The deadly whistle of an incoming mortar breaks up the constant gunfire. Residents rush to provide lifesaving care to a mock casualty as they move him out of the line of fire. An instructor calls out what the wounded soldier might cry -- "I'm bleeding! It hurts!" -- to add to the chaos.

The urgency of the exercise was very real for the 72 graduating residents and interns who participated in the CAPSTONE field training exercise May 15 and 16.

"What we really try to do is make sure that we bring all the residents through all the levels of care, starting at that point of injury that a soldier experiences all the way through until they get that definitive surgery that they need. It is condensed, but we really try to give them a little taste of what they could expect in all the different roles of care and what resources could be available," said Maj. (Dr.) Lindsay Grubish, Madigan Army Medical Center's Graduate Medical Education core curriculum director.

Practicing their physician skills in environments similar to downrange settings helps residents prepare now for deployments many will see later.

"I feel like I'm going to be a lot more comfortable when I'm put in a real scenario like that," said Capt. (Dr.) Bryce Harmon, a transitional year intern.

The field training exercise is a key part of the weeklong CAPSTONE event held May 13-17 for graduating residents, which also included a transition conference that offered insight from officer record briefs and evaluations to panel discussions on deployments and advice on future careers to "give residents skills to bridge the gap between being a resident and being a staff," Grubish said.

While the exercise gave residents exposure to aid stations and to damage control surgery, one aspect of the exercise that planners purposely skewed from real-world procedures was to keep the same team of residents with their casualty the entire time from point of injury to MEDEVAC and beyond.

"To be able to achieve that, they basically have to morph roles, and become the providers in each one of those roles to really understand what it's like," said Col. (Dr.) Imad Haque, a general surgeon and, as one who helped develop the exercise over the past several years, an adviser to the CAPSTONE planning. "They have an understanding that when someone steps on an IED, how does it start, what does that initial chaos look like."

As a veteran of practicing medicine downrange, Haque stressed that doctors new to those settings need to not only work well with their medics, but to understand them and the situations they face -- like the 18-year-old medics with a year of training who make medical decisions and start saving lives alone.

"It is an exercise in empathy, so when they're a battalion surgeon or they're assigned to a unit, and they are the doctor for that unit -- ultimately those medics work for them ... It would be a good idea to understand exactly what they're doing and the challenges they face in the process," he said.

As a former Special Forces medic, and an infantryman, one of the participating residents could more easily relate to this objective. What was new for Capt. (Dr.) Kevin Kearney, though, was the chance to practice medicine with doctors from other specialties, especially surgeons -- something the emergency medicine physician doesn't often get to do in everyday practice.

"There's a good chance we could be downrange with a surgical team, so it's good to have that hands-on (knowledge) of this and what they would be doing next and how I could be useful for them," said Kearney, whose next assignment will be at Fort Campbell, Kentucky, with the Special Forces group he once served in. "It's the reason I went to medical school to go back to be a battalion surgeon for Special Forces."

Maj. (Dr.) Jillian Phelps, the director of the Andersen Simulation Center at Madigan and also the lead planner for the field training exercise, went through CAPSTONE herself before it became more operationally relevant. Her experience as a new battalion surgeon in which she was expected to teach and train medics, and get them ready to deploy, is one of the reasons she encourages graduating residents to pick up the habit of reaching out for support.

"It's also the communication of these are resources for you; this is what other skillsets can do so that when you're out there and you're feeling alone, you feel like you have a way to at least reach for help or a resource to look at so you don't feel as isolated," Phelps said.

She helped ensure this year's exercise included psychology interns and nursing students as well to offer more of the broader team this training.

In fact, the exercise expands in scope every year; in 2019, the planners added a prerequisite of an online course on tactical medicine, and included prolonged field care. Haque explained that while the military is used to casualties being evacuated from the battlefield quickly, this could change in the future -- requiring medical personnel to provide prolonged care with perhaps limited resources in an austere environment.

"Given that challenge, both for personnel and for training, we recognize that we need to leverage technology to help, and so we integrated telemedicine this year," said Haque.

The field exercise incorporated units from across Joint Base Lewis-McChord, the Guard and Reserve, and all three military services.

"It's a joint operation, truly tri-service, as we're all moving," said Grubish.

The realism of the field exercise was made possible by the participation of units that simultaneously achieved their own training objectives, from the 1st Special Forces Group to a Stryker brigade, and from Washington Army National Guard to an Air Force aeromedical team to a Navy surgical team.

"The units that are participating and supporting know and fully understand that it is in everyone's best interest to ensure that young physicians are well-trained in operational medicine," said Haque. "They want young doctors to know and understand these pieces."

The careful orchestration of the exercise allows Madigan to offer an experience that would otherwise be outside of their resources.

"No one in the DoD is doing anything like this. We truly are the leaders," said Grubish.