• Bushmaster: Preparing Students for Leadership Since 1979

    Students walk in a line to a large military helicopter. For a couple of years, including 2008, students going to Fort Indiantown Gap for Operation Bushmaster were transported by air to get an appreciation of what it’s like to treat patients in the noisy, vibrating environment of a helicopter. (Image credit: Sharon Holland)
    By Sharon Holland

    It’s been nearly 40 years since the first Uniformed Services University of the Health Sciences (USU) field exercises were developed, and though the faculty, staff and scenarios have changed over time, the biggest exercise, Operation Bushmaster, is still meeting its intent: to help shape the next generation of career military medical officers and leaders.

    A group of four students stand looking at a map while Sanford looks on.
    Former USU President and founding medical school dean Dr. Jay P. Sanford (center, right)
    looks on as students review and plan their next moves during a scenario at Operation
    Bushmaster. (File photo)
    USU was established by Congress in 1972. As founding dean Dr. Jay P. Sanford and others created the school’s curriculum, it was important to ensure that it addressed the military unique requirements that would distinguish USU graduates from other medical school alumni. Sanford sought recommendations for establishing a clinical curriculum in the fourth year that would prepare USU graduates to successfully serve, immediately following internship, in a medical officer assignment in the farthest forward location in support of combat operations, and also in peacetime.

    The original proposal was for four weeks of classroom learning to prepare students to care for patients from the point of injury through evacuation to a higher level of care or return to duty. That was to be followed by a two-week field medicine component as well as a three-day “field problem” at Camp Bullis in San Antonio, a two-week rotation in an Army or Air Force medical facility in San Antonio, or Army facility in El Paso, a two-week rotation in a military Emergency Department at Brooke Army Medical Center or Wilford Hall Air Force Medical Center, and a two-week clinical rotation in a civilian Emergency Department at Ben Taub Medical Center in Houston or at Parkland Hospital in Dallas.

    A bird's eye view of the Bushmaster training site from years ago.
    For years, Camp Bullis in San Antonio, Texas, was the site of the
    Bushmaster exercise.  (File photo)
    Sanford accepted the proposal and established the USU Section on Operational and Emergency Medicine and appointed Army Col. (Dr.) Barry Wolcott chair in September 1978, with guidance to start the course a year later.

    USU had no people, equipment, supplies, infrastructure, training areas or planning experience to develop a medical field scenario that also included development of an individual assessment tool. The three-day military medical “field problem” was run with support of the faculty and NCOs from the Military Science Branch of the Academy of Health Sciences (AHS) at Fort Sam Houston, Texas, and was loosely based on a field exercise component of the Army Medical Department Basic Officers Course. The AHS staff provided equipment and personnel, including using AHS students as mock casualties for the exercise, while AHS moulage experts provided their simulated wounds.

    The first three-day exercise was held in October 1979. The 32 charter USU medical students each played the role of a field medic, battalion aid station physician, a Combat Support Hospital physician, and a physician in a mass casualty situation.

    A student practices field medicine on a volunteer at one of the first Bushmaster exercises
    At Camp Bullis. (Image credit: MSgt. Jim Coker, U.S. Air Force)
    They also undertook different military leadership roles and solved a variety of leadership problems associated with conducting medical operations in the field. Duties ranged from ordering routine resupply, establishing perimeter defenses, establishing, supplying and executing mess schedules, establishing and executing sleep discipline, responding to movement orders, conducting helicopter and ground evacuation of casualties; establishing camp, dealing with the media, dealing with local-national issues, dealing with the threat of a chemical or biological attack, conducting chemical decontamination, and establishing and supervising treatment teams. Initial exercise observers included senior representatives from each of the Service medical departments, USU faculty, and Congressional staffers.

    Later, at the request of the Service Surgeons General, the University put together two iterations of a pilot course at Camp Bullis to prepare military physicians to provide high quality care to individual casualties in a combat environment during the first four post-wound hours. This tasking – a Combat Casualty Care Course, or C4 -- was also given to Wolcott. USU alumni would receive constructive credit for C4 based on completion of their more complex military medical curricular content.

