Keywords

1 Introduction

Tactical Combat Casualty Care (TC3) is team decision-making under stress. It requires interdependent squad members, performing their role-based critical tasks, to make decisions that achieve a set of common goals under extreme circumstances. Squads must be able to flexibly and simultaneously accomplish mission objectives while treating their wounded in a fluid tactical environment. This requires squad leader situational awareness of the tactical medical situation and squad leadership coordinated with TC3 first responders, or the casualty himself, providing life-saving treatment. Failure to manage the tactical situation can lead to more casualties or mission failure. Not treating life-threatening injuries can lead to preventable combat death. The challenge that squads face is in the implementation of tactics, techniques and procedures that enable mission completion and life-saving without becoming distracted by one or the other. Becoming distracted when there are combat casualties can have catastrophic consequences, as decision-making, information processing, attention, and situational awareness is impaired [5]. Having squads engage in realistic TC3 scenarios, during a high stress unit level event, could optimize squad leadership, teamwork, and tactical and medical skills required to succeed in these challenging situations and develops resiliency for future situations.

However, Medics/Corpsman and infantry units rarely train together at the company level or below prior to training for a specific deployment. Various medical training centers exist (e.g., Medical Simulation Training Center (MSTC), Defense Medical Readiness Training Institute (DMRTI), Medical Simulation Training Centers (MSTC), and the Brigade Combat Team Trauma Training (BCT3)) to sustain and certify skills. But, no formal curriculum exists to support the integration of these medical skills into tactical operational environments. Providing infantry and their Medics/Corpsman the opportunity to train at the team level has been the focus of a joint effort called Squad Overmatch TC3 Training for Readiness and Resilience (SOvM TC3). Building on the SOvM studies started in 2012 by the U.S. Army Study Board [1]. The current effort is managed by the Program Executive Office for Simulation, Training, and Instrumentation (PEO STRI), with collaboration between the Army Research Laboratory, Human Research and Engineering Directorate (ARL HRED) and the Naval Air Warfare Center Training Systems Division (NAWCTSD). The objective of the SOvM TC3 2015 demonstration at FT Benning, GA was to develop and test instruction, simulations, and training technology prototypes embedded in Live scenarios using an Integrated Training Approach (ITA) that could foster individual and team process skills within the context of tactical medical care, rather than to focus solely on tactical outcomes. As such, this effort emphasized process skills, those skills that enable squad members to achieve targeted tactical outcomes and ultimately, improve mission performance.

The goal of this paper is to describe self-report results obtained during the demonstration with participants that included four U.S. Army and three U.S. Marine Corps Squads, each augmented with an Army Medic or U.S. Navy Hospital Corpsman, respectively. We describe how the Team Dimensional Training (TDT) model was used to enable squads to practice and apply knowledge and skills within the training content areas developed for SOvM TC3: TC3, Advanced Situational Awareness (ASA), and Resilience/Performance Enhancement (R/PE). We describe the ITA approach utilized and discuss the self-report measures from squad members on the degree to which they felt the TDT approach fostered individual and team process skills during virtual and live training.

TDT was developed as part of a program sponsored by the Office of Naval Research (ONR) called Tactical Decision-making Under Stress (TADMUS) as a training methodology for enhancing performance through improved team processes [3]. The methodology helps teams diagnose and correct their own performance problems during an Integrated After Action Review (IAAR). This trains teams to adapt quickly to unfolding events and to learn from and build on their previous experiences together. The foundation of TDT was determining “What makes a team of experts an expert team?” The TADMUS effort identified four critical dimensions of teamwork (and their associated subcategories) that help teams monitor and regulate their own performance:

  • Information Exchange – knowing what information to pass to whom and when

    • Using available sources

    • Passing information before being asked

    • Providing situation updates

  • Communication Delivery – how information is delivered

    • Using correct terms

    • Providing complete reports

    • Using brief communications

    • Using clear communications

  • Supporting Behavior – compensating for one another in order to achieve team objectives

    • Correcting errors

    • Providing and requesting backup

  • Initiative/Leadership – behaviors that provide direction for the team

    • Providing guidance

    • Stating priorities

Research has shown that by focusing on and evaluating these areas of team performance each time a training exercise or combat situation has been concluded, the performance of the team can be significantly improved to meet future training and real life situations [4]. Furthermore, Smith-Jentsch, Cannon-Bowers, Tannenbaum, and Salas (2008) demonstrated that teams who participated in facilitator-led guided self-correction developed more accurate mental models of teamwork, demonstrated superior teamwork processes, and achieved more effective performance outcomes than did those briefed and debriefed using a traditional method. The TDT model is particularly suited for application in the TC3 domain and has been utilized within numerous operational and training environments where individuals and teams are required to make critical decisions during changing and intense situations [2]. To perform successfully in tactical and medical environments, team members must be able to assess situations quickly, perform TC3 skills when necessary, and engage in R/PE methods to quickly recover from stressful situations.

