. When they have completed the scenario we bring the cut suit back and begin the healing process by cleaning it and then closing the cuts with clear silicone.”
Using the suit “allows them to be able to provide invaluable training to go beyond notional training and be able to actually go through the process of real surgery,” Boettcher said.
Officials said the cut suit is used as part of the exercise scenarios given to medical personnel at either the Expeditionary Medical Facility that is being operated by the Navy, or the Combat Support Hospital that is operated by the Army.
Once the scenarios and wounds are planned, exercise participants like Reese and Boettcher get to work choosing which organs will be damaged by an improvised explosive device, a gunshot wound, or even adding live earthworms to the intestines.
“We try to make everything as real as possible. Yesterday we added live earthworms to the intestines to act as parasites,” Reese said. “A soldier, sailor or airman could very easily drink parasitic water while deployed, so this just makes it more real. I like to see the reactions of the docs when they cut into the organs and there are different materials and smells in there.”
Army Spc. Devonne Woodruff, a dental assistant, 912th Dental Company, Twinsburg, Ohio, was one of three soldiers that volunteered to wear the cut suit. Woodruff met the physical profiles needed to wear the suit.
“It was something different to do besides the other training we are getting while we’re here,” Woodruff said.
“There was one soldier I had to get out of the suit halfway through the scenario. He got claustrophobic,” Reese recalled. “This suit weighs about 35 pounds and it’s worn just like a backward flight suit because it zips up the back.”
The cut suit is designed to be worn by a male weighing about 150 to 200 pounds and 5 feet 10 inches tall, officials said. These requirements are due to the length and girth of the suit. It needs to be form-fitted to the body, with no loose material. The volunteer is also only allowed to be in the suit for up to 4 hours.
The cut suit team employs a blood-pumping system that’s attached to the patient.
“We will add the BPS for the wound on his leg,” Boettcher said, “so that the first responders will have to apply a tourniquet before he can even go into the emergency room. I have a remote that is linked to the BPS and I can let more blood flow until I believe they have the tourniquet on correctly.”
Combat medic Army Spc. Kevin Strebler, an Akron, Ohio, native with the 912th Dental Company at Twinsburg, Ohio, was the volunteer for one of the cut suits.
“I’ve done this two times before — this is my third time,” Strebler said. “It’s fun. I get to yell and scream about my injuries to play along. The mannequins don’t yell and scream, so they [the doctors] have to pretend more.”
The drill was staged by Strategic Operations, a part of the Stu Segall movie production company. Creators at the Kearny Mesa lot use movie techniques to make the training more realistic. They say the more real the training environment, the better the body adapts to stress.
“To get the heart rate up and to be able to work under actual stressful environments. To make the correct decisions at the correct time,” physician’s assistant trainee Kellen Gumm said.
This is the 12th year Strategic Operations has staged this type of training.
The widely cited U.S. policy of “Pacific Rebalance” is impacting trans-Pacific relationships across a spectrum of governmental, economic and security environments.
Within the trans-Pacific security environment, Department of Defense components are working to incorporate many of the critical Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) lessons learned over the past 14 years into a framework of cooperation and understanding with new regional partners. And one set of critical lessons involves the importance of cultural and language training for forces operating on a global stage.
Some of the new efforts to support cultural and language training range from simplified language efforts to specialized training facilities to new software developments designed to accelerate regional capabilities among U.S. forces.
One fairly basic example of early trans-Pacific/Asia language efforts can be seen in “Disaster Assistance Translator for Asia,” developed by Kwikpoint on behalf of the Department of the Navy’s Center for Language, Regional Expertise, and Culture. Similar to the company’s American Red Cross Disaster Assistance Translator, the 24-panel laminated card not only features hundreds of visual images covering applications from medical to family issues, but also adds key phrases in Bengali, Burmese, Cantonese, Dzongka, Hindi, Japanese, Khmer, Korean, Lao, Maldivian, Mandarin, Nepalese, Sinhala, Tagalog, Thai and Vietnamese.
At the other end of the complexity spectrum, San Diego-based Strategic Operations is configuring regional training facilities to support the same levels of “hyper-realism” that have been applied to their Iraqi and Afghan training settings over the past decade.
Kit Lavell, executive vice president at Strategic Operations, said much of the current work is being done with the Marine Corps through the Program Management Training Systems (PM TRASYS) Atmospherics contract, a multi-year contract under which the company provides “all of the things that go inside and outside MOUT [military operations on urban terrain] facilities to make them look realistic and that have the ability to be changed to reflect whatever the current theater of operations happens to be.”
