US Army conducts ground-breaking research in the Campbell Gross Anatomy Lab

Can a commercial technology create a capability for a downrange, non-surgical provider to give surgical care for a discrete number of predetermined tasks for fellow soldiers to save lives and limbs?

The Vyas Anatomy Lab is serving as the host facility for a research project with partnerships between Womack Army Community Hospital’s Col. (Dr.) Tyler Harris, the principal investigator and orthopedic hand surgeon, the Uniformed Services University of Health Sciences, and Bio Mojo, a woman-owned small business based in Research Triangle Park.

Bio Mojo focuses on XR, extended reality, related technologies and has been working with the U.S. Army at Fort Bragg since 2017 on the idea that you could use commercial technology to create a capability for downrange non-surgical providers to provide surgical care for a discrete number of predetermined tasks for fellow soldiers. Phase 2 of the project led by Col. Dr. Harris is being tested at Campbell.

“This specific project is an outgrowth of the initial work we started in 2017. It went from, ‘is this even possible?’ To, ‘how does this become something that is rolled into training?” said Jerry Heneghan, chief design officer for Bio Mojo.

“Under the leadership of Lt. Col. (Ret.) Steve Delellis at the Fort Bragg Research Institute, the Army came up with a dozen tasks deemed that a physician assistant, a nonsurgical physician, or a special forces medic, ought to be able to do to save a life downrange. Bio Mojo got involved to provide augmented reality heads-up display so that a remote expert, a surgeon, could draw on the heads-up display to identify physiological anatomical landmarks and provide visual guidance via HoloLens – kind of like John Madden on the screen when you are watching a football game.”

Doctor Boyer, a renowned trauma surgeon at the Uniformed Services Medical School, created and teaches a course accredited by the American College of Surgeons for such downrange interventions and it has been used at Fort Bragg.

The study at Campbell is evaluating the use of a pictorial flipbook of procedures versus the heads-up display - specifically to treat compartment syndrome by dissecting apart and releasing fascia. One such procedure - a two-incision, four-compartment fasciotomy of the lower leg - is an effort to save the life and limb who has sustained significant trauma to the lower leg. The procedure releases pressure from internal bleeding inside the fascia saving muscle tissue and preventing toxins that develop and can cascade to a variety of life-threatening conditions.

In Phase 1 of the study, small cohorts of 15 to 20 military personnel were brought into the medical simulation training center at Fort Bragg and trained on these procedures including a didactic review the anatomy and physiology, as well as a pre-test to establish participants’ baseline knowledge of fasciotomy, what compartment syndrome is, and when it’s an appropriate treatment.

About a year after this training, the study brings them back for Phase 2 at Campbell to determine their proficiency in retaining the knowledge of how to do the procedure.

The evaluation process consists of pre and postprocedure questions and a compartment syndrome procedure on cadavers with some participants using the heads-up display with live guidance and some of them using the flipbook.

Bio Mojo was hired to provide the technology for the study, which Jerry Heneghan explains in four key components.

“The military can give someone a fairly complex piece of equipment, train them up in about 15 minutes on how to use it, explain the goals for how this would work in the future - in the field - they would connect through a satellite connection or a tactical phone or radio connection, and talk to a surgeon at Walter Reed or in Germany who will guide them through the procedure.”

Lt. Col. Dan Hankes, deputy surgeon for clinical operations at 18th Airborne Corps and Corps Senior Physician Assistant is serving as a liaison between the director of this program and the operational force to bring in the PAs to actually execute the test procedure and share the potential future life and limb saving significance of the project.

“Over the past 20 years, the United States has been involved in the global War on Terror in places like Afghanistan and Iraq, where we have had air support. Outside of shooting at us from the ground, there have been no helicopters or other types of aircraft in the air to shoot down our aircraft including those airlifting injured soldiers in need of emergency treatment.”

“In this uncontested environment, we have been able to medevac patients off the battlefield within the golden hour pretty much with impunity. We have had little problem getting them back from the battlefield, where they were treated and stabilized by the medic and the PA, then to be transported if needed to an operating room if they are an emergent surgical case. We have been able to put them in a helicopter, and in relatively short order, get them there pretty quickly.”

“This project is inspired by preparedness. These are America’s sons and daughters, and we need to provide them the best care possible to get them home.”

“If, God forbid, we ever have a war where the air space is part of the battlefield, and we won’t have easy medivac ability. We won’t have the freedom of movement that we once did, so the PA’s who are pushed out with the units need to be able to do these types of procedures that would otherwise be done by surgeons in a field hospital.”