2 SOvM TC3 Integrated Training Approach (ITA)

The SOvM TC3 ITA is a three day curriculum beginning with classroom instruction, moving on to skills practice in Simulation-Based Training (SBT), and then Live training exercises. Subject Matter Experts (SMEs) developed curricula to emphasize building communication and decision-making skills in managing combat casualties during Care Under Fire and Tactical Field Care situations. SMEs identified the key TDT teamwork behaviors within each of the foundational topics of TC3, ASA, and R/PE. They analyzed the content areas to determine instances of TDT behaviors that contribute to mission success (see Table 1 below for a subset of examples) and these points were instructed and demonstrated during the ITA.

Table 1. TDT related behaviors in ASA, TC3, and R/PE content areas
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2.1 Classroom Instruction

On day 1, instruction provided squad members with opportunities to acquire specific knowledge and included PowerPoint, interactive discussion, scenario diagnostic exercises, and hands on part-task medical simulators.

TC3.

TC3 SMEs developed the classroom instruction to focus on the efficient communication and coordination behaviors needed between the squad leader, Fire team leaders, and the Medic or first responder. Communications to determine mission success provide the squad leader with information about his capability, allowing decisions to be made about continuing the mission. Communications about severity of wounds allows the Medic to make decisions about priority and resource needs.

ASA.

ASA SMEs developed curriculum focused on providing knowledge and developing skills in pattern/threat recognition and decision-making to include behavioral profiling skills (i.e. proximity between people as an indicator of relationship), kinesics (i.e., nonverbal body language), autonomics (i.e., observable physiological signals), geographics (e.g., patterns of how individuals move through an environment) atmospherics (e.g., new rubble, bullet holes), and heuristics (e.g., using tactical cunning, tactical patience, keeping an overwatch/“guardian angel,” and building relationships/“good shepherd”). In addition to the development of individual situational awareness, it is critical that the team members share this information across the squad to ensure that they have a more complete picture of the situation, and to pass that information to the squad leader for situational awareness, and for decision-making. Given this, the coordination of the team was defined in terms of the teamwork behaviors that facilitated a shared understanding of the situation.

R/PE.

R/PE SMEs developed curriculum focused on providing knowledge and developing skills in maintaining tactical effectiveness under combat stress (acceptance, what’s important now, deliberate breathing, self-talk and buddy talk, grounding, and Personal After Action Review (AAR). This involves both individual skills, as well as team supporting behaviors. With respect to teamwork, team members were encouraged to provide positive communication to other team members who were struggling with a stressful event, to try to refocus them on the mission task.

TDT/IAAR.

TDT SMEs developed curriculum that focused on introducing the four dimensions of teamwork and how the TDT model (Prebrief, Perform, Debrief) can be used to facilitate discussions involving the teamwork behaviors identified in the TC3, ASA, and R/PE instruction. Emphasis was on mastery of team-level processes rather than maximization of scenario-specific outcomes. Then curriculum focused on how the IAAR enables the squad to discuss team TC3, ASA, and R/PE behaviors in the context of the four teamwork dimensions. The IAAR uses guided team self-correction, which refers to the use of a facilitator who (a) keeps the squad’s discussion focused, (b) establishes a positive climate, (c) encourages and reinforces active participation, (d) models effective feedback skills, and (e) coaches team members in stating their feedback in a constructive manner [3] to diagnose team strengths and weaknesses, identify solutions, and establish goals for improvement.

2.2 Simulation-Based Training (SBT)

On day 2, the Virtual Battlespace 3 (VBS3) training simulation was used to provide SBT. VBS3 is an Army Training Program of Record platform for practicing within a semi-immersive environment with dynamic terrain. For this effort, VBS3 was integrated with a medical simulation program, TC3Sim, which supports the assessment and treatment of casualties. SMEs developed six tactical/medical event-based scenarios to enable squads to practice what they had learned in the classroom and to conduct IAARs. The Combined Arms Collective Training Facility (CACTF) - McKenna Military Operations on Urban Terrain 2 (MOUT) site used for the live exercises (described below) was modeled in the VBS3 urban terrain to increase the transfer of skills from simulation to the live environment. TDT behaviors were identified in the event-based scenarios so that the TDT/IAAR model could be applied, allowing squads to collectively (and even individually) engage in a cycle of practice, application, and feedback to create self-monitoring and correcting teams. During the pre-brief, mission clarification was emphasized, the teamwork development focus of the exercise was stressed (process skills), and any previously set goals for improvement were stated.

