Navigation

Nuclear Medicine Education

Introduction

The increasing threat of the use of weapons of mass destruction on the battlefield and as agents of terrorism has gained considerable attention in the military, medical, and lay press. The events of September 11, 2001, and the subsequent wave of anthrax letter attacks have sharpened our focus on this threat. Accompanying this increasing focus is a significant military preparedness and response requirement. Essentially, the U.S. nuclear, biological, and chemical (NBC) defense systems consist of four components: detection, personal protection, medical defense measures, and deterrence policy.' Within this context, health care providers must be trained and prepared to implement these medical defense measures by instituting prophylactic measures and diagnosing and treating casualties arising from an attack with NBC agents. This holds true in the civilian public health sector as well; the Centers for Disease Control and Prevention has recommended that "a cadre of well-trained health-care and public health workers will be available in every state."2 In this article, we discuss various initiatives aimed at addressing this training requirement within the U.S. military, many of which are applicable for civilians. Moreover, we highlight certain training programs available through military sources. Finally, we develop a model for conceptualizing NBC military medical defense training requirements and responsibilities and we suggest that this model may be generally applicable to other military training needs.

The Model

Given the wide variety of missions and situations facing the U.S. military and its allies, it is unlikely that one specific training method or program will fulfill all needs. Rather, to be maximally effective, training must occur in a wide variety of settings and must be aimed at disparate audiences with varying skill levels. Additionally, training must be dynamic rather than static; that is, it must continue throughout the service member's career, building on prior knowledge and adapting to the situations in which the individual finds himself. Thus, military medical training requirements (using the Army example) can be summarized in the model presented in Figure 1.

Different types of training are appropriate for individuals with different skill sets and military occupations. Our model takes into account this reality (the "Who"). In this regard, every soldier, sailor, airman, and marine requires some rudimentary medical knowledge, which might include basic first aid and "buddy aid" procedures. The combat medic requires a more extensive skill set. The medical planner, operator, and logistician require some understanding of the medical threat and of medical countermeasures. Finally, the health care professional will likely require an extensive amount of military medical training to function optimally on the future battlefield.

Over the course of their military service, personnel will have ongoing training needs that vaiy with their experience and situation (the "What and Where"). Thus, we argue that although all personnel might require some "core" training in a given field, only select individuals might warrant certain "situation specific" training. For example, a particular Navy ship may be equipped with a unique chemical defense apparatus. Personnel stationed aboard that ship may require specific training in the operation of this equipment, whereas those stationed elsewhere would not benefit from such training. Similarly, all medical professionals will not require the same high degree of expertise in each and every medical procedure or skill set. In fact, the complexity of modern medicine makes this impossible. However, our model addresses the reality that a subset of providers must become "experts" in a given skill. Thus, "Graduate Medical Education" is treated in the model as a separate and additional training requirement beyond that of "core" training. As such, it may not be applicable to as large an audience as the core training, and may not necessarily be provided in the same setting or by the same cadre of instructors, whose knowledge bases are also expected to vary considerably.

Finally, the model takes into account (the "When") the reality that knowledge, especially when rarely exercised, must be sustained through "refresher" training. This training may, of necessity, be given in a venue different from that used for "entry-level" training (which may optimally be accomplished when personnel present a captive audience during initial military training and processing). Taking all of these factors into account, we have derived a 2 × 3 × 4 matrix (Fig. 1) within which to consider and plan training requirements. We devote the remainder of this article to a more detailed discussion of these requirements, using medical NBC defense training as an example that emphasizes certain educational initiatives and potential solutions to training challenges.

Training Requirements

Situation-specific training, as the term implies, must be tailored to each individual setting. It does not lend itself to the type of dogmatic or doctrinal fixes such as are proposed here, nor should it. Operators familiar with the nuances of a particular situation can best accomplish such training at the unit level. Further discussion of situation-specific training is beyond the scope of this article. Similarly, the training provided to nonmedical soldiers, sailors, airmen, and marines is best discussed elsewhere. Such training is typically "hands on" in nature, and is best accomplished by noncommissioned officers during entry-level basic combat training or at the small unit level. The various military services have a great deal of experience in providing hands-on training in such venues. Likewise, a certain amount of "core" training is already appropriately provided very early in a service member's career. In the U.S. Army, for example, medics receive instruction during a period of Advanced Individual Training through the Army Medical Department's (AMEDD) Center and School. Such instruction includes basic medical NBC defense measures such as the administration of nerve agent antidotes and anticonvulsants. Army officers in medical career fields also receive some basic NBC medical defense training during the AMEDD Officer Basic Course, also under the auspices of the AMEDD Center and School. The Navy, Air Force, and Marine Corps provide analogous training. Finally, venues already exist for the provision of a certain amount of sustainment training, which reinforces and updates the core base. In the Army, officers receive such training during the AMEDD Officer Advanced Course, and noncommissioned officers receive training during the Basic and Advanced Noncommissioned Officer Courses.

