17-Ukrainian Healthcare Professionals Experiences During Operation Gunpowder Implications for Increasing and Enhancing Training Partnerships

COMMENTARYMILITARY MEDICINE, 00, 0/0:1, 2023Downloaded from <a href="https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usad484/7505053bygueston30January2024">https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usad484/7505053 by guest on 30 January 2024</a>Ukrainian Healthcare Professionals’ Experiences DuringOperation Gunpowder: Implications for Increasing and Enhancing Training PartnershipsHM1 Jonathan T. Shumaker, USN; Col Cynthia Shen, DO, USAF; Rebekah Cole, PhD, MEd<a href="https://orcid.org/0000-0003-2628-8658"><img src="/media/202408//1724838589.434804.png" /></a>ABSTRACT Because of the diverse backgrounds of their healthcare professionals, Ukrainian military medicine needs expanded and enhanced military medical training to increase their readiness in the war against Russia. During March 2023, eight Ukrainian healthcare professionals participated in Operation Gunpowder, a high-fdelity prolonged casualty care simulation conducted by the USU as a part of its Military Unique Curriculum. In order to evaluate their experiences, we interviewed each healthcare professional and analyzed the data to determine common themes. The participants frst described the challenges of operational medicine in Ukraine. They then described the benefts of simulation training such as learning how to navigate a resource-limited operational environment, learning prolonged casualty care, and enhancing leadership and teamwork. Finally, they discussed how they planned to implement training such as Operation Gunpowder in Ukraine in order to increase force readiness. After experiencing the prolonged casualty care simulation training, the Ukrainian participants believed Operation Gunpowder to be a valuable training tool due to its ability to help them overcome the current challenges they are facing in their war against Russia. They described how they would integrate similar training in Ukraine, and follow-up correspondence revealed the success of these efforts. Other universities and institutions are likewise called to use their knowledge and resources to help train Ukrainian health professionals using simulation-based training or other education modalities.BACKGROUNDOn February 24, 2022, Russia attacked Ukraine by initiat- ing a large-scale assault by ground forces and targeting large <a id="bookmark1"></a>metropolitan cities with detrimental air strikes<a href="#bookmark2">.1</a> The results of the confict have been devastating, destroying cities and infrastructure and causing Ukrainian citizens to seek refugee status in neighboring allied countries to the west. However, the most harmful impact has not been the destruction of cities and their supporting elements, but the extensive loss of human life. After more than a year of confict with Russia, Ukraine has suffered an estimated 100,000 military and 25,170 civilian <a id="bookmark3"></a>casualties<a href="#bookmark4">.2</a>To assist in treating and managing substantial numbers of casualties, Ukraine recruited civilian volunteers to join the Ukrainian health service support team to support the ongo- ing war. However, many volunteers have limited to no prior <a id="bookmark5"></a>experience practicing military and emergency medicine<a href="#bookmark6">.3</a>OneDepartment of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USAThe opinions and assertions expressed herein are those of the authors and do not refect the offcial policy or position of USU, the United States Navy, the United States Air Force, or the DoD.doi:https://doi. org/10 . 1093/milmed/usad484Published by Oxford University Press on behalf of the Association of Mil- itary Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.replicable training solution to this training disparity may be implementing simulation-based training throughout Ukraine. Simulation-based training has proven to be an effective train- ing approach for the military medical personnel that enhances knowledge and skill development while receiving formative <a id="bookmark7"></a>instructor feedback<a href="#bookmark8">.4–</a><a href="#bookmark9">7</a>One example of a military medical simulation is Operation Gunpowder, a two-day medical feld practicum held annually for third-year medical students at USU as a part of USU’s <a id="bookmark10"></a>700-hour Military Unique Curriculum<a href="#bookmark11">.8–</a><a href="#bookmark12">10</a> Active duty mil- itary medical students at USU complete this curriculum in addition to their regular medical school training in order to increase their operational readiness. Operation Gunpowder consists of realistic patient scenarios focusing on prolonged casualty care (PCC) that encourage third-year military medi- cal students to developeffcient leadership skills imperative to operate in austere, resource-restrictive environments. Opera- tion Gunpowder drives an ultra-realistic training environment by integrating high-fdelity, interactive mannequins, life-like moulaged patient actors, and