A bomb goes off. It's noisy. It's smoky. Lights are flashing, people are shouting. The wounded are bloody and dying. But this isn't a real war zone. It's a training class inside a simulator in San Antonio that recreates the real-life chaos and pressure of combat.
Thousands of U.S. military medics, corpsmen ad technicians are deployed around the world — from war zones to hospitals and clinics. And in the last five years, nearly all these workers have trained at the Medical Education and Training campus at Fort Sam Houston. Medical experience gleaned from combat in Iraq and Afghanistan, has been incorporated in simulations here to better save lives.
"So this is a marketplace somewhere in the Middle East," Donald Parsons tells me about today's fictional scenario. He's deputy director of the campus's department of combat medic training. "A suicide bomber came in," Parsons says. "He blew himself up, blew up a bunch of soldiers and civilians."
Parsons was a medic in Vietnam, and was trained to civilian standards. His students, he says, are learning trauma techniques through a military lens, instead.
"It's dramatically different than it is in treating trauma in the civilian community," Parsons says, "because it addresses the underlying tactical situation."
Army medics used to be discouraged from using tourniquets to stanch the flow of blood for fear it would lead to more amputations. Now trauma specialists know that as long as a tourniquet is applied first and left on for less than two hours, the bleeding can be stopped and the arm or leg can be saved.
Forty years ago, morphine was the standard painkiller on the front lines. In 2011 medics started carrying other effective drugs in their kits, including the synthetic opioid fentanyl and ketamine — options for anesthesia that, when used properly, can reduce the risk of dangerously slowed breathing or blood pressure that's too low.
Transfusions in the field can help wounded service members who are hemorrhaging and in shock. And in 2012, evacuation helicopters started carrying packed red blood cells and plasma, to get the life-giving therapy to the wounded sooner.
"They can stabilize the person and get them back," explains Army Col. Keith Michael Johnson.
Consolidating each branch of the military's medic training happened as part of the 2005 Base Realignment and Closure legislation. San Antonio' program had room to expand, so the base there was picked as the hub.
About 5,000 young men and women undergo the training on any given day. The campus graduates 18,000 service members a year in 48 programs, from radiology to surgical technology. Three-quarters of them serve with troops. The other 25 percent are assigned to hospitals.
The pressure is intense, the program's directors say, because the end game is so important. Military medical training has evolved as warfare has changed. The difference is not in the injuries, but in how they are treated. From cannonballs during the American Revolution, to musket fire in the Civil War, to IEDs in Iraq, bleeding and trauma are still the biggest threats to life and limb. But 21st century training gives the wounded a fighting chance.
"We're saving a heck of a lot more lives on the battlefield," than in previous eras, Johnson says.
Figures from a 2012 study in the Journal of Trauma and Acute Care Surgery back him up. During World War II, 19 percent of those hurt in combat ended up dying. In Vietnam, that statistic dropped to 15 percent. In modern conflicts, 9 percent of the wounded ended up losing their lives.
Technology has made a big difference, Johnson says. The hundred mannequins — "patient simulators" — at the school make hands-on training feel more real, students say. These dummies move, groan and have vital signs, so it's easier to simulate the experience of treating a real-life casualty.
And when service men and women step into a fake Middle Eastern marketplace that's under attack, or a mocked-up camp made to look like one on an Afghan mountain, they say their classroom training suddenly seems more relevant.
"It's really effective," says fellow student Pvt. Victor DelReal. "It puts you in that mentality where people are going to be screaming at you. There are going to be gunshots. There's going to be everything going on around you. So you have to get into that mindset where you can just block everything out and focus on your casualty."
Depending on the course, students spend six weeks to 13 months at the San Antonio campus, honing their skills.
Parsons says U.S. Army information gathered over the last 15 years from battle experience in Iraq and Afghanistan shows if frontline military medical personnel can get the wounded to the hospital alive, 97 percent of them will live to tell their story.