    The C4 course incorporated elements of the earlier course, and the associated medical field practicum was based on the previous exercise. However, because the first exercise had been designed for a smaller class size and the number of USU students had subsequently increased four-fold, the scope of the field problems were expanded to include medical play at three levels of care simultaneously. The C4 medical field practicum was dubbed “Operation Bushmaster” by Army Maj. Dennis Duggan, who served as the Operations Officer for the exercise.

    Students in gas masks stand around a patient on a stretcher, also wearing a gas mask.
    Students don full MOPP gear to practice a decontamination scenario during Operation
    Bushmaster at Camp Bullis in 1990. (Image credit: MSgt. Jim Coker, U.S. Air Force)
    Because of growing class size, clinical sites could not accommodate the loss of students from rotations during the same six-week period, so half went to the exercise, half remained on rotations. Wolcott’s curriculum proposal for the fourth-year military medicine course was changed from its original configuration to now reflect a four-week didactic and skills acquisition element; a four-week clinical rotation in military and civilian teaching hospitals with very busy emergency departments; and Operation Bushmaster, lasting one week instead of three days. The curriculum committee accepted the first two recommendations but were concerned that Operation Bushmaster would conflict with scheduled MS-IV rotations. They ultimately accepted the proposal with the caveat that the training week occurred during an elective rotation and not a required course.

    Operation Bushmaster locations eventually expanded and among the sites were Camp Lejeune and Fort Bragg in North Carolina. However, the exercise later returned to Camp Bullis as its only site, where it continued to take place for well over two decades. Conditions often ranged from hot and dusty to torrential downpours.

    “The class flew down to San Antonio in a C-something with wings,” said Vice Adm. (Dr.) Forrest Faison, USU class of 1984 alumnus and current Navy Surgeon General, recalling his Bushmaster experience. “When the cargo doors opened, it was pouring rain...monsoon in Texas. Water everywhere. Our instructor was Lt. Cmdr. Mike Cowan [later Vice Admiral and Navy Surgeon General]. I looked at him and opined we would have to go to the BOQ because of the weather. He just laughed. We loaded on the bus and went out to Bullis and were billeted in these leaky tents, Korean War era. Mud everywhere. I asked Lt. Cmdr. Cowan directions to the bathroom and he pointed to a tree. This was not what I signed up for. … Not monsoons, leaky tents, mud, and MREs.

    “Then, over the next week, Cowan and the other instructors made us run scenario after scenario, at all hours, under all conditions, and all on very little sleep. By the last day and the MASCAL [mass casualty scenario], we were all exhausted. All I wanted was a shower, a decent meal, and a warm bed. At the hotwash, Lt. Cmdr. Cowan told us he knew we were tired, cold, wet, hungry, but then he said something: ‘you do it because that guy on the stretcher...and his family back home...are depending on you to do it.’"

    Five military medical students making MREs in field conditions
    Fourth-year medical students improvise a cookstove to heat their meals-ready-to-eat (MREs) during Operation Bushmaster. (File photo)
    Eighteen years later, those words came back to Faison as a brigade surgeon for 1,000 Marines training in Australia. A Marine in another part of the training area fell ill and was short of breath. One of the junior medical officers radioed Faison, who had him helicoptered to his site for care. The Marine had the “worst, most rapidly progressive pneumonia” Faison had ever seen and had to be intubated. They had no ventilator, but Faison knew there was one in a small town a mile away so he had him transferred there and “filled him with every antibiotic, antifungal and antiviral” they could find. The young man continued to decline and Faison had to call the Marine’s parents, telling them they would try to keep him alive until they arrived in Australia. “All the years of training, all the care we could think of, and all the best that we had to offer, and we couldn’t even save this young man’s life,” he said. “It was a low point. I’ve never felt worse.” And then Cowan’s message entered his thoughts, giving him renewed energy to do everything he could to save him. By the time his parents arrived, the Marine had started to recover and was airlifted out. “As we were loading him on the plane, he grabbed my hand and looked into my eyes and said two words I never forgot: ‘thanks Doc.’ I couldn’t speak because I was so choked up, and I couldn’t see him for the tears in my eyes.”

