Women injured in combat in Afghanistan and Iraq died at higher rates than their male peers with the same injuries, often because medics were hesitating to treat them, medical researchers found. To end that hesitancy, the Army will soon field new manikin-style patient simulators designed as female bodies.
Mark Schenk is a former Army master sergeant who served as a chief medical operations supervisor at Fort Cavazos, Texas. He said he’s seen many otherwise well-trained male medics lose focus while treating a woman.
“You physically see that the medic’s hands come back and then they start asking for permission to touch, permission to treat, meanwhile the casualty is laying on the ground either unconscious because of blood loss or not able to respond so it delays the treatment,” Schenk said. “They would spend an inordinate amount of time trying to find something to cover her up to begin exposing her, which leads to their ultimate demise because they are bleeding out while [the medic is] trying to keep the humility intact.”
Schenk’s experience lines up with research and data collected during the last two decades that discovered women were dying on the battlefields in Iraq and Afghanistan at higher rates than their male counterparts, even with injuries that women might be more likely to survive in the civilian world. In fact, some civilian research indicates women have higher chances of survival than men with similar wounds.
U.S. military researchers found that women who suffered abdominal and chest wounds during operations in the Middle East were dying at higher rates: in Afghanistan, women’s survivability rates were 17% versus 35.9% for men; in Iraq, survivability rates for women were 12% compared to 14.5% for men.
Military researchers concluded that there had to be an outside factor. What they found was “a prominence of male-centric training” with simulators and manikins that combat medics used for training. The lack of female representation in training scenarios impacted the way medics approached casualties in battle by hesitating to treat women.
Training norms would lead medics to focus too much on trying not to expose women’s bodies on the battlefield rather than providing immediate lifesaving care, according to Schenk, who works for Operative Experience, which is co-developing the new simulators with the Army over a six-year period.
The new simulators are the service’s most anatomically authentic ones to date. They are smaller and lighter than than male simulators, have soft, lifelike tissue and come in Caucasian, Black, Asian, and Hispanic skin tones. The simulators have 14 pulse points, a speaker to respond to student’s questions, physiological responses to blood loss, and interchangeable wound configurations for a variety of injuries like IED explosions, blunt trauma, and gunshot wounds.
The new simulators are the first to be standardized by the Army and will be fielded to 25 Army Medical Simulation Support Centers. The first simulator will be set up at Fort Bliss, Texas in October.
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The Army has used manikins for combat care training as far back as the 1940s and the technology has grown exponentially since then. The more lifelike a simulator is, the more “emotional buy-in” a medic can have in the training, Schenk said.
But military training has traditionally been overwhelmingly done on male manikins.
When medical centers did create female simulators, they often used “gender retrofit kit” with breast overlays to make male manikins appear more like females.
“You can’t just use sand bags and two by fours to simulate somebody. That only works for testing equipment but not for human behavior,” said Michael Eldred, deputy director for the Army Medical Center of Excellence’s Directorate of Simulation at Joint Base San Antonio-Fort Sam Houston in Texas.
Lack of representation
While the manikins evolved, Eldred said the retrofit kits that the Army used in the ‘80s were “very cartoonish” and almost made a mockery of the training. The new simulator’s “change in dimensions is probably the biggest thing that really comes out of this,” he added.
The new simulators are designed to anatomically and physiologically resemble the average soldiers of both sexes: the males are 6 feet tall and weigh 180 pounds while the females are 5 feet, 4 inches and 130 pounds. The closer resemblance to average male and female proportions mean that medic’s training will be more realistic, Army and company officials said.
Tourniquets, for example, are easier on larger arms than a smaller one, Schenk said. Simulator testing even revealed the importance of anatomical accuracy with the tools in soldiers’ medical kits.
“They were kitting everything for a 6-foot-tall male versus a [5 foot, 4 inch] female so they had to learn to put stuff in their bags that treated a range of physical bodies,” he said.
The lack of female representation in medical studies and its impact on women’s treatment and health outcomes go beyond the military – although it is an issue that the Pentagon is investing more money in to help with progress. Civilian emergency medicine studies have shown that women have higher mortality rates than men for things like sudden cardiac arrest, Schenk noted.
“When a man has a sudden cardiac arrest, you run up, you rip the shirt open, pop buttons and you find your landmarks and you do CPR,” Schenk said. “On females, they leave them fully clothed while they do that so they don’t actually get their good landmarks and treat them appropriately.”
Fielding the simulators
The hope is in future conflicts, medics have enough realistic training they can fall back on in the stress of real-world combat.
“What you do in training is what you fall back on in combat and if you train only to a level of success and not trained to a level of impossible failure, then when you get in a situation where you are completely overwhelmed, emotionally, physically, tactically and you have to rely on the basic memory of what you have to do,” Eldred said. “You want to be able to practice it and practice it, practice it until there’s just no way that you can fail it.”
Officials at Fort Sam Houston, Texas are in charge of providing training to 2,500 combat medics each year. Depending on the unit’s training, medics may use the new simulators a handful of times each year, officials said.
The simulator was also designed with the Army’s new combat casualty standards which takes into account a future conflict where the U.S. might not have air superiority.
“The simulator has to be able to also train the student, not just for immediate trauma care, but prolonged nursing care,” Schenk said. “You have to administer fluids. You have to measure the output of the fluids. You have to have the ability to monitor the patient and you have to have the ability to do minor surgical procedures, whether that be a fasciotomy for burns, alleviating the pressure by cutting the skin around the burn area.”
CORRECTION: (9/25/2024); A previous version of this story incorrectly referred to medical simulators as mannequins. The correct term is manikin.
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