training spaces that resemble Role 1 and Role 2 treatment facilities, which support current Tactical Combat Casualty Care (TCCC) and PCC guidelines. Students learn how to maintain circulatory and respiratory stability, infection control, and forward surgical resuscitative skills necessary to provide their patients with the pre-eminent probability of survival. They serve on small teams comprisingMILITARY MEDICINE, Vol. 00, Month/Month 2023 1Ukrainian Healthcare Professionals’ Experiences During Operation Gunpowdermilitary physician and medic roles and collaborate through intimate teamwork to provide life-sustaining treatment to their patients as they transition from each echelon of care, utilizing military tactical vehicles and aircraft for patient transport.During Spring 2023, Ukrainian medical personnel inte- grated with platoons of USU military medical students to develop their TCCC skills and establish new skill sets, includ- ing PCC, and to gain the knowledge and expertise to advance Ukrainian military medical training. In this commentary, we will describe experiences of the Ukrainian military medical personnel participating in Operation Gunpowder and their perceptions of its utility as a training tool for the austere oper- ational environment. We urge other institutions, both civilian and military, to likewise contribute their expertise and train- ing resources to Ukrainian’s military medical readiness as we frsthand saw and heard about its impact from our Ukrainian partners.PARTNERSHIP PROCESS AND EVALUATION METHODSThe USU invited six physicians and two medics to partic- ipate as learners during Operation Gunpowder in order to provide them with an example of simulation training and an opportunity to learn how to teach skills within the operational environment (see <a href="#bookmark13">Figs. 1</a>–<a href="#bookmark14">3)</a>. The physicians’ backgrounds included a pathologist with a Ph.D. in medical biochemistry, an infectious disease specialist, an anesthesiologist, a pedia- trician, and two surgeons. The medics’ backgrounds included an engineer/construction manager and a railway manager. The participants had been serving in the Ukrainian military since the Russian invasion in March 2022. Although most of the Ukrainian healthcare professionals had a background in vari- ous disciplines of medicine, none had technical or experiential knowledge in components offeld medicine, including TCCC or PCC.To evaluate their experience during the simulation, our <a id="bookmark13"></a>research team conducted semi-structured interviews with<img src="/media/202408//1724838589.484616.png" />FIGURE 1. Ukrainian military healthcare professionals and USU medical students perform damage control surgery in a simulated Role 2 environment under the guidance of the US Military trauma surgeons during Operation Gunpowder (Photo credit: Tom Balfour).<img src="/media/202408//1724838589.533103.jpeg" />Downloaded from <a href="https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usad484/7505053bygueston30January2024">https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usad484/7505053 by guest on 30 January 2024</a>FIGURE 2. Ukrainian military healthcare professionals and USU students exhibit teamwork and peer leadership to move simulated patients to the next <a id="bookmark14"></a>echelon of care during Operation Gunpowder (Photo credit: Tom Balfour).<img src="/media/202408//1724838589.576622.jpeg" />FIGURE 3.A Ukrainian physician provides life-sustaining cardiopulmonary resuscitation to a simulated patient during a PCC scenario at Operation Gunpowder (Photo credit: Tom Balfour).Ukrainian healthcare professionals throughout Operation Gunpowder. Each interview averaged 20 minutes. We then triangulated this interview data with written notes taken by our research team during the participants’ panel discussion at USU prior to Operation Gunpowder as well as follow-up emails to the participants.We followed the steps of qualitative data analysis to deter- mine the data. As we read through each interview, we coded important words and phrases that described the participants’ perceptions and experiences. Next, we determined how to divide the codes into major categories. We decided how to collapse these categories into four main themes, which served <a id="bookmark15"></a>as the results of our investigation<a href="#bookmark16">.11</a>RESULTSThe following themes emerged from our data analysis, reveal- ing how the participants: (1) noted challenges of the austere operational environment, (2) recognized the training benefts2 MILITARY MEDICINE, Vol. 00, Month/Month 2023Ukrainian Healthcare Professionals’ Experiences During Operation Gunpowderof Operation Gunpowder, and (3) became inspired to integrate PCC simulation training in Ukraine.Theme 1: Noted Challenges of the Austere Operational EnvironmentThe participants noted three signifcant obstacles to Ukrainian military medicine: resources, logistics, and time. “I think we teach [at] a very high level, but we don’t have enough resources, mannequins, or [simulated] blood,” one of the par- ticipants