    “No greater words could be said about why we serve and why USU is so important: to make good on the promise we make to every mom and dad in America whose son or daughter raises their hand and volunteers to defend our freedom; that we will do all in our power to provide them the best care our nation can offer and, one day, return them home safely. That's what Bushmaster means to me and that's why I go up there every year to visit and ensure that the most important lesson I ever learned is, in turn, passed on to the generations who follow and who will, one day, stand the watch to continue to make good on that promise,” Faison said.

    A member of the Israeli military shakes Dean Kellerman's hand at Bushmaster 2017
    2017 International Honor Graduate- Cadet Ofek Arieli from Israel. (Image
    credit: Tom Balfour)
    The Operational and Emergency Medicine course eventually morphed into the Military Contingency Medicine course to meet the changing military operational mission environment and medical unit capabilities and organization changes. Over time, foreign medical students from USU-equivalent academies in allied nations joined the course and exercise. To date, more than 100 international students, including representatives from Britain, France, Australia, Israel, Russia, Germany, Mexico, and Japan, among others, have taken part.

    “The Military Contingency Medicine course and the exercise phase in Texas – Bushmaster -- was one of my earliest introductions to military healthcare in field conditions and, as such, had a profound and lasting impact on the way in which I conducted myself as a medical officer during the rest of my career,” said Dr. J. H. Nicholas Fisher, a retired major in the British Royal Army. “In 2004, I was in my final year at medical school and had yet to attend Sandhurst [the Royal Military Academy] or go through my Entry Officer Course with the Royal Army Medical Corps. I certainly felt in a much better position when I went through the special-to-arm training with the medical corps when it came to tactical field care because of my experiences on this exercise.

    Military students about the move a patient on the ground to a stretcher for transport
    Students practice tactical combat casualty care in austere settings at Camp Bullis during
    the 2004 Operation Bushmaster exercise. (Image credit: courtesy of Dr. Nick Fisher)
    “I later deployed to Iraq with a UK Medical Group and worked out of a field hospital in Basra, as well as being deployed on various operations to help protect the southern border along the Shat-al-Arab waterway. Later in my career, I joined 2nd Battalion, the Parachute Regiment, as their Medical Officer for a tour of Afghanistan. The lessons I learned at Bushmaster about care under fire, tactical combat casualty care and managing a mass casualty situation were put into use on several occasions during these kinetic tours of duty. Now as a rural emergency/family physician in British Columbia, Canada, I still reflect on some of these lessons when it is 3 a.m., I’ve got a critical patient and there is only me and one nurse available,” Fisher continued.

    In 2001, the exercise was held on the USU campus.

    “I was class leader of the first Military Contingency Medicine rotation of the 2001-2002 academic year in September 2001,” said USU alumnus Army Lt. Col. (Dr.) Andrew Morgan, now an astronaut with NASA. “I remember [Dr.] John Wightman lecturing to us when his pager went off with a cryptic message that pulled him away to the unfolding disaster that none of us knew about—that an airplane had struck the Pentagon. Within the hour, it was clear that we were watching history unfold.

    “With all commercial aircraft grounded in those days after 9/11, we were unable to travel to Camp Bullis and we improvised the entire exercise on the softball fields and greenbelts behind and around the University. It certainly lacked the fidelity of a ‘real’ field environment, but the faculty and students were completely invested in making the best of it. … We were fairly certain that our world had changed forever. Though the U.S. had not yet taken military action at this point, it seemed inevitable and we were glued to a small radio through the entire exercise, listening to updates. The reality of a major military action made this block of instruction incredibly poignant. As senior medical students we knew we could be applying these field medical skills in combat immediately in our careers, in a way that few USU graduates had ever experienced. Little did we know that this would shape our lives and careers far beyond the decade that followed. The adaptability that MEM and my class displayed in what we affectionately called, ‘Operation Weedwhacker,’ was a premonition of the courage and adaptability that USU graduates would demonstrate in the actions in Afghanistan, Iraq and Africa.”

