Page 119 - JSOM Winter 2023

A Military Forward Surgical Team Inside a Civilian Virtual Reality Simulation for
Structure: The Belgian EMT-2 Experience in Turkey Unconventional Warfare Medicine
After the Earthquake of 6 February 6 2023 Col John R. Dorsch, DO USAF (Ret.); Michael G. Barrie, MD;
J-C de Schoutheete, MD; A. Bun, MD, Queen Astrid Military ler Andre, MD; Nilesh Patel, MD1; Jennifer Polson, PhD;
Hospital, Brussels, Belgium Karthik V. Sarma, PhD, SimX, Inc., San Francisco, CA
hile deploying a surgical team for high-intensity operations ombat casualty care has been predominantly driven by the
Win austere environments is the primary objective of most C“Golden Hour” policy throughout the last two decades, under
military surgical teams, opportunities to exercise this capability in which U.S. and partner military forces have maintained expedient
real-life conditions are infrequent. medical evacuation of the wounded to surgical hemorrhage con-
trol within 1 hour of injury. In the setting of Great Power Com-
Following the catastrophic earthquake in Turkey in February petition, unconventional warfare medicine (UWM), a form of
2023, Belgium deployed an Emergency Medical Team with sur- extreme prolonged casualty care (PCC), will be a key requirement
gical capacity (EMT-2) through its national interdepartmental for many forces as they operate in denied and semi-permissive en-
relief organization, B-FAST [1]. Belgian Defence supported the vironments. Given the ever-increasing expanse of protocols and
deployment by providing a lab, a pharmacy, an X-ray machine, a procedures across both Tactical Combat Casualty Care (TCCC)
sterilization unit, a post-anesthesia care unit, and a surgical team. and PCC/UWM, advanced medical skill development and sustain-
ment will remain an even more significant barrier to operational
The surgical team consisted of pairs of surgeons, anesthetists, and readiness in the future fight. As a result, simulation training will be
operating room nurses in a junior/senior configuration. Two se- critically important in providing the “clinical” exposure necessary
nior medical logisticians reinforced the team as well. Turkey was to maintain readiness, especially in UWM, which requires a high
the first deployment for the junior team members. However, each level of expertise, adaptability, and improvisation. Here, we dis-
of them had already followed initial military training in forward cuss the development of the next generation of medical simulation
surgery. training (MST) using immersive virtual reality (VR) that provides
dynamic flexibility, immersive realism, and real-time accessibility
to prepare military personnel for UWM. Recent advances in MST
Regarding the timeline, a B-FAST reconnaissance team arrived have focused on austere, protracted casualty treatment, with more
two days after the earthquake. The logistics team landed five days holistic and operationally complex capabilities under development
after the event, while the medical team joined three days later.
within VR, which can be used to target UWM requirements. When
paired with full mission profile exercises, integrated didactics, and
Although initial surgical capability with damage control surgery self-study education, VR initiatives will provide the key founda-
was available as soon as the medical team arrived, full surgical ca- tion for ensuring that military troops get the “reps” required to
pacity in orthopedics, general surgery, and gynecology was avail- render life-saving care in the future operating environment.
able two days later, which means 10 days after the earthquake.

The surgeons performed 180 surgical consultations and proce- Military Operations in Cold Weather
dures during the first two weeks of deployment. During the same LTC (Ret.) Dr. Raimund Lechner, MD, Bundeswehr Hospital Ulm,
period, the anesthetists performed 62 anesthetic procedures. Chil- Department for Anesthesiology
dren represented 24% of the treated surgical population. To the Introduction: Since ancient times, military conflicts have taken
best of our knowledge, all patients survived and none of them place under extreme environmental conditions, including severe
experienced major, direct postoperative complications. The type cold. The aim of this lecture is to give a brief historical outline of
of pathology encountered can explain this. Indeed, ten days after significant military operations in extreme cold and to present the
the event, life-threatening issues no longer accounted for most sur- most relevant influences of cold on military operations. Methods:
gical indications [2,3]. Selective literature search in PubMed and own experiences. Re-
sults: Significant historic events under the influence of extreme
This experience shows that prior military training of a surgical cold include Alexander the Great’s crossing of the Khawak Pass,
team, pre-existing cohesion, and standard operating procedures Hannibal’s crossing of the Alps, Napoleon’s Russian campaign,
are key factors for a successful short-notice deployment in an aus- the Finnish Winter War, the Falklands War, and, currently, the
tere environment. In addition, logistics need to be robust and rus- Indo-Pakistani-Chinese border conflict and the War in Ukraine.
tic backup equipment should always be available as plan B. In addition to latitude and season, sea level has a significant ef-
fect on ambient temperature, with a temperature decrease of at
The future perspective is to allow a Belgian forward surgical team least 0.65°C per 100 meters in altitude. On the one hand, the cold
to be available much more quickly after the event, independent causes direct cold injuries. On the other, it increases the risk of
of an EMT-2. Other medical modules could then be plugged into common colds, trauma from snow and ice, UV radiation dam-
that surgical stronghold gradually within the first weeks of de- age, and carbon monoxide intoxication from cooking in confined
ployment. However, such an implementation will require both spaces. In addition, it affects military operations by aggravating
material and human availability and reactivity. hygiene conditions, generally making warehouse life more diffi-
cult, reducing physical and mental capabilities, complicating logis-
References tics, and causing material failures. Military units are more affected
1. B-Fast Sends Medical Aid and Field Hospital to Turkey - Türkiye. by the cold than civilians because of tactical constraints. Caring
ReliefWeb, 11 Feb. 2023, reliefweb.int/report/turkiye/b-fast-sends- for the wounded and injured requires numerous medical and tacti-
medical-aid-and-field-hospital-turkey. Accessed 03 July 2023. cal adaptations. Conclusion: Cold can alter the geopolitical world
2. Gao P, Wang YD. Subacute Phase After an Earthquake: An Even order. The impact of cold is regularly underestimated by military
More Important Period. Disaster Med Public Health Prep. leaders and has been responsible for more casualties than combat
2019;13(5-6):1011–1016. DOI:10.1017/dmp.2019.7 operations with immense losses of combat troops in numerous
3. Zhang L, Liu X, Li Y, et al. Emergency medical rescue efforts af- conflicts. Current world political events make it likely that mili-
ter a major earthquake: lessons from the 2008 Wenchuan earth - tary operations in the cold will increase in importance. Cold pro-
quake. Lancet. 2012;379(9818):853-861. DOI:10.1016/S0140- duces its own disease and injury patterns, reduces performance,
6736(11)61876-X. and requires modified tactical casualty care.

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