explained. Ukrainian TCCC and Combat Life Saver (CLS) instructors have the knowledge and frsthand experi- ence necessary to facilitate and train Ukrainian medics in CLS. Still, they believed their training capability and poten- tial has been barred by logistical constraints that are beyond their control. “I think if we will have simulation equipment, it will improve our teaching.” Concurrently, the time allot- ted to train Ukrainian medics is vastly limited. “They want us to [train] medics for fve days.” Our participants noted they inquired about additional time to train Ukrainian medics from the Unit Commanders; however, they were told, “No, we have no time.”In the midst of these logistical challenges, the participants described how Ukrainian medics are often civilian volunteers with limited to no experience or training in the realms of TCCC. “They are not soldiers; they are just citizens who went to the front…” Another participant explained, “One day a teacher, hairdresser, or an information systems technician. Next day, soldier.” As a result of this lack of training, a partic- ipant described their limited experience in TCCC, “Ihad not practiced military medicine yet. Twenty years I practice, in surgery, in general surgery, but it is only civilian medicine.” A Ukrainian physician participant told the story of one of the medics participating in Operation Gunpowder.One of our participants, he [has only been to] the fve-day course at our center. And before, he spent maybe a few weeks in the Army; he came to the army as a volunteer. So they gave him a rife, and they trained him for a few weeks. They sent him to our center for only fve days. After…they sent him directly to the combat, in trenches. And he saw tanks com- ing to his trench,and he saw a lot of casualty. And he was the only medic in this squad.Theme 2: Recognized Training Benefts of Operation GunpowderAfter recognizing these obstacles, the participants recognized PCC simulation training like Operation Gunpowder as a fea- sible training solution to an austere operational environment. The participants frst described the realism of the simulation to the operational environment. “It was so real, like on the battle- feld,” one of the participants described Operation Gunpowder after completing the exercise. Another Ukrainian healthcare professional described howThe team can act almost as in real life, close to the feld envi- ronment. [It provided] the feeling of reality. The whole team,the whole squad, all the people are functioning like one organ- ism…this training is so close to reality…and is actually the great part why this training is so good.Within this resource-limited environment, the participants explained that PCC is a newer concept that needs more famil- iarity and integration into their training curriculum. One expounded that “PCC was something new for us because we don’t have a PCC course in Ukraine.” Through their frst expo- sure to PCC during Operation Gunpowder and successfully completing the exercise, another participant recognized the signifcance of PCC and how PCC will beneft Ukraine in the ongoing confict. “We do need [such a] course in Ukraine because…we have delayed evacuation times,” another par- ticipant elucidated. One Ukrainian physician noted that due to logistical constraints of military tactical vehicles and air- craft to evacuate casualties on the front lines, “medics are often forced to sit on patients for extended amounts of time while located at the point of injury, requiring medics to render treatment beyond the scope of CLS.” Another concluded that after refecting on the importance and benefts of PCC, “hope- fully we develop such a course in Ukraine…we do need to do that.”Downloaded from <a href="https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usad484/7505053bygueston30January2024">https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usad484/7505053 by guest on 30 January 2024</a>Additionally, the participants described how they learned the importance and benefts of working with limited resources. One explained that by applying “the right skills in the right moment of time with little resources,” teams of physicians and medics can provide their patients with the best possibility of survival. The participants concurred that the resource-limited conditions established throughout the exercise propelled them into a prophylactic mindset to plan for multiple methods to treat their patients when logistical support is scarce. Another physician elaborated, “This course gives us the possibility to think in advance and plan our resources.”Theme 3: Became Inspired to Integrate Simulation PCC Training in UkraineBecause of the applicability of Operation Gunpowder to the current landscapes of war in the Ukraine, the partici- pants described how they would integrate similar training in Ukraine. The Ukrainian healthcare professionals explained the impact of Operation Gunpowder’s high-fdelity PCC train- ing simulation resonated among all the participants during the exercise and inspired future integration. One Ukrainian physician concluded that they were