Removing the above training requirements from further consideration, we are left with the six groups depicted in Figure 2. This slice of intense "graduate"-level medical education is, in some ways, the most difficult to provide, for several reasons. First, the necessary depth of such instruction makes it difficult to provide during standardized military training blocks, where time is often at a premium. second, the complexity of the material often makes maintenance of a large cadre of qualified instructors problematic. Third, the opportunity to interact with expert instructors close to the medical research base and the sharing of ideas desirable at the graduate level is difficult to implement in more traditional military venues. Finally, because not all personnel require such in-depth training, which is often costly, a forum must be found wherein only those requiring or desiring advanced instruction can be reached. Over the past several years, we have developed a series of initiatives aimed at addressing these six challenging slices of the overall medical NBC defense training requirement.

Training Initiatives

For the past several years, the USAMRIID has offered clinically oriented instruction to a small handful of military medical practitioners in the medical management of biological casualties. Similarly, for over 20 years, the USAMRICD has offered analogous medical chemical defense training. Since the Persian Gulf War of 1991, this instruction has been combined in a quarterly course known as the "Medical Management of Chemical and Biological Casualties" (MCBC). This week-long resident course is taught on-site at Fort Detrick and the Aberdeen Proving Ground, both located in Maryland. A review of the history, content, and philosophy of this course has recently been published.3 A separate course, the "Medical Effects of Ionizing Radiation" (MEIR) is offered by the AFRRI in Bethesda, Maryland. While providing graduate-level medical education, these courses were formatted to meet the educational needs of those medical professionals without a great deal of specific knowledge of NBC defense issues. For this reason, we refer now to these training initiatives as "entry-level graduate medical education (GME)." Moreover, we envision the MCBC and MEIR courses as satisfying the training requirements denoted by Block III in Figure 2. A separate course, entitled "Field Management of Chemical and Biological Casualties" (FCBC) is also offered by USAMRICD and is designed for the advanced paraprofessional and the health policy planner; we believe that the FCBC course satisfies the training requirements denoted by Blocks I and II in Figure 2.

By most measures, these courses have been rather successful. Over a 9-year period from the beginning of fiscal year 1993 through the end of fiscal year 2001, almost 3,000 students took the week-long MCBC course in Maryland. An additional 5,300 students enrolled in shortened 2- or 3-day "road" versions of the course presented by traveling instructors from USAMRIID and USAMRICD. Similarly, approximately 5,900 students had taken various versions of the MEIR course in Maryland and elsewhere.

Although the training provided in the MCBC, FCBC, and MEIR courses is rather thorough and provides hands-on exercises and interactive learning, several issues soon became apparent: the number of students is severely restricted by space considerations; the courses are costly (~$1200 per student) given the requirement for students from around the world to travel to Maryland; and the opportunities for civilian providers and public health officials to attend are limited. To address these shortcomings, and in the context of the Department of Defense's Advanced Distributed Learning initiative,4 USAMRIID, USAMRICD, and AFRRI have expanded their educational efforts into multiple mass media, distance learning, and electronic formats.

One straightforward method of reaching large numbers of providers and health officials has been to mass produce pocket-sized reference handbooks dealing with the basics of medical NBC defense. USAMRIID, for example, is currently distributing the fourth edition of its handbook, Medical Management of Biological Casualties. Over 100,000 hard copies of the four editions have thus far been distributed at no cost to recipients. Companion manuals distributed by USAMRICD and AFRRI deal with the Medical Management of Chemical Casualties (third edition), the Field Management of Chemical Casualties (second edition), and the Medical Management of Radiological Casualties. Moreover, all three institutions have established web sites (Fig. 3) wherein these manuals, as well as other educational materials, are accessible electronically, and all three have produced CD-ROM versions of their handbooks as well as other instructional materials. Finally, electronic training aids formatted for personal digital assistant devices (e.g., Palm Pilot®) can be downloaded from USAMRIID's web site, and devices preloaded with such NBC defense materials are being issued to incoming medical students at the Uniformed Services University of the Health Sciences.

However, premier among expanded educational efforts is a series of live, interactive satellite television broadcasts on various topics related to the medical management of chemical and biological casualties. The first of these broadcasts aired in September 1997. Entitled "Medical Management of Biological Casualties," it provided an intensive 12-hour GME-level course aimed at professional and advanced paraprofessional health care providers and health policy planners. In this sense, it fulfilled requirements similar to those addressed by the MCBC, FCBC, and MEIR courses (Blocks I, II, and III in Fig. 2). A new version of the broadcast has aired annually since 1997. In 1998, a companion course entitled "Medical Management of Chemical Casualties" aired for the first time, and in 2001, the biological and chemical broadcasts were combined in a program entitled "Management of Biological and Chemical Casualties: Medical Issues and Response."