Following up on a record of implementing cultural realism across a variety of U.S. training site locations, Lavell pointed to Atmospherics support of the Pacific Rebalance, offering, “In Guam, for example, we are currently making the MOUT facilities look like the Far East.”
Lavell explained that the company’s business is split between manufacturing and training.
“On the manufacturing end, in addition to our Atmospherics, we are building for the military services and other governmental agencies MOUT facilities and other types of buildings, including embassies and governmental buildings and compounds that might be found through all parts of the world,” he said.
“In addition to that, we are involved in training in a big way,” he added. “And being one of the very first companies to use actors who know the culture and the language 12 years ago, starting with the Middle East, we have provided role player support and everything that goes along with it—wardrobe, special effects and things like that—to replicate different parts of the world. We have supplied role players who know other languages of the Far East—including Tagalog, Korean and others. So we see the shift and we are prepared to provide role players and cultural experts in those parts of the world.
“We’re using all of the same hyper-realistic techniques that we have developed to support OEF and OIF,” he added. “And for OEF and OIF those were used in a very kinetic way. But we are now using those same techniques to train our men and women in uniform in those types of situations and environments where it is necessary to work with indigenous elements—either government, military or local populations.”
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Lavell declined to give his company’s revenue, but said the bulk of it is in military training. The business began as a movie studio in 1991 but shifted to military training after 9/11. Today, Strategic Operations competes for its work. “We don’t get sole-source contracts,” Lavell said. In June, the business got a deal to train British soldiers at a military base in Alberta, Canada. Strategic Operations also offers training for law enforcement agencies. Part of Strategic Operations’ business, both on- and off-site, is building sets. Its construction crews recently built a Navy destroyer interior at one of its Kearny Mesa sound stages to train sailors for scenarios like the bombing of the USS Cole. The enterprise put together a mock Middle Eastern village in the undeveloped, eastern part of Marine Corps Air Station Miramar in 2004. And under the guidance of a U.S. Marine Corps general, it converted a 33,000-square-foot building at Marine Corps Base Camp Pendleton into an infantry simulator. Strategic Operations recently developed an actor-worn “cut suit” which bleeds when cut. The business is trying to interest its government client in using it more. The demand for such simulators may increase since animal rights advocates have objected to the military using live farm animals for medical lessons.
by Henry Grabar
“Even local businesses these days have response plans in place,” says Rick Nelson, a veteran of the National Counterterrorism Center and a senior associate at the Center for Strategic and International Studies.
So when two pressure-cooker bombs exploded on Monday afternoon, Boston’s emergency operations centers knew what to do. Emergency medical personnel affixed tourniquets – Boston’s first responders all carry these battlefield dressings, though many ambulances and hospitals nationally do not – to bloodied limbs. The most serious casualties were distributed among area hospitals, a technique known to optimize critical care during disaster events. Boston Marathon medical tents set up for fatigued runners were transformed within minutes into trauma centers. Police officers took up positions to keep spectators off the course and turned back runners approaching the finish line.
As the medical response unrolled, a parallel series of preventative measures were put into action. Service on Boston’s Green Line, which has a station at Copley Square near the scene of the attacks, was suspended between Kenmore and Park Street. Security checks were installed at local transit hubs. The FAA temporarily grounded all flights at Logan International Airport.
The scene on Boylston Street was an admirable display of bravery, skill and calm by first responders and volunteers. But less remarked, and equally remarkable, was the value of the city’s foresight. Few U.S. cities could have been better prepared for the events of this week.
“Everything that you saw happen within seconds of the explosion,” says James Baker, the president of security consultancy Cytel Group, “was all because someone thought they should be prepared for that.” Baker would know. In the past 24 months, he has helped Boston run two massive, 24-hour worst-case scenario simulations that bore no small resemblance to the situation unfolding this afternoon in Watertown.
Over the past decade, the Department of Homeland Security has funneled billions of dollars towards the protection of U.S. cities. Boston is one of the DHS’s “Tier 1” U.S. metro areas — in DHS’s view, one of the country’s ten most likely targets for terrorism. The Urban Areas Security Initiative (UASI), the largest part of the Homeland Security Grant Program, distributes half a billion dollars annually to 31 U.S. metros, and sent $11 million to Boston in the 2012 fiscal year.
