Military Medicine

Escrito por PCRM.

Military_Medicine

The Current Use of Live Monkeys, Goats, and Pigs

The DoD’s current use of animals in combat trauma training and chemical casualty management training programs includes courses conducted by the Army and Navy, as well private contractors such as the Virginia-based company Advanced Training and Solutions (ATS), identified in the U.S. Central Contractor Registration as Assessment & Training Solutions Consulting Corp (ATSCC).

The DoD’s current use of animals in combat trauma training and chemical casualty management training programs includes courses conducted by the Army and Navy, as well private contractors such as the Virginia-based company Advanced Training and Solutions (ATS), identified in the U.S. Central Contractor Registration as Assessment & Training Solutions Consulting Corp (ATSCC).

In some DoD combat trauma training courses, pigs are subjected to gunshot and burn wounds while trainees attempt to keep these animals alive, resulting in prolonged suffering and death. In a 2006 New York Times article, one soldier reported that he was charged with keeping an anesthetized pig alive for as long as possible after the animal was subjected to serious injuries, saying of the pig that, “they shot him twice in the face with a 9-millimeter pistol, and then six times with an AK-47 and then twice with a 12-gauge shotgun. And then he was set on fire.” The soldier kept the pig alive in this condition for fifteen hours.1

A recent paper describes Madigan Army Medical Center’s (Tacoma, Wash.) trauma training course, which involves subjecting goats to serious injuries, including amputation and induced hemorrhaging. Although goats are anesthetized during the exercise, trainees are instructed to “evacuate” these animals from a simulated battlefield to a surgical team, raising concerns that animals may be paralyzed without sufficient sedation or analgesia during the exercise. A drug that is commonly used for anesthesia and analgesia in military trauma exercises using pigs is ketamine,2,3 which causes a dissociative state without loss of consciousness, muscle relaxation, or reflexes. Ketamine also produces better superficial pain relief than internal pain relief. Thus, animals wounded during such exercises likely feel intense pain from internal injuries.

The paper on Madigan’s trauma training exercise states that because “[t]he goat model is not ideal for venous access,” many trainees are unable to properly secure intravenous access in the goats, causing some of the goats to suffer fatal hypovolemic shock and hypothermia.4 Additionally, pigs are known to develop hyperthermia (a potentially fatal rise in body temperature) and a variety of abnormal physiological responses when given anesthesia, and are also susceptible to fatal ventricular fibrillation (uncoordinated contractions of the heart muscle).

A similar course that takes place at Fort Sam Houston in San Antonio is described in the Aug. 8, 2008 Express-News. The reporter describes the scene:

Two combat medics hold the rear leg of an unconscious goat stretched out on a blue sheet atop the nylon mesh of an Army litter. Instructor Armand Fermin places a tree trimmer over a joint in the leg, closes it, applies pressure and a ‘crack’ echoes inside the dimly lit tent at Fort Sam Houston.

Other such courses designed to train military personnel take place at Schofield Barracks in Honolulu and the ATS facility in Virginia Beach. Documents obtained by PCRM through the federal Freedom of Information Act (FOIA) show that, between July 2005 and September 2007, DoD agencies had 64 contracts with ATS and paid the private company a total of more than $4 million for its services. FOIA responses are still pending for information regarding most of these contracts, but a response from the Navy’s Fleet & Industrial Supply Center in Norfolk, Va. shows that the agency paid ATS $65,088 in March 2007 for a two-day course involving live pigs. At the end of this course and the others described above, the animals were killed.

The use of pigs and goats for trauma training is suboptimal due to their anatomical and physiological differences from humans. Compared with humans, pigs and goats have smaller torsos and limbs, thicker skin, different responses to anesthesia and analgesia (pain relief), and important differences in anatomy of the head and neck, internal organs, limbs (e.g., no hands or feet), blood vessels, and airway.

As a result of these differences, it is impossible to mimic human wounds, skin injuries (e.g., burns and chemicals), altered baseline and injury-related physiology, airway control, or correlations for head, facial and limb injuries, vascular access and hemorrhage treatment in pigs and goats. Differences related to vascular anatomy, access, and hemorrhage may have particular importance, since uncontrolled hemorrhage is by far the major cause of death for wounded soldiers.

In the U.S. Army Medical Research Institute of Chemical Defense’s “Medical Management of Chemical and Biological Casualties Course,” vervet monkeys are given an overdose of the chemical physostigmine, which acts as a nerve agent inducing cholinergic crisis, symptoms of which include severe diarrhea, vomiting, a very low heart rate, and sometimes death.5 Medical personnel then attempt to resuscitate the monkeys. The animals involved may be subjected to this procedure as many as four times per year until their death.6

Nonanimal Training Methods Exist

The most important elements of military trauma and chemical casualty management training are realism, human-specific injuries and treatments, volume of trauma exposure, simulation of austere environments, stabilization and transport, and team building. All of these elements are readily provided by a combination of medical simulation and cadaver use, as well as a strong focus on civilian trauma center training.