For training to be effective, it must be put to use. A common criticism of military training in the past has centered on the uninteresting "rote memorization" approach to dogmatic principles.5 Although this approach may be necessary in certain instances (teaching young soldiers critical battlefield tasks that must become "second nature" to avoid death or injury), it is an approach shown to fail when applied to adult learners in medical training.6-8 Conversely, medical distance learning initiatives have been very well received by students. In fact, studies have shown no significant differences in cognitive testing among those who received training via satellite broadcast when compared with traditional lecture settings.9,10 The series of satellite programs that USAMRIID and USAMRICD developed used innovative training mechanisms and attempted to increase viewer interest by using a lively and varied format. This format combined a live broadcast, with its ability to address current "up-to-the-minute" questions from audience members through fax or phone lines, with pretaped interviews and field scenarios filmed on location at various military and civilian locations and training venues.

We found that this new format afforded several advantages. First, nationally recognized subject matter experts could appear live on camera. Whereas the costs and busy schedules of these professionals may have precluded them from supporting multiple on location courses, a single annual live broadcast was often feasible. second, for those unable to attend the live broadcast, pretaped interviews could be recorded by sending a camera crew to the expert at his or her convenience. Third, travel costs for students could be eliminated and time away from other duties minimized. Fourth, large numbers of students could be reached with a single block of instruction, ensuring not only cost savings, but also guaranteeing uniformity of the educational experience and minimizing the chance for a misunderstanding or misinterpretation of doctrine. Train-the-trainer initiatives are another potentially cost-effective mechanism for training large numbers of personnel. However, we feel that such initiatives are often unsuccessful owing to a lack of in-depth subject matter expertise on the part of trainers. Satellite broadcasts circumvent this problem. Fifth, the medium of television permits instructors considerable flexibility in tailoring plausible and realistic scenarios to specific educational objectives. Finally, live broadcasts can be professionally recorded, permitting their rebroadcast on weekends for the benefit of military reserve component personnel, or their viewing (on VHS tape) on an "anytime" or "need-to-know" basis by interested medical professionals.

The seven live satellite broadcasts (four biological, two chemical, and one combined) produced through 2001 have enjoyed considerable success. In the case of the biological programs, for example, over 61,000 students registered to receive the broadcasts over a 5-year period. These students also received professional continuing medical education credits at a cost of approximately $6.00 per credit hour. This compares very favorably with a cost of approximately $30.00 per hour for the traditional course format when offered on site in Maryland. Moreover, the broadcasts have earned a number of Industry awards for teleconferencing and video production, including the prestigious "Cine," "Telly," and "Aegis" awards. Finally, the Agency for Healthcare Research and Quality evaluated clinician training for bioterrorism preparedness and determined that satellite broadcasting was as effective as classroom learning, albeit at a fraction of the cost.11

The Future

Despite this success, challenges remain. Foremost among these is the time commitment. Busy clinicians cannot easily devote 12 consecutive hours (broadcasts aired 4 hours daily for 3 consecutive days) annually out of a busy workweek to view a program on biodefense and another 12 hours to view an analogous program on chemical defense, nor should they. Recent experience suggests that most military health care providers and planners have now received some biological and chemical defense training (at least to the awareness level) in one venue or another. Thus, these adult learners' requirements shift from a need for entry-level GME training (Blocks I, II, and HI in Fig. 2) to a need for "sustainment" GME training (Blocks IV, V, and VI in Fig. 2).

To address Block VI of these requirements in particular, we propose to shift the emphasis and format of the live broadcasts to a monthly 1-hour program (or, alternatively, a bimonthly 2-hour program or quarterly 3-hour program) that would serve to update experienced clinicians on the latest developments in military medicine. We further propose that this new program be aimed at addressing the entire spectrum of medical threats unique to the military. As such, we would title the program "Military Medical Grand Rounds: The CREDIBLE Threats" (Fig. 4). Such a change in format would have numerous advantages: (1) it would bring military medical training into a format consistent with that used in traditional medical settings; (2) it would spread the commitment of time out over the course of the year, requiring clinicians to devote only 1 hour per month; (3) it would consolidate numerous military medical training initiatives into a consistent and familiar format; similarly, (4) it would foster a desirable "all-hazards" approach to the problems of military medical and counter-terrorism training; (5) it would allow a standard vehicle for the Surgeons General to disseminate critical medical training and information on a timely and consistent basis; and (6) it would result in extensive cost savings because students could receive much of their military medical training without being required to travel away from their duty stations. New accessions into the military medical departments and personnel who, for whatever reason, have not obtained entry-level GME training in the past can continue to receive this training in a traditional manner through the MCBC, FCBC, and MEIR courses, as well as through videotapes, CD-ROMs, and other prerecorded electronic media.