Few U.S. cities could have been better prepared for the events of this week.
The Metro Boston Homeland Security Region (MBHSR) — nine cities including Boston — directs that money into an array of local counterterrorism programs. In the past few years, the MBHSR has upgraded over 5,000 portable radios for first responders and installed a communication system inside the tunnels of the Boston T.
Part of that money must go towards live drills, so over the past couple years, Boston has conducted two citywide disaster simulations with Cytel Group’s Urban Shield, using the preparation and after-action reports from the first trial (in May 2011) to improve the city’s preparedness in the second, in November 2012. (The city also hosted an emergency management summit last August.)
U.S. cities have been doing disaster drills for decades, and some exercises — such as Detroit’s World War II black-out drills or Portland’s 1955 “Operation Greenlight” — have been of some magnitude. But in the last decade, the trend in disaster drills has moved from the purely local exercise to the vertically integrated simulation that coordinates a reponse across the different levels of government. “What is different,” Nelson says, “is the range and depth of missions they’re responding to.”
Urban Shield, which Baker started in 2007, is one of several drill programs that have sprung up over the last decade in response to DHS grants for thorough emergency preparedness training. In 2010, it received UASI’s honorable mention for best overall program.
In Boston, Urban Shield was sufficiently disruptive and expansive that Mayor Thomas Menino’s felt obliged to ask residents to remain calm:
“Urban Shield: Boston will run for a 24-hour period. As a result residents in the area may hear simulated gunfire, observe officers responding to simulated emergencies, or see activity in the Boston Harbor. Each scenario will be run multiple times, and organizers urge residents not to be alarmed.”
The drills, which included hostage situations, HazMat incidents and a movie theater shooting, brought together emergency officials from the city, state and federal government, as well as from the Boston Police, SWAT teams, the Fire Department, EMS, local hospitals, the Massachusetts Bay Transportation Authority, the Coast Guard. All in all, there were over 600 participants in the November drill, from over fifty different departments and agencies.
“What the Urban Shield program does is test it all at the same time – bomb squads working, swat teams working, fire, HazMat, search and rescue, command centers activated, all your radio systems, hospitals activated – everyone’s kind of working together,” says Baker, who worked closely with the city to execute the simulation. “That’s where you start to find your gaps – who can’t speak to whom on the radio. You identify the real problems when you get everyone together.”
The drills are intended to be strikingly lifelike. Urban Shield has worked with Strategic Operations, a Hollywood effects company that also helps prepare army medics for the battlefield. (Their disaster scenario staff, Baker says, include an amputee.) With a generous helping of moulage, their drills aim to force officials to confront both the logistical and atmospheric challenges of a disaster.
“The leadership is outstanding,” Baker says, referring to Boston. “I have found that they are proactive and forward thinking – they invested a lot of time and energy in getting ready for something that they never thought would happen.”
Speaking of the Urban Shield program in a video released in September, Daniel Linskey, superintendent-in-chief of the Boston Police Department, sounded oddly prescient. “You have to train for things that may be out of the ordinary,” he said, “because you can’t wait for them to happen to be ready.”
Nationwide, the hierarchy of emergency management can be staggeringly complicated, and the varying power structures within U.S. states — think of how L.A. County contains 88 cities, while New York City contains five counties — make it difficult to generalize about who calls the shots.
“Even local businesses these days have response plans in place.”
For example: Boston has an Emergency Operations Center run out the city’s Office of Emergency Management. Massachusetts has a State Emergency Operations Center, run out of the Massachusetts Emergency Management Agency. The MBHSR (which runs the Boston Regional Intelligence Center) is a federal jurisdiction that contains nine cities.
What began as the Cold War-era Office of Civil Defense has long since evolved into alphabet soup, which poses two related problems for disaster planners: first, how do all these agencies communicate when something goes wrong, and second, and more importantly, how does the DHS begin to regulate and standardize city responses, making it easier for the federal government to lock up with local jurisdictions during crises?
Since 9/11 and Hurricane Katrina, experts say, collaboration and communication between agencies and jurisdictions has been one DHS’s highest priorities. “Government agencies are better at talking to each other, coordinating, cooperating,” says Stevan Weine, a psychiatry professor at the University of Illinois at Chicago who studies counterterrorism and resilience. “They’re better at partnering with other entities, local communities, the business community.”
