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U.S. Air Force, Romanian surgical exchange highlights Vigorous Warrior 19

Vigorous Warrior 19 is NATO’s largest-ever military medical exercise, uniting more than 2,500 participants from 39 countries to exercise experimental doctrinal concepts and test their medical assets together in a dynamic, multinational environment. (U.S. Air Force photo by 1st Lt. Andrew Layton)

Dr. Bogdan Mihalache, general surgeon, Iași Military Hospital, Romania, participates in a multinational surgical exchange drill at the U.S. Air Force 86th Medical Group Role 2 field hospital during Vigorous Warrior 19, Cincu Military Base, Romania, April 11, 2019. Vigorous Warrior 19 is NATO’s largest-ever military medical exercise, uniting more than 2,500 participants from 39 countries to exercise experimental doctrinal concepts and test their medical assets together in a dynamic, multinational environment. (U.S. Air Force photo by 1st Lt. Andrew Layton)

Vigorous Warrior 19 is NATO’s largest-ever military medical exercise, uniting more than 2,500 participants from 39 countries to exercise experimental doctrinal concepts and test their medical assets together in a dynamic, multinational environment. (U.S. Air Force photo by 1st Lt. Andrew Layton)

A Romanian surgical team participates in a multinational surgical exchange drill at the U.S. Air Force 86th Medical Group Role 2 field hospital during Vigorous Warrior 19, Cincu Military Base, Romania, April 11, 2019. Vigorous Warrior 19 is NATO’s largest-ever military medical exercise, uniting more than 2,500 participants from 39 countries to exercise experimental doctrinal concepts and test their medical assets together in a dynamic, multinational environment (U.S. Air Force photo by 1st Lt. Andrew Layton).

Vigorous Warrior 19 is NATO’s largest-ever military medical exercise, uniting more than 2,500 participants from 39 countries to exercise experimental doctrinal concepts and test their medical assets together in a dynamic, multinational environment. (U.S. Air Force photo by 1st Lt. Andrew Layton)

Maj. Lindsey Marquez, certified registered nurse anesthetist, 86th Medical Group, Ramstein Air Base, Germany, and Maj. Florin Buia, general and vascular surgeon, Cluj-Napoca Emergency Military Hospital, Romania, participate in a multinational surgical exchange drill at the Romanian Role 3 medical unit during Vigorous Warrior 19, Cincu Military Base, Romania, April 11, 2019. Vigorous Warrior 19 is NATO’s largest-ever military medical exercise, uniting more than 2,500 participants from 39 countries to exercise experimental doctrinal concepts and test their medical assets together in a dynamic, multinational environment. (U.S. Air Force photo by 1st Lt. Andrew Layton)

Dr. Bogdan Mihalache, general surgeon, Iași Military Hospital, Romania, and 1st Lt. Roxana Oparlescu, Military Hospital Brașov, participate in a multinational surgical exchange drill at the U.S. Air Force 86th Medical Group Role 2 field hospital during Vigorous Warrior 19, Cincu Military Base, Romania, April 11, 2019. Vigorous Warrior 19 is NATO’s largest-ever military medical exercise, uniting more than 2,500 participants from 39 countries to exercise experimental doctrinal concepts and test their medical assets together in a dynamic, multinational environment (U.S. Air Force photo by 1st Lt. Andrew Layton).

Vigorous Warrior 19 is NATO’s largest-ever military medical exercise, uniting more than 2,500 participants from 39 countries to exercise experimental doctrinal concepts and test their medical assets together in a dynamic, multinational environment. (U.S. Air Force photo by 1st Lt. Andrew Layton)

Maj. Florin Buia, general and vascular surgeon, Cluj-Napoca Emergency Military Hospital, Romania (left), Capt. Hendrik van de Krol, trauma surgeon, Royal Netherlands Navy (center), and Maj Daniel Hatz, orthopedic surgeon, 86th Medical Group, Ramstein Air Base, Germany, participate in a multinational surgical exchange drill at the Romanian Role 3 medical unit during Vigorous Warrior 19, Cincu Military Base, Romania, April 11, 2019. Vigorous Warrior 19 is NATO’s largest-ever military medical exercise, uniting more than 2,500 participants from 39 countries to exercise experimental doctrinal concepts and test their medical assets together in a dynamic, multinational environment. (U.S. Air Force photo by 1st Lt. Andrew Layton)

CINCU, Romania --

Since April 3, approximately 50 Airmen from the 86th Medical Group, Ramstein Air Base, Germany, have been working side-by-side with counterparts from 39 partner nations at Cincu Military Base, Romania, for Vigorous Warrior 19, NATO’s largest-ever medical exercise.