The medical departments of the military services have a centuries-old tradition of providing quality care to sick and injured service members and a similarly lengthy tradition of providing state-of-the-art medical education to the providers who are called upon to render that care. Although much of the training necessary to provide quality care in a military environment can be acquired in civilian institutions, a certain amount of this training is unique to the military. We have attempted to address some of these unique needs and, in the course of doing so, have developed a model for considering these needs in planning future training, using medical NBC training as an example. Moreover, we suggest innovations in such training that will likely be necessary to carry the services' unique medical training needs into the 21st century.

References

1. King WE: Biological warfare: are U.S. armed forces ready? The Land Warfare Papers. Arlington, VA, The Institute of Land Warfare, Association of the United Stales Army, i999, No. 34, p 16.

2. Centers for Disease Control and Prevention: Biological and chemical terrorism: strategic plan for preparedness and response. Morb Mortal WkIy Rep 2000; 49: 1-14.

3. Romano J, Hurst C, Newmark J: Supporting homeland defense; training for chemical casualty management. U.S. Army Medical Department J 2002; PB 8-02-4/5/6: 46-52.

4. LeVee LN: Training from afar. Milit Med Technol 1999; 3: 20-3.

5. Hearings on National Defense Authorization Act for Fiscal Year 2000-HR 1401 and Oversight of Previously Authorized Programs before the Committee on Armed Services, House of Representatives, One Hundred Sixth Congress, First Session. Military Readiness Subcommittee Hearings on Title Ill-Operation and Maintenance. Hearing held March 4, 1999. Military Training Capabilities and Shortfalls, House of Representatives, Committee on Armed Services, Military Readiness Subcommittee, Washington, DC, Thursday, March 4, 1999.

6. Barrows HS: Problem-based, self-directed learning. J Am Mcd Assoc 1983; 250: 3077-80.

7. Witte MH, Kerwin A, Witte CL, Scadron A: A curriculum on medical ignorance. Med Educ 1989; 23: 24-9.

8. D'Eon MF, Harris C: If students are not customers, what are (hey? Acad Med 2000; 75: 1173-7.

9. Paegle RD, Wilkinson EJ, Donnelly MB: Videotaped vs. lradilional lectures for medical students. Med Educ 1980; 14: 387-93.

10. Umble KE, Cervero RM, Yang B, Atkinson WL: Effects of traditional classroom and distance continuing education: a theory-driven evaluation of a vaccine-preventable diseases course. Am J Public Health 2000; 90: 1218-24.

11. Catlett C, Perl T, Jenckes M, et al: Training of Clinicians for Public Health Events Relevant to Bioterrorism Preparedness (Evidence Report/Technology Assessment No. 51, prepared by Johns Hopkins Evidence-Based Practice Center under contract no. 290-97-006). AHRQ Publication No. 02-EO11. Rockville, MD: Agency for Healthcare Research and Quality, January 2002.

Guarantor; COL Theodore J. Cieslak, MC USA

Contributors: COL Theodore J. Cieslak, MC USA*; LTC ju lie A. Pavlin, MC USA[dagger]; LtCoI Donald L. Noah, BSC USAF[double dagger]; COL Daniel J. Dire, MC USAR§; LTC Scott A. Stanek, MC USA¶; LTC Mark G. Kortepeter, MC USA¶; COL David G. Jarrett, MC USA¶; LTC Ross H. Pastel, MS USA¶; CAPT Robert G. Darling, MC USN¶; COL John M. Jacocks, MC USA||; COL Charles G. Hurst, MC USA**; Barbara A. Richards[dagger][dagger]; COL Edward M. Eitzen, Jr., MC USA[dagger][dagger]

* San Antonio Military Pediatric Center, San Antonio, TX.

[dagger] Walter Reed Army Institute of Research, Silver Spring, MD.

[double dagger] Office of Air Force Surgeon General, Boiling Air Force Base, Washington, DC.

§ Fifth Medical Group, United States Army, Birmingham, AL.

¶ United States Army Medical Research Institute of Infectious Diseases, Fort Detrick, MD.

|| Armed Forces Radiobiology Research Institute, Bethesda, MD.

** United States Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD.

[dagger][dagger] United States Food and Drug Administration, Center for Radiologic Devices and Health, Gaithersburg, MD.

[double dagger][double dagger] United States Dept of Health and Human Services, Washington, DC.

Reprints: COLTheodore J. Cieslak, Department of Pediatrics, Brooke Army Medical Center, Fort Sam Houston, TX 78234; e-mail: Ted.Cieslak@amedd.army.mil.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as necessarily reflecting the views of the Department of Defense or its individual component institutions.

This manuscript was received for review in January 2003 and was accepted for publication in July 2003.

Copyright Association of Military Surgeons of the United States May 2004
Provided by ProQuest Information and Learning Company. All rights Reserved