“A scalpel is being given to a non-surgical provider in some cases for the first time. In that case, it’s cutting edge, but I think forward thinking people like the folks that hired us to do this know that in near peer kind of conflicts, access to surgical providers is not necessarily guaranteed,” affirmed Heneghan.

“This all came about through the vision of Col. (Dr.) Tyler Harris when he was in Afghanistan a few years ago. He contacted me and asked ‘can you build something for me where you can see through my eyes and see what I’m seeing? I’m an orthopedic surgeon, and I have to deal with everything that comes into my facility, and you know I need sometimes a subject matter expert or different occupational areas to help me to do my job’. So, we put something together for him that seemed to work.”

“Now, the goal of all of this research - and this is just one of many procedures that Dr. Harris and the Uniformed School wanted to train our soldiers on - is to equip our PAs in a war zone to do advanced provider techniques - damage control procedures that would be otherwise done by a surgeon in an operating room. Once this project is done, then they’ll move on to a different procedure. There is a whole host of other procedures this training could apply to.”

Gerald Robertson, research assistant on the project and a former special forces medic, has also been key in all aspects of the project including supporting Lt. Col. Hankes in coordinating personnel participants.

Lt. Col. Hankes shared the participants in this project include PAs along with special operations combat medics, special forces medics, conventional side medics and some sister service medics and corpsman from the Navy for a total of 70 personnel completing Phase One, the training, and the Phase Two procedure in Campbell’s lab.

“For purposes of study right now, Bio Mojo is facilitating and simulating communication to a remote expert who could be anywhere in the world through the magic of an Internet connection, and he has the ability to see in 3D what the downrange provider sees. Whether you get the flipbook Dash 1, which is a book that gives you step by step instructions with photographs, pictures, good imagery to jog your memory and give you a good landmark of where you need to cut and separate the muscles, or HoloLens in Phase 2 is randomized.”

The project has been impacted by COVID-19.

“The intent was to bring back the participants from Phase 1 six to eight months later, but because of COVID, all kinds of complications got in the way. So now, it’s been roughly a year since the first cohort. I was in the first cohort, and when I came in to do Phase 2, I was feeling like ‘Oh my gosh I’m so rusty!’

“I was selected to use HoloLens where the surgeon can see what you see - they can see the leg; they can see everything. They can see your hands moving and talk you through it; if you get hung up, they can help you or just reassure you that you are doing fine. For me, it was a good fasciotomy.”

Dr. Harris’ thesis is that he can train personnel to do these types of procedures in a day, and Bio Mojo is refining the technological process with the hope that the study affirms this process works and the Generals can approve implementation for real practice.

“Dr. Harris’ intent is to use the data from Phase 1, a year ago with the didactic and the hands-on training, then Phase 2 a year later to see how much you retained, and then put all the results together to move forward with the army credentialing and privileging bodies after the study has proven mid-level providers can do this with skill and safety into an expert level,” explained Lt. Col. Hankes.

“There are lots of details to work out. How HoloLens would be incorporated into our kits and how they would hold up in the field, for example. But to be able to go to a General and say, this is a dynamite piece of equipment helps.”

The collaborative team is already thinking about applications for the project in civilian medicine.

“This is starting to happen in other countries, not necessarily ours - folks are looking at how to use this for emergency medicine,” shared Heneghan. “You’ve got paramedic talking to attending physician in the ER at a tier one facility in terms of what’s happening at the car wreck that’s 20 miles away. I think this will eventually transition out to be used when appropriate.”

Bio Mojo is focused on the technology at the operator level - what’s the operator seeing and doing. What information are they collecting? Also, what are the options for connectivity?

“In the aftermath of a hurricane, it could be a satellite truck, or a blimp, or a balloon. It could be anything. So, our question is, how do you plug into that network to take a signal and then manage a situation and get help for folks?”

“Campbell has bought into the idea of researching this cutting-edge approach, and I’m excited to be here,” said Heneghan. “I’ve worked at universities, and I think Campbell has provided unique capabilities here in terms of the anatomy lab and some of the faculty and the staff here available to this study. Everything is set up. It’s very efficient. This is a world-class operation here in terms of putting this together that I haven’t really seen anywhere before, so I think from an integration standpoint, Campbell has really provided that role in terms of providing the study resources, the staff, the faculty, the resources in the anatomy lab for this to happen in a way that could have taken more time.”

“Hopefully this will save some lives, Heneghan concluded. “If it saves one life, it’s worth it, right? So, that’s what we’re trying to do.”