already thinking about taking their training to another level “doing this combat med- ical course” and offering the PCC training to all Ukrainian medics. The participants believed that integrating the training framework and principles of Operation Gunpowder into their combat medic curriculum would close the currently existing casualty care gap from “delayed” casualty evacuation (CASE- VAC) times, causing combat medics “to stay with the injured for hours, if not days.” One physician explained the following:MILITARY MEDICINE, Vol. 00, Month/Month 2023 3Ukrainian Healthcare Professionals’ Experiences During Operation GunpowderIt was really interesting and I think we do need such kind of a course in Ukraine because it was dedicated mostly to the pro- longedfeld care and we don’t have such as course…we have delayed evacuation and really prolonged time, this prolonged feld care is really that we do need…hopefully we have such kind of course in Ukraine…we do need to do that.The Ukrainians also envisioned implementing similar inter- national training partnerships to those they experienced at Operation Gunpowder. One explained how they hoped tobuild similar course [with] Ukrainian[s] and American[s] together in our country or in NATO countries in Europe…Your country has a lot of experience of war and military medicine, and yet our country, like last years, had very big experi- ence…Hopefully we can exchange experience[s] together.Four months after the training, we followed up with the participants via email to ask them if they were implementing the training they received at Operation Gunpowder in Ukraine. They responded describing how they were better prepared to practice medicine and had been implementing simulation- based training. For example, one participant described how they had “become much more confdent about treating trauma on the battlefeld, secondly we have become much more conf- dent as teachers.” They listed the specifc aspects of Operation Gunpowder that they integrated into their training as follows:preparation of realistic scenarios, careful planning of the course, timings, practice of skills in separate small groups, teamwork, some certain subtleties in the performance of skills, (establishing intravenous access, tamponade of the wound, cricothyrotomy, casualty displacement and others), teaching the FAST protocol, debriefngs, checklists, some practical advice from the rangers (for example, how to keep documents dry). The importance of implementing blood transfusions in units.The participants also described the impact of these train- ing improvements. “We have a team of well-prepared, self- confdent trainers who work with the military on a permanent basis. Since the visit, we have trained about fve thousand military personnel in various locations.”DISCUSSIONThe Department of Military and Emergency Medicine at USU leveraged its Military Unique Curriculum to support the Ukrainian healthcare professionals during Operation Gun- powder. Other universities andinstitutions might follow this model in order to contribute their support to Ukraine’s efforts against Russia. The themes from the interviews confrmed the positive impact of this international collaboration as the par- ticipants: (1) noted the challenges of the austere operational environment, (2) recognized the training benefts of Operation Gunpowder, and (3) became inspired to integrate PCC simu- lation training in Ukraine. After participating in the two-daysimulation training, the participants recognized its potential to impact Ukrainian military medicine, especially in regards to PCC and providing care in an operational environment with limited resources.The participants frst described how limited TCCC expe- rience and training resources, in conjunction with time constraints, places strain on medics’ ability to learn and develop skills critical in executing a platoon medic’s duties and responsibilities. To address this problem, implementing simulation-based training within their current training cur- riculum may optimize and extend their tactical advantage over Russia, enhancing the TCCC knowledge and the skill sets for health service support personnel necessary to triage, treat, and evacuate casualties effciently throughout Ukrainian military medicine.Downloaded from <a href="https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usad484/7505053bygueston30January2024">https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usad484/7505053 by guest on 30 January 2024</a>The participants reported that CASEVAC capability is sig- nifcantly limited for Ukrainian medics to transport injured soldiers to the next echelon of medical care as a consequence of enemy combatants in the battle space and tactical decisions to allocate military vehicles and aircraft. As a result, they described how Ukrainian medics are forced to hold patients and render life-sustaining treatment for a prolonged amount of time that may accumulate from hours todays. Due to the delayed CASEVAC, medics must provide treatment to main- tain patient stability that extends beyond the scope of CLS. As a