    Students carrying a patient on a stretcher hurry somewhere off frame
    As a result of the terrorist attack on the U.S. on September 11, 2001, and the subsequent grounding of all commercial airline flights, Operation Bushmaster was held for the first and only time on the USU campus. The picnic area behind the university was converted into a mock deployment scene for several days. (Courtesy of Lt. Col. Andrew Morgan, U.S. Army)

    Two years later, USU’s Daniel K. Inouye Graduate School of Nursing students were fully integrated into the Military Contingency Medicine course and the Bushmaster field training exercise for the first time, although GSN faculty had begun exploring the possibility of joining the exercise in the late 1990s.

    In 1998, Army Maj. Lorraine Fritz, the GSN Commandant, visited the exercise when it was still at Camp Bullis to see if the exercise might be of value in the GSN's Advanced Practice Nursing curriculum. In 2000, when it did not appear that GSN students would be able to participate, Army Maj. Richard Ricciardi created a one-credit-hour operational readiness course for GSN students. The course was no longer needed in 2003 because, by then, all Family (and later Women's Health) Nurse Practitioner students were fully integrated into the exercise. Over the years, GSN participation has varied; Adult-Geriatric Clinical Nurse Specialist students participated from 2005-2008, eventually transitioning to a different exercise more aligned with the Operating Room setting. In 2009, the Psychiatric Mental Health Nurse Practitioner students began participating, but they play different roles in the exercise. The time commitment is too great for the Nurse Anesthesia program, so faculty are taking advantage of different field exercises (Mountain Medicine, Wilderness Medicine, and Dive Medicine).

    A man applies moulage to a volunteer on her chin at Bushamster
    First year students and volunteers get decked out in realistic fake wounds in
     order to create as realistic an environment as possible for students at Bushmaster.
    (Image credit: Tom Balfour)
    In 2005, the exercise was once again relocated – this time closer to home at the National Guard Training Center at Fort Indiantown Gap (FIG), Pa., about two hours northwest of USU. Operation Bushmaster, and the University’s first-year exercise, Operation Kerkesner (later MFP 101), moved to FIG to save money, resources and time. The training scenarios were revamped. Bushmaster was held twice within a three-week period – once for half of the senior class, followed by the freshman MFP-101 exercise, followed by the second iteration of Bushmaster for the rest of the fourth-year class. First-year medical students became the mock casualties for their fourth-year colleagues.

    The exercise was revamped to include a simulated month-long “deployment” in medical platoons to support combat operations in the notional country of Pandakar. Students practice tactical combat casualty care under realistic conditions in an austere environment. While the field practicum challenges the students’ medical knowledge and skills, the underlying lesson is in leadership and teamwork. The conditions are stressful, students are sleep-deprived, and yet must learn to make decisions that could have serious consequences for their patients and their platoon.

    Operation Bushmaster 2017 involved a scenario at "Quesar Village" where students learn how to speak with citizens about a sickness outbreak they’ve had. "Quesar Village" is made up of various small buildings on the side of a mountain in Fort Indiantown Gap, PA and is used to represent Middle Eastern villages our forces have to interact with on deployment. Students are taught how to bridge the cultural gap and provide healthcare services to people that may be suspicious of their motives. The purpose is to prepare them for situations overseas where they are expected to provide healthcare in foreign settings.

    USU’s Postgraduate Dental College faculty and students were incorporated into the exercise in 2014.