Advanced simulation tools for trauma training can replace animals to teach emergency and trauma procedures. Management of hemorrhage, the most common cause of battlefield death for wounded military personnel, can be taught using SimMan from Laerdal (Stavanger, Norway) and the SimQuest Limb Hemorrhage simulator (Silver Spring, Md.). The development of the latter was funded by the U.S. Army. Treatment of fractures and amputations can be taught using SimMan, as well as the Human Patient Simulator and Emergency Care Simulator from Sarasota, Fla.-based Medical Education Technologies, Inc. (METI). Burn wound management can be taught using the Medical Readiness Trainer from MEDSMART, Inc. (Ann Arbor, Mich.).

Invasive lifesaving skills can be taught using Simulab’s TraumaMan System (Seattle, Wash.), Laerdal’s SimMan, and METI’s Emergency Care Simulator. The TraumaMan System is used in lieu of live animals in nearly 90 percent of Advanced Trauma Life Support programs in the U.S. The U.S. Army’s own Combat Trauma Patient Simulator is described as “simulating, replicating, and assessing battlefield injuries by type and category such as hemorrhaging, fractures, amputations, and burns; monitoring the movement of casualties on the battlefield; capturing the time of patient diagnosis and treatment; comparing interventions and outcomes at each military healthcare service delivery level.”7

Several other military simulation training tools are detailed in a seminal 2005 review article authored by Maj. E. Matt Ritter, M.D., and Col. Mark W. Bowyer, M.D., of the National Capital Area Medical Simulation Center and the Norman M. Rich Department of Surgery of the Uniformed Services University of the Health Sciences (USUHS).8 In criticizing the use of live animals for trauma and casualty training, they noted that animals are “poor surrogates for human anatomy” and that their use “raises ethical issues, as well as not allowing for repetitive practice.”

The issues of fidelity and realism are addressed not only by simulation tools, but also by human-based training methods. Neurosurgeon Emad Aboud, M.D., has developed a model for teaching surgery and trauma skills, using a human cadaver connected to reservoirs of artificial blood. Artificial blood is pumped through the cadaver to replicate blood circulation and hemorrhage in a human body. Numerous medical experts have endorsed Dr. Aboud’s model as an effective training tool that could replace the use of animals in surgery and trauma training. Drs. Kemal Yücesoy, Mustafa Güvençer, and Salih Sayhan have written that “we can easily say that this model is a perfect model for surgical training.”9 Dr. Paul H. Young has written that Dr. Aboud’s model could replace the use of live animals in trauma technical training.10

The ideal trauma and casualty training method is exposure to real injuries in humans, such as that provided by the participation of U.S. military medical teams at high-volume trauma centers. The three major programs are the Army Trauma Training Center (ATTC) in Miami, the Navy Trauma Training Center (NTTC) in Los Angeles, and the Air Force Trauma Training Center (AFTTC) in Baltimore. The ATTC has been described as providing “exposure to a high volume of traumatic injuries that closely mimic those seen on the battlefield.”11

The success of this approach is touted in many military publications, and there appears to be a general consensus that trauma center training is the very best preparation for battlefield medical care. As stated by Army Colonel (Dr.) David G. Burris, USUHS Surgery Department Chair: “The CTSC [DoD’s Combat Trauma Surgical Committee] has made significant strides partnering with civilian trauma training centers, whose caseloads match battlefield injuries.”12

These three military trauma center programs, and other military partnerships with level one civilian trauma centers in major U.S. cities, provide not only skills training but also critical training in triage, decision-making, transport, operation in austere environments, and team building. As stated by DoD: “The ultimate goal of the Army Trauma Training Center is to ‘train teams to be a team.’”13

The Air Force’s Center for Sustainment of Trauma and Readiness Skills (C-STARS) program exemplifies how effective trauma training can be achieved by combined use of simulators, human cadavers, and civilian trauma centers. At centers in St. Louis, Cincinnati, and Baltimore, C-STARS courses teach chest tube insertion (to remove air or fluid) using simulators, fasciotomy (a limb-saving procedure in which connective tissue is cut to relieve tension or pressure) using cadavers and a number of other procedures using live human patients who enter the trauma centers with severe injuries. No animals are used in the C-STARS program.

The trauma center approach is an accepted standard of practice for trauma training in the United Kingdom. In a 2006 editorial, the Royal College of Surgeons of England (RCSE) stated that animal laboratories cannot “substitute for supervised experience in high volume trauma centres such as those in North America.”14 The RCSE does not endorse animal use for trauma training, and this practice is prohibited by law in the UK.15

This type of nonanimal trauma training is further endorsed by Michael P. Murphy, M.D., a vascular surgeon on faculty at Indiana University School of Medicine who served in the Army Reserve Medical Corps during the current Iraq War. Specifically, Dr. Murphy served in a Baghdad field hospital in 2004 during Operation Phantom Fury (also known as the Second Battle of Fallujah), one of the bloodiest and most intense battles of the war. According to him:

I am intricately aware of the importance of training military physicians and medics with the best available teaching tools. Unfortunately, the current use of live animals within Army and Navy training courses is an inferior model.

