The Homeland Defense and Security Information Analysis Center received a request for technical information and analysis on emerging technologies, challenges and solutions in simulation and medical mannequin training to reduce preventable battlefield deaths due to hemorrhaging, airway obstruction and pneumothorax. This inquiry fell into HDIAC’s medical focus area, one of the
eight core areas for HDIAC. The medical focus area encompasses any facet of medical research relating to security or military operations, including training and combat life support equipment. HDIAC provided research and a comparative analysis on new human-like medical mannequin technologies for medical training and simulation.
Treating injured soldiers on the battlefield presents a major challenge for the military due to limited access to medical units. HDIAC identified recent technological advances in compressible bandages  and prosthetics increase survivability, but providing more resources and materials can better equip and train military personnel in the field. The Department of Defense needs to
prepare and train military personnel to assess and treat traumas in dynamic combat zones.
According to the Wound Data and Munitions Effectiveness Team,  the leading causes of preventable death in Operation Enduring Freedom and Operation Iraqi Freedom were compressible hemorrhage and airway compromises. [2, 3, 4]
The autopsy records from the study showed that 33 percent of deaths caused by hemorrhage could have been prevented with proper tourniquet application, [2, 4] and a majority of fatalities occurred before transportation to a treatment facility.  This emphasizes the need for increased training and readily available supplies for medical and nonmedical personnel in the field.
Airway obstruction is the third leading cause of preventable deaths in combat.  A multitude of external factors can complicate injuries—including food, debris, and in extreme cases, tissue and flesh from explosions, burns and damage to the face— cause airway obstructions. If the muscles at the base of the tongue lose their support, airway obstruction can also occur when the
tongue rolls back, blocking the airway. [7, 8] A few basic and advanced airway support techniques exist that can be employed by DoD personnel, however, many require prior training and those techniques without a training requirement are not suitable long term solutions.
Medical mannequins can provide a wide range of simulations from traumatic wounds to airway obstructions. Different simulation trainings require varying types of mannequins. Numerous companies provide trauma mannequins to aid in simulating combat zone injuries. The DoD currently employs many of these options, but it is looking for mannequins with realistic features, such as tissue structure and blood flow simulation. Some mannequins available employ realistic anatomy and ruggedized materials to create life-like and challenging training scenarios, helping prepare medical providers to save lives on the battlefield. 
HDIAC’s analysis included DoD applications that will benefit service members as well as civilians. Other companies design, manufacture and market simulators for health care education. Some feature wireless communication to program the mannequin as a trauma simulator that allows for realistic simulation of combat wounds similar to what a soldier might experience in the field.  A few companies provide a customizable trauma mannequin as a military training solution. The mannequins allow for training in rapid assessment of trauma emergencies, hemorrhage control
and airway management. Currently, special effects companies are assisting surgeons by developing a lifelike model that look and feel human. 
Surgeons work collaboratively with special effects artists to capture the tensile properties of human tissue. These lifelike materials allow for surgical simulation, giving surgeons the ability to prepare for procedures with precision and accuracy. A special gel mimics real brain tissue and allows surgeons to practice hand-eye coordination.  The realistic-feeling tissue including
the membrane between the muscle and veins  can help military personnel to hone their skills by practicing specialized techniques, such as those used to determine the pressure required to treat trauma wounds. HDIAC highlighted additional areas of research showing that the rigid plastic of traditional mannequins often makes it difficult to judge the appropriate pressure
needed for treatment in the field, but the mannequins made from specialized tissue could mitigate this issue.
Accompanying software provide a wide range of training simulations and enhances different scenarios to complete unique learning objectives.  The Portsmouth Naval Medical Center’s Healthcare Simulation Unit utilizes mannequins to create a customized experience. 
Medical mannequins offer a unique solution to trauma training because they can simulate real injuries in a controlled environment. Studies show simulation-training results in quicker and more accurate situational interpretation for medical professionals. Skills acquired while practicing on medical mannequins transfer to human patients, improving the accuracy and speed of potentially
lifesaving treatment methods. [15, 16] Due to the increased use of improvised explosive devices and the complexity of blast injuries, hemorrhage control is a priority in military medical training.  Medical personnel who complete a simulation and are debriefed and taught correct techniques are better able to retain knowledge and make use of it in the field.  The use of mannequins
will allow military personnel to hone their skills and gain confidence to perform lifesaving procedures on their fellow mates in times of need. The information provided by HDIAC allows the customer to compare current and emerging technologies to best provide training for military medics.