    “Navy Lt. Cmdr. Jayson Huber from the Naval Postgraduate Dental School brought two Advanced Education in General Dentistry (AEGD) residents to Fort Indiantown Gap to participate in the mass casualty drill on the final day of the exercise. These residents were inserted into the platoons and served as extra medical assets for triaging and treating casualties,” said Navy Lt. Cmdr. Jared Geller, AEGD program director at the Navy PDS. “In 2015, Huber returned with three AEGD residents and a field dental unit for the final two days of the exercise. They practiced assembling the field dental unit and discussed its uses, limitations, and support requirements, and were integrated into the platoons for the mass casualty exercise.

    The following year, Huber and Air Force Maj. (Dr.) Kevin Semelrath, the MCM course director, completely redesigned the role of the dental residents to more accurately reflect the role of a dental officer in “down range” setting. “Sick call scenarios were developed that were more characteristic of what a deployed dental officer would routinely encounter. These dental ‘casualties’ were first encountered by the student ‘forward surgical teams,’ who evaluated the patients and made a determination as to whether they needed to be evacuated to a higher echelon of care where dental support was more robust. At that point, the casualty would be transported to a location where the dental resident could perform a more thorough examination, describe all of the diagnostic tests that were needed and describe the treatment that could be delivered in a deployed setting,” Geller continued.

    An instructor shows students how to care for an injured canine in the field
    USU students use a canine simulator to practice treating a “military working dog” during the
     Bushmaster exercise. USU’s staff veterinarians and veterinary technicians served as faculty
    for the scenario. (Image credit: Sharon Holland)
    In 2016, a military working dog simulator was added, providing a role for USU’s veterinarians and veterinary technicians in teaching USU students.

    Teaching students at Bushmaster has been a coveted role for years. Alumni and faculty and other volunteers from around the country for the opportunity to participate in the exercise as instructors.

    “When people ask me why I continue to return to Bushmaster as an instructor, year after year for the last twenty+ years, my response is simple: because it saves lives,” said Dr. Troy Johnson, an Army reserve Colonel and emergency physician, who graduated from USU in 1995.

    “In October of 1996, I was on my first deployment as the 2nd Battalion Surgeon for the 160th Special Operations Aviation Regiment as part of a Joint Special Operations Task Force in Qatar. We were on a remote base co-located with a U.S. Marine Expeditionary Force and I was the only physician on the base. Just three months earlier, I had completed my internship in family medicine and it had been just over a year since I earned my medical degree from the Uniformed Services University,” Johnson recalled in the published photo and essay capstone project book, “Bushmaster” by then-USU student Army 2nd Lt. Evan Baines.

    “We had not been there a week and were still conducting orientation flights around the country. I was boarding an aircraft with my battalion commander when a young Marine officer ran up to the aircraft yelling that they needed medical help. There had been a structural collapse of the guard tower and eight Marines had been severely injured. I grabbed my medical rucksack and ran with her off the flight line.

    “Within minutes, I arrived at the Marine aid station to find one nurse, many corpsmen, and a radiology tech. I quickly organized them into treatment teams, establishing a triage officer, an evacuation officer and a personnel accountability officer. I directed a Marine guard to control traffic in and out of the aid station under strict entry criteria. I contacted MEDEVAC to stand by and quickly consulted with the Naval medical assets afloat to confirm their capabilities and bed status. When the casualties arrived ten minutes later, we were ready,” he continued.

    “The entire event seemed all too familiar to me at the time, but I could not immediately figure out why. … Only later would I realize why I did so well and why such an extraordinary event occurring in a sister service aid station would seem so amazingly familiar to me. It was because of Operation Bushmaster. I had done this all before and was just validating the lessons instilled in me just 18 months prior.

    “I have now been involved in many mass casualty events, including being in downtown Manhattan on 11 September 2001. The lessons of Operation Bushmaster are enduring and, without a doubt, have saved countless lives when chaos attempted to win.

    “That is why I will continue to return to Bushmaster to teach. If only to save one more Soldier, Sailor, Airman or Marine, through the efforts of our graduates, it will be worth it.”

    Four students carry a stretcher to a medical evacuation helicopter
    Students practice helicopter evacuations at Operation Bushmaster 2016. (Image credit: Tom Balfour)

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