The ideal training paradigm for military trauma and casualty preparedness combines simulation tools and trauma center training. In this context, the use of live animals is inferior to simulation for specific skills training and inferior to trauma centers for human-specific training similar to the battlefield experience. Continued appropriate use of simulation, continued efforts to develop and implement improved simulation tools, cadaver use, and expansion of the trauma center training initiative will best prepare our military medical personnel to save soldiers.

Likewise, superior nonanimal training methods exist that could replace the use of vervet monkeys in the DoD’s chemical casualty management training. Researchers with the Israel Defense Forces Medical Corps and Israel’s Carmel Medical Center have developed a nonanimal training curriculum for the medical management of patients exposed to nuclear, biological, and chemical weapons.16 The course includes lectures, simulation training, and the use of moulaged actors.

The Use of Live Animals Violates the DoD’s Regulation on Animal Welfare

Given the availability of nonanimal alternatives to the use of animals in combat trauma training and chemical casualty management courses, the DoD’s continued use of animals in these programs constitutes a violation of its own animal welfare regulation. Known as Army Regulation 40-33, Secretary of the Navy Instruction 3900.38C, and Air Force Manual 40-401(I), The Care and Use of Laboratory Animals in DOD Programs requires that, “Alternative methods to the use of animals must be considered and used if such alternatives produce scientifically valid or equivalent results to attain the research, education, training, and testing objectives.”17

The DoD’s animal welfare regulation also prohibits inflicting injuries on nonhuman primates “to conduct training in surgical or other medical treatment procedures,”18 including injuries caused by “Acute poisoning…resulting from exposure to a toxic or poisonous substance.”19 As a result, the DoD’s chemical casualty management training program involving vervet monkeys constitutes a violation of its own animal care and use regulation.

Conclusion

Multi-faceted approaches to improving the educational value of these courses are crucial considering the ethical imperatives to eliminate the use of animals whenever possible and advance healthcare for U.S. military troops, the existence of superior nonanimal alternatives, and the DoD’s own regulation requiring the use of such alternatives when available. In addition, the growing medical challenges presented by unconventional warfare in Iraq, Afghanistan, and elsewhere require that the Army, Navy, and other DoD agencies collaboratively solve this problem. Considering these imperatives, the DoD should immediately implement human-centered teaching methods in its combat trauma and chemical casualty management courses.

References

1. Chivers, C J. “Tending a Fallen Marine, with Skill, Prayer and Fury.” New York Times 2 Nov. 2006.
2. Thurmon JC, Nelson DR, Christie GJ. Ketamine anesthesia in swine. J Am Vet Med Assoc. 1972;160(9):1325-30.
3. Ketamine Consensus Working Group. Ketamine and its use in the pig. Recommendations of the Consensus Meeting on Ketamine Anaesthesia in Pigs, Bergen 1994. Laboratory Animals 1996;30:209-19.
4. Sohn, V.Y., et al. (2007). “From the Combat Medic to the Forward Surgical Team: The Madigan Model for Improving Trauma Readiness of Brigade Combat Teams Fighting the Global War on Terror.” Journal of Surgical Research. 138. p. 27.
5. U.S. Army Medical Research Institute of Chemical Defense, "Chemical Casualty Care Resuscitation Practical Exercise Using the Nonhuman Primate Model," 7 Nov. 2005. p. 3
6. Ibid, p. 5.
7. DoD First Annual Report to Congress: Defense Acquisition Challenge Program Fiscal Year 2003. Sue C. Payton, Deputy Under Secretary of Defense (Advanced Systems and Concepts): page 10. Presented March 2004.
8. Ritter, E.M., Bowyer, M.W. Simulation for trauma and combat casualty care. Minimally Invasive Therapy. 2005;14(4-5):224-34.
9. Yücesoy, K., Güvençer, M., Sayhan, S. Letter to Emad Aboud. 5 March 2007.
10. Young, P.H. Letter to Emad Aboud. 20 Feb 2007.
11. Champan, C. “Army Medical Team Trains for Wartime Mission.” Defend America (US DoD newsletter)
12. Ramos, J. “Medical leaders discuss future of military trauma medicine.” Air Force Surgeon General Newswire Jan 2006.
13. Chapman, C. “Army Medical Team Trains for Wartime Mission.”
14. Tai NR, Ryan JM, Brooks AJ. The neglect of trauma surgery. BMJ 2006;332:805-6.
15. Select Committee on Animals in Scientific Procedures. Supplementary memorandum by Lord Sainsbury of Turville, Parliamentary Under-Secretary of State, Department of Trade and Industry (June 2002).
16. Rubinshtein, R., Robenshtok, E., Eisenkraft, A. “Training Israeli Medical Personnel to Treat Casualties of Nuclear, Biologic and Chemical Warfare.” The Israel Medical Association Journal. 2002. p. 545.
17. U.S. Departments of the Army, Navy, Air Force, Defense Advanced Research Projects Agency, and the Uniformed Services University of the Health Sciences. Army Regulation 40-33. The Care and Use of Laboratory Animals in DOD Programs. Paragraph 5b. (16 March 2005).
18. Ibid. Paragraph 5h.
19 Ibid.