Though every city has an all-hazard plan by one name or another, it can be difficult to predict how various authorities will interact in a time of crisis. “Coordination is key,” Nelson says. Boston’s MBHSR, like many regional DHS jurisdictions, is working to implement the National Incident Management Program (NIMS), a national framework for disaster reporting and response.
“When you talk about disasters, it’s all about partnerships,” says Ken Kondo, a program specialist at the Los Angeles County Office of Emergency Management. Training exercises are indispensable. Last month, Kondo says, L.A. County performed an exercise in response to an imagined 7.8-magnitude earthquake, working out hypotheticals with the National Guard, the Red Cross and dozens of city and county departments in between.
Not every effort at integration across departments has gone so smoothly. In 2003, DHS began to develop a network of “fusion centers,” cross-agency intelligence outlets designed to assist law enforcement, public safety, emergency response, and other regional authorities in “preventing, protecting against, and responding to crime and terrorism.” The program has had its growing pains: a 2012 Senate investigation found that fusion centers mostly gathered “irrelevant, useless or inappropriate intelligence,” and often spent money frivolously.
The Boston Regional Intelligence Center (BRIC), one of 77 U.S. fusion centers, was not available for comment this week. But Mike Sena, the President of the National Fusion Center Association, who defended the program after the Senate report, said the BRIC was designed to operate in exactly the sort of inter-agency crisis situation occurring in Boston “This is what fusion centers were built for,” Sena told the Wall Street Journal.
The DHS has also strived to institute a system of best practices across cities. According to Cytel’s James Baker, the impetus for this is obvious: “If we’re doing it one way, and you’re doing it another way, we should figure out which way is better.”
But given the variations in the power structure, not to mention the geographic and structural differences between cities, a standard municipal operating procedure is, for now, beyond reach. “Every city has its unique requirements,” Nelson says. Additionally, resource allocation varies widely. (New York City receives nearly one-third of UASI funding; many of the country’s populous metros do not receive any at all.)
FEMA’s “Comprehensive Preparedness Guide 101” [PDF], released in 2010, tentatively positions itself as a textbook for emergency operations plans — while acknowledging the critical differences between cities, and the virtues of bottom-up disaster planning (my italics): “This Guide recognizes that many jurisdictions across the country have already developed EOPs that address many emergency management operations. Therefore, CPG 101 establishes no immediate requirements, but suggests that the next iteration of all EOPs follow this guidance.”
The Emergency Management Accreditation Program (EMAP) further encourages a convergence of local and state planning strategies. Established in 2003 under the guidance of DHS and FEMA, EMAP is the country’s first accreditation program for all-hazards plans — the first comparative body that holds all municipal, state, and university emergency plans to a common, respective standard. In November, under the leadership of Rene Fielding, director of the Mayor’s Office of Emergency Management, Boston became one of only four cities nationwide to receive EMAP accreditation.
DHS-funded programs like Urban Shield also help spread best practices between cities — as they move from region to region, they share lessons learned. (Two of the EMAP-accredited cities, Boston and Austin, have also held Urban Shield events.) Each Urban Shield simulation also draws dozens of professionals from other, smaller cities, who come to watch and learn.
Municipal departments also study each other’s tactics. While a city like Boston might have a hard time learning from New York City — the world’s most sophisticated police force is actually too good to be helpful (they have over a dozen foreign operatives, for example, and in some countries rivaling the CIA for intelligence) — it can draw lessons from elsewhere.
For U.S. cities, Israel is a particular area of focus. In October, officials from ten U.S. police departments (though not Boston) traveled to Israel to study counterterrorism, security and resilience. And Israel is a case study for more than just police: Mass General Hospital in Boston, which received dozens of victims from the Marathon bombings, had previously consulted Israeli doctors to “revamp their disaster-response planning.”
Resilience, in particular, is one area in which the Israelis excel — and one that U.S. authorities have been eager to import to U.S. disaster areas.
“When you think about political violence, there’s ‘How do we stop it?’, and if we can’t stop it, ‘How do we respond?'” says Victor Asal, director of the Homeland Security Certificate concentration at the Rockefeller College of Public Affairs and Policy. “One of the components is resilience – how do you get back to the way things were. And that’s different than finding out who did it.”
“In Jerusalem, when a terrorist attack happens,” he adds, “if you walk by six or 12 hours later, you wouldn’t know it. They clean it up and they get people going.”