training solution for addressing these challenges, Oper- ation Gunpowder provided an immersive team-oriented PCC training that simulated austere battlefeldand resource-limited conditions. As a result, Ukrainian medical personnel gained the knowledge and skills to ensure patient stability, includ- ing monitoring patient hemodynamics, sepsis, and respiratory management, while learning how to ration scarce medical supplies appropriately and operate as an essential component of the health service support team.While the Ukrainian medical personnel who participated in Operation Gunpowder learned and developed new PCC skills, life-saving interventions, and inspired future TCCC curricu- lum revisions, we learned from their experiences of providing medical support and surmounting healthcare adversities on the austere battlefeld. The information exchange between Ukraine and USU faculty at Operation Gunpowder proved to be dually advantageous as both nations were able to learn from each other’s experiences. Lessons learned can be used toopti- mize military physicians’ and medics’ health service support capabilities and establish stronger multinational relationships. 	Universities and other institutions are called to con- tinue pursuing information and training partnerships, like the one initiated by USU with other allied nations’ com- bat medical teams, so that both stakeholders can continue to evolve and develop health service support abilities and strengthen multinational relationships. Civilian institutions can contribute to Ukraine’s war effort by involving Ukrainian healthcare professionals in simulation-based training like Operation Gunpowder. Providing Ukrainians with medical training and approaches to providing care in resource-limited4 MILITARY MEDICINE, Vol. 00, Month/Month 2023<a id="bookmark17"></a>Ukrainian Healthcare Professionals’ Experiences During Operation Gunpowderenvironments can further expand their health service sup- port capability and ability to provide care in austere loca- tions. We recognize that facilitating large-scale, high-fdelity simulation-based training to emulate a foreign battlefeld like Operation Gunpowder is not always feasible. However, civil- ian universities and institutions might offer support through small-scale simulation training, didactic instruction, and/or skills training, which will prove valuable to Ukrainian health- care professionals who, like some of our participants, may not have any prior medical training. For example, lessons learned throughout civilian medicine during COVID-19 regarding practicing medicine with limited resources, personnel, time, and supplies may apply to Ukraine’s austere, resource-limited operational environment.CONCLUSIONLeveraging the Military Unique Curriculum to support <a id="bookmark4"></a>Ukrainian partners proved to be a valuable training tool and learning experience for both stakeholders. Our results <a id="bookmark6"></a>revealed the benefts of PCC simulation training like Opera- tion Gunpowder for Ukrainian military medical personnel as a vehicle for multiplying training efforts and increasing military medical force readiness. Other institutions and universities <a id="bookmark8"></a>are called to use their expertise and resources to partner with Ukrainian healthcare professionals in order to provide trainingand support that can then be multiplied throughout Ukrainianmilitary medicine.ACKNOWLEDGMENTSWe would like to thank CAPT Sherri L. Rudinsky, Chair of the Depart- ment of Military and Emergency Medicine, for her support in conductingthis research.FUNDINGNone declared.CLINICAL TRIAL REGISTRATIONNot applicable.INSTITUTIONAL REVIEW BOARD (HUMAN <a id="bookmark12"></a>SUBJECTS)This study was determined to be exempt by the Institutional Review Board at the USU.INSTITUTIONAL ANIMAL CARE AND USE <a id="bookmark16"></a>COMMITTEE (IACUC)Not applicable.CONFLICT OF INTERESTNone declared.INDIVIDUAL AUTHOR CONTRIBUTION STATEMENTJS, CS, and RC collected and analyzed the data and drafted the origi- nal manuscript. RC designed this research and reviewed and edited themanuscript. All authors read and approved the fnal manuscript.DATA AVAILABILITYDownloaded from <a href="https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usad484/7505053bygueston30January2024">https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usad484/7505053 by guest on 30 January 2024</a>The data that support the fndings of this study are available on request from the corresponding author. All data are freely accessible.INSTITUTIONAL CLEARANCEInstitutional clearance approved.REFERENCES<a id="bookmark2"></a><a href="#bookmark1">1.</a> Ellyat H: Russian forces invade Ukraine. CNBC, 2022. Available at <a href="https://www.cnbc.com/2022/02/24/russian-forces-invade-ukraine.html">https://www.cnbc.com/2022/02/24/russian-forces-invade-ukraine.</a> <a href="https://www.cnbc.com/2022/02/24/russian-forces-invade-ukraine.html">html;</a> accessed August 1, 2023.<a href="#bookmark3">2.</a> UN News: ‘Grim milestone’ as Ukraine war reaches 500-day mark. 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