2.3 Live Training Exercise

On day 3, two Live training exercises were conducted at the CACTF MOUT site with scenario events designed to be very similar to the ones developed in VBS3. The site was outfitted with a suite of TC3 simulators and a wide variety of other Virtually Enhanced Live Technologies in order to significantly increase the number of realistic TC3 tasks that could be trained. This included:

  • Simulated battlefield effects provided audio of combat sounds (e.g. gunshots), artillery, and Improvised Explosive Device (IED) blasts;

  • Live role-players acting as key leaders, townspeople, and casualties made up with moulage (e.g. wearable wound models) and simulated injuries to increase realism and incorporation into triage and TC3 scenario management;

  • A variety of interactive virtual enemy combatants projected on walls of MOUT buildings playing characters that could be shot and illustrate wounds;

  • Interactive modeled components: tourniquets, nasal pharyngeal airway, chest decompression needle, chest seal, TC3 card, bandage, and compression bandage.

Squad members and role-players were equipped with the Multiple Integrated Laser Engagement System (MILES) gear, which was augmented with a prototype Electronic Casualty Display Device (ECDD). This device displayed information about the medical condition of a patient such as changing health status (e.g., pulse, respiration, and pain level), and ability to communicate and move. This enabled TC3 responders to identify, prioritize and succeed or fail to provide appropriate treatment according to realistic timelines and prognoses. Trainees could render medical aid with their sensored first aid kit, the Improved First Aid Kit (IFAK II) Simulators for Medical Devices. IAARs were conducted after each scenario. As with the VBS3 scenarios, TDT behaviors were identified in the event-based live scenarios so that the TDT/IAAR model could be implemented.

3 Findings

After each day of SBT and Live training, squad members were administered questionnaires asking the degree to which the VBS3 and Virtually Enhanced Live Technologies allowed them to practice teamwork behaviors. Seventy-one Army and Marine squad members participated in the demonstration, each going through the same ITA.

3.1 VBS3 Technology Survey

Trainees scored items on a 5-point Likert scale, rating whether they agreed that the VBS3 training technology supported the learning objectives: 1 (completely disagree), 2 (disagree), 3 (not sure), 4 (agree), and 5 (completely agree). Selected questionnaire items that focus on the degree that VBS3 supported team dimensions and team performance are presented in Table 2.

Table 2. VBS3 and Teamwork
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3.2 Virtually Enhanced Live Technologies and Overall Impact of Live Training Surveys

Trainees were instructed to provide ratings for those Virtually Enhanced Live Technologies encountered. For Table 3, trainees rated the effectiveness on a 5-point Likert scale from: 1 (not at all), 2 (a limited amount), 3 (adequately) and 4 (extremely well). Trainees were also instructed to provide ratings regarding the overall impact of Live Training. Table 4 reports on a 5-point Likert scale: from 1 (completely disagree), 2 (disagree), 3 (not sure), 4 (agree), and 5 (completely agree).

Table 3. Virtually enhanced live technologies and teamwork
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Table 4. Overall impact of live training on teamwork
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For VBS3 and the Virtually Enhanced Live Technologies, trainees agreed that training provided opportunities to practice team performance skills. In VBS3, squad members agreed with statements that they could practice communications in support of determining anomalies (M = 4.3, SD = .7), a component of developing team ASA. Also, squad member agreed with the statement that they could practice sending key casualty information to other team members (M = 4.1, SD = .9). In the Live scenarios, all representations of combatants adequately supported communicating information on targets, key to team ASA (pop-up targets, M = 3.1, SD = 1.5, live role players M = 3.9, SD = .4, interactive virtual characters M = 3.6, SD = .7, and non-interactive virtual characters M = 3.6, SD = .9). For the team dimensions, squad members agreed that the live training overall provided the ability to practice. Specifically, live training supported Information Exchange (M = 4.3, SD = .7), Communication Delivery (M = 4.3, SD = .7), and Supporting Behaviors (M = 4.3, SD = .6). As VBS3 and Live Technologies are part of the overall training approach for team performance, these results suggest that the technologies support squads’ ability to effectively practice team dimensions. This practice supports team members in developing an understanding of how the roles (and individuals in the roles) exchange information, communicate, and support each other. In future work, it may be helpful to provide squads with feedback about the impact of coordination on medical and mission outcomes, such as number of casualties and time and accuracy in managing combatants. Feedback data could be fed forward into IAAR, to provide squads with the natural consequences of good or poor team performance.

4 Conclusion and Future Research

Future analyses will include reviewing the individual and team related TDT survey questions asked after classroom instruction, as the focus of the current paper was on SBT and Live training days. This will also include reviewing survey questions that focus on the other three content areas (TC3, ASA, and R/PE) and whether team members felt the ITA in these content areas fostered individual and team process skills. Currently, a SOvM TC3 experiment is planned for June 2016 in Fort Benning, GA. While SOvM TC3 2015 (the focus of this paper) was considered a demonstration, SOvM 2016 will be a training effectiveness evaluation conducted using a quasi-experimental design comparing the perceptions and performance of warfighters completing the ITA with warfighters completing similar exercises in a control condition. Lessons learned from SOvM TC3 2015 will be applied, including an additional half day of training to offer a Live test scenario, to evaluate the impact of the ITA curriculum on performance.