With over 2,500 participants united in a series of challenging medical scenarios, Vigorous Warrior 19 gives providers from a diversity of backgrounds the opportunity to test doctrine and techniques together in an austere environment. Drills are scripted by experienced physicians, with live “patients” made-up in detailed mulage to make the experience look and feel as close to real-life trauma care as possible.

While testing interoperability with NATO partners has been a dominant theme throughout the week, the 86 MDG surgical team went a step further Thursday by swapping places with Romanian counterparts, who up to that point in the exercise had been staffing Romania’s division-level field hospital, designated a “Role 3” medical facility under NATO doctrine. The Romanian surgical team reciprocated, themselves relocating to the 86 MDG’s Role 2 expeditionary medical support facility (EMEDS).

Two drills were performed during the experiment: the first paired an all-Romanian surgical team with U.S. medical support staff, and vice versa; the second featured fully-integrated U.S.-Romanian surgical teams. For the second drill, a Dutch trauma specialist also joined the surgical team at the Romanian Role 3 facility for an additional perspective.

“The purpose of this surgical exchange was to see what the challenges would be if we had a scenario in real life where a separate surgical or resuscitative team was dropped into an unfamiliar facility,” said Lt. Cdr. Sanita Atwal, general surgeon, Royal Canadian Navy, one of the scenarios’ lead planners in cooperation with the NATO Centre of Excellence for Military Medicine, Budapest, Hungary, which oversees the exercise. “We wanted to see if we, as NATO forces, really could make that work to resuscitate desperately injured patients together.”

With minimal coordination prior to the drill, participants faced the dilemma of working through a high-stress scenario in an unfamiliar space with colleagues that did not share a common native language. Added to this was a challenging exercise script, which placed in the surgical teams’ care a “patient” with devastating vascular injuries from a gunshot wound in the abdomen.

According to Dr. Bogdan Mihalache, general surgeon, Iași Military Hospital, Romania, the experience of working through a simulated surgery at the U.S. Air Force facility provided lessons that will ultimately help improve his scope of care as a provider.

“Because the patient was in a critical state, we had to clamp the aorta, we had to secure the inferior vena cava,” said Mihalache. “In planning this intervention, for me, it was very good because we had to work together as a team to focus on the critical points and then take our time to focus on everything else.”

During the exercise, Mihalache’s U.S. counterpart at the Romanian Role 3 facility was Maj. Daniel Hatz, orthopedic surgeon, 86 MDG, Ramstein Air Base, Germany. Hatz agreed that the scenario tested his capacity to adapt and overcome in an austere environment.

“The utility of this exercise, from a surgical standpoint, was to go over any type of complication we could have, with a multinational perspective as to how to best treat our patients,” Hatz said. “That involves a lot of being able to adapt on the fly and intercommunication between nationalities; all those things come with complications and we need to anticipate those. The ability to run through those scenarios is invaluable for preparedness if a situation like this were to actually happen.”

In both drills, after approximately 90 minutes of exercise inputs, simulated surgical procedures, and deliberations between U.S. and Romanian staff, experts from the NATO MilMed COE determined that the operative care would likely have been successful if the exchange had occurred in a real-world situation.

“In our regular assignments, you sometimes get so used to being where you are, it’s easy to take that comfort level for granted,” said Maj. Lindsey Marquez, certified registered nurse anesthetist, 86 MDG, Ramstein AB, Germany, who participated in the exchange at the Romanian Role 3 facility. “When you take the fact that we’re working outside our normal areas, and then mixing different nations together, it’s a very positive thing to have the assurance that we could do this in real life, and we could do it very well.”

Although the Romanian exchange participants all had a level of proficiency in English as non-native speakers, both surgical teams expected communication barriers while working through the highly-complex scenario together. Surprisingly, their concerns were mitigated early in the experiment.

“We had to figure out how we were going to communicate with our partners; how we were going to get what we need from them and how they were going to get what they need from us,” said Marquez. “In the end, medicine is medicine, and we all come together on that common ground of wanting to provide the best patient care possible no matter what language we speak.”

As a civilian surgeon, Mihalache brought additional insight into how the skills practiced in this military-centric environment can also be translated to benefit civilian communities.

“For me, it’s very interesting because I am a civilian and I am not accustomed to this type of surgery, but you can use it not only in wartime, but also in times of civil disaster,” he said. “I think the idea for this exchange was excellent because you should be able to help different teams interchangeably to assure medical procedures for the wounded, even if your team and your hospital is not right there with you.”

Even more than the professional knowledge gained by its participants, Thursday’s exchange highlighted the value of multinational military exercises such as Vigorous Warrior 19, which enhance professional relationships and improve overall coordination with allies and partner countries who share common values, vision, and experience.

“This is my first NATO exercise,” Marquez said. “This is a great way to meet different people and talk about the common experiences we have, and I think those relationships and that trust can be key to ensuring patients receive the best care we can possibly provide.”