The Atlantic‘s Jeffrey Goldberg, writing in Bloomberg View on Tuesday, also cited Israeli resilience. A decade ago, arriving at a Jerusalem cafe the day after a terrorist attack there killed seven people, he found the scene nearly indistinguishable from any other day. “There is no satisfactory solution to the problem of mass anonymous violence,” he writes. “As a result, resilience becomes the paramount response. Keeping your wits about you as individuals, as a government and as a culture is what counts.”
Whether today’s Boston lockdown, prompted by the manhunt for Marathon bombing suspect Dzhokhar Tsarnaev
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Animal activists say the animals are shot, stabbed, bludgeoned and blown up to simulate the types of injuries soldiers face.
For three decades, the activists have tried to end the practice. Their efforts appear to have finally paid off.
The 2013 National Defense Authorization Act, signed into law this month, requires the Department of Defense to provide Congress with a strategy and detailed timeline by March for the replacement of animals for medical training.
People for the Ethical Treatment of Animals, which applauds the move, said Fort Bragg training accounts for about a third of the animal deaths caused by the military each year.
Government documents show that officials at Fort Bragg’s Army Special Operations Command solicited up to 3,600 goats for use in training last year.
The documents show that the command planned to use about 300 goats a month.
Officials with the John F. Kennedy Special Warfare Center and School and Army Special Operations Command confirmed that they use animals for training but said they could not comment further.
The officials said they have not been given specific guidance on the requirements outlined by the authorization act.
PETA and other groups have protested the use of live animals in military training, advocating for simulation and other modern, nonanimal methods, said Justin Goodman, director of the group’s Laboratory Investigations Department.
In the 1980s, advocates were able to stop the use of dogs and cats in the training, Goodman said, but the language in the authorization act represents the first time Congress has required the military to formalize its efforts to end all animal use.
Goodman said 10,000 animals are killed each year during trauma training conducted by the military and private military contractors.
Up to a third of those animal deaths are attributed to training on or around Fort Bragg, and several thousand more are attributed to civilian contractors who do work for various military groups.
Dr. John Pippin, a Dallas cardiologist who advocates on behalf of the Physicians Committee for Responsible Medicine, said it is important to realize that this isn’t a choice between saving a soldier and saving a goat.
“The use of goats and pigs for this type of training, if it was ever the best method, is not the best now,” he said. “Anyone who tells you it’s choosing between a goat and a soldier is devoid of a valid argument. That’s a cop-out. It’s not the only way or the best way.”
The committee helped to craft a bill last year that would force the Department of Defense to end the practice of using live animals in trauma training within five years.
That bill did not pass the U.S. House but served as the basis for the language inserted into the authorization act, officials said.
Pippin said the use of live animals in medical training was commonplace when he went through medical school in the late 1970s.
But even then, he said, many questioned the practice.
“We just knew, intuitively, that this was not relevant,” he said.
Now, only about five medical schools out of nearly 180 in the United States and Canada use live animals as part of their curriculum, Pippin said.
Pippin and Goodman advocate for the use of various simulators, including “cut suits” that they say are better suited for the trauma training.
Some simulators look like humans, they said, and feature lifelike skin, anatomically correct organs, breakable bones and realistic blood flow.
Others can be worn by humans while still providing many of the realistic features.
“The anatomy and physiology of a goat and a pig are dramatically different from humans,” Goodman said. “The simulators are better in all regards.”
Goodman and Pippin said many military schools moved to simulators long ago, including the Rascon School of Combat Medicine at Fort Campbell, Ky., the Air Force Center for Sustainment of Trauma and Readiness Skills and the Navy Trauma Training Center.
PETA officials said Camp Lejeune, at one point, also stopped using live animals in training.
Lejeune officials did not respond to inquiries, but government documents show that officials on the Marine base do use live animals for trauma training, stating on bid paperwork that the live tissue training “has proven to save lives and lessen the severity of injury in combat.”
Goodman said PETA would ask the Marine Corps to cease the use of animals in training.
Part of the problem, Goodman said, is that the training curriculum within the military is decentralized, with no overarching structure.
The use of live animals occurs on at least 20 bases across the country, he said.
But, he said, it’s largely nonexistent in other parts of the world.
Twenty-two of the 28 countries in the North Atlantic Treaty Organization have banned the use of live animals in training, Goodman said.
And news reports indicate that German officials have barred U.S. soldiers stationed in that country from training involving live animals in the past.
Once the military’s ban on using live animals is in place, Goodman said, it will bring the U.S. up to the standards set by those countries, while improving the training itself.
“It’s a win-win,” he said.
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