1. Dowling, M., Kumar, R., Keibler, M., Hess, J., Bochicchio, G., & Raghavan, S. (2011). A self-assembling hydrophobically modified chitosan capable of reversible hemostatic action. Biomaterials, 32(13), 3351-3357. doi:10.1016/j.biomaterials.2010.12.033
2. Gerhardt, R., Mabry, R., De Lorenzo, R., & Butler, F. (2012). Chapter 3: Fundamentals of Combat Casualty Care. In M. Lenhart, E. Savitsky, & B. Eastridge (Eds.), Combat casualty care: Lessons learned from OEF and OIF (p. 88). Fort Detrick, MD: The Office of the Surgeon General: Borden Institute. Retrieved from http://www.cs.amedd.army.mil/borden/book/ccc/CCCFull.pdf (accessed March 31, 2016).
3. Holcomb JB, McMullin NR, Pearse L, et al. Causes of Death in U.S. Special Operations Forces in the global war on terrorism 2001– 2004. Annals of Surgery. 2007;245(6):986–991.
4. Kelly JF, Ritenour AE, McLaughlin DF, et al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006. Journal of Trauma 2008; 64 (2 Suppl): S21–27.
5. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating Preventable Death on the Battlefield. (2011) Arch Surg, 146(12):1350-1358. doi:10.1001/archsurg.2011.213. Retrieved from http://archsurg.jamanetwork.com/article.aspx?articleid=1107258 (accessed March 31, 2016).
6. Fisher, L., Callaway, D., & Sztajnkrycer, M. (2013). Incidence of Fatal Airway Obstruction in Police Officers Feloniously Killed in the Line of Duty: A 10-Year Retrospective Analysis. Prehospital and Disaster Medicine, 28, pp 466-470. doi:10.1017/ S1049023X13008650
7. Strate RG, Boies LR. The emergency management of trauma. (1976) Otolaryngol Clin North Am. 9:315–330.
8. Matson, M. (1995). Chapter 18: Injuries to the Face and Neck. In R. Zajtchuk & R. Bellamy (Eds.), Anesthesia and Perioperative Care of the Combat Casualty (pp. 438-442). Washington, DC: The Office of the Surgeon General at TMM Publications Borden Institute Walter Reed Army Medical Center. Retrieved from https://ke.army.mil/bordeninstitute/published_volumes/anesthesia/
ANch18.pdf (accessed March 31, 2016).
9. North American Rescue. (2010). Combat Trauma Simulator (CTS) 1: Facial Trauma & Bleeding. Retrieved from http://www.narescue.com/Portal.aspx-?CN=BACEF7407E86&SEARCH=mannequin (accessed March 31, 2016).
10. Gaumard Scientific Company. (2015). Trauma HAL® S3040.100. Retrieved from http://www.gaumard.com/pdf/Trauma-HAL-S3040-100.pdf (accessed March 31, 2016).
11. Boston Children’s Hospital. (2015, November 9). Makeup special effects heighten medical simulations, training. Retrieved from http://vector.childrenshospital.org/2015/11/hollywood-sfx-take-medical-training-to-anew-level-of-realism/ (accessed March 31, 2016).
12. Weintraub, K. (2015, November 09). Artificial Patients, Real Learning. Retrieved March 09, 2016, from http://www.nytimes.com/2015/11/10/health/heart-surgery-simulation-
medical-training.html?_r=0 (accessed March 31, 2016).
13. Laerdal. (2015). Patient Simulators, Manikins & More. Retrieved from http://www.laerdal.com/us/nav/36/Patient-Simulators-Manikins-More#Patient_Simulators (accessed March 31, 2016).
14. Simulation Center. (2014). Naval Medical Center Portsmouth Healthcare Simulation Center. Retrieved from http://www.med.navy.mil/sites/NMCP2/EduTrain/SimCenter/Documents/2014-SimulationCenterCatalog.pdf (accessed March 31, 2016).
15. Freeland, T., Pathak, S., Garrett, R., Anderson, J., & Daniels, S. (2015). Using Medical Mannequins to Train Nurses in Stroke Swallowing Screening. Dysphagia. doi:10.1007/s00455-015-9666-6
16. Smart, J., Kranz, K., Carmona, F., Lindner, T., & Newton, A. (2015). Does real-time objective feedback and competition improve performance and quality in manikin CPR training – a prospective observational study from several European EMS. Journal of Trauma, Resuscitation and Emergency Medicine, 23(79). doi:10.1186/s13049-015-0160-9. Retrieved from http://www.sjtrem.com/content/23/1/79 (accessed March 31, 2016).
17. Linde, A., Kunkler, K. (2015). The Evolution of Medical Training Simulation in the U.S. Military. Proceedings of NextMed/ MMVR22 conference. doi: 10.13140/ RG.2.1.3643.4647
18. Zendejas, B., Cook, D., & Farley, D. (2010). Teaching First or Teaching Last: Does the Timing Matter in Simulation-Based Surgical Scenarios? Journal of Surgical Education, 67(6), 432-438. doi:10.1016/j. jsurg.2010.05.001