Integrating physiological monitoring systems in military aviation: a brief narrative review of its importance, opportunities, and risks.

Military pilots risk their lives during training and operations. Advancements in aerospace engineering, flight profiles, and mission demands may require the pilot to test the safe limits of their physiology. Monitoring pilot physiology (e.g. heart rate, oximetry, and respiration) inflight is in consideration by several nations to inform pilots of reduced performance capacity and guide future developments in aircraft and life-support system design. Numerous challenges, however, prevent the immediate operationalisation of physiological monitoring sensors, particularly their unreliability in the aerospace environment and incompatibility with pilot clothing and protective equipment. Human performance and behaviour are also highly variable and measuring these in controlled laboratory settings do not mirror the real-world conditions pilots must endure. Misleading or erroneous predictive models are unacceptable as these could compromise mission success and lose operator trust. This narrative review provides an overview of considerations for integrating physiological monitoring systems within the military aviation environment.Practitioner summary: Advancements in military technology can conflictingly enhance and compromise pilot safety and performance. We summarise some of the opportunities, limitations, and risks of integrating physiological monitoring systems within military aviation. Our intent is to catalyse further research and technological development.Abbreviations: AGS: anti-gravity suit; AGSM: anti-gravity straining manoeuvre; A-LOC: almost loss of consciousness; CBF: cerebral blood flow; ECG: electrocardiogram; EEG: electroencephalogram; fNIRS: functional near-infrared spectroscopy; G-forces: gravitational forces; G-LOC: gravity-induced loss of consciousness; HR: heart rate; HRV: heart rate variability; LSS: life-support system; NATO: North Atlantic Treaty Organisation; PE: Physiological Episode; PCO2: partial pressure of carbon dioxide; PO2: partial pressure of oxygen; OBOGS: on board oxygen generating systems; SpO2: peripheral blood haemoglobin-oxygen saturation; STANAG: North Atlantic Treaty Organisation Standardisation Agreement; UPE: Unexplained Physiological Episode; WBV: whole body vibration.

Effects of resilience training on mental, emotional, and physical stress outcomes in military officer cadets.

Resilience is an important factor in counteracting the harmful effects of stress and is associated with healthy physiological and psychological responses to stress. Previous research has demonstrated the effectiveness of resilience fostering training programs in psychobiological stress response and recovery. Few studies, however, have examined training effects in real-life high-stress situations. In this study, we compare effects of a brief resilience training (RT) and an active control training in diversity management (DMT) on psychobiological stress response to and recovery from an intense military exercise of 81 male officer cadets. Five weeks after training completion, autonomic, endocrine, and subjective state measures of cadets were measured while undergoing stressful military exercise. The RT group perceived the military stressor as more challenging, and showed higher values in motivation and positive affect than the DMT group. Cortisol increased in both groups during stress, but showed a lower cortisol increase in the RT group thereafter. These results suggest that this brief resilience training helped cadets reframe the stressful situation in a more positive light, experiencing more positive emotions, and recovering faster from stress. To strengthen young military leaders in stressful situations, resilience promoting programs should become part of basic or leadership trainings.

Relationship Education for Military Couples: Recommendations for Best Practice.

Military couples have a number of distinctive strengths and challenges that are likely to influence their relationship adjustment. Military couples' strengths include stable employment, financial security, and subsidized health and counseling services. At the same time, military couples often experience long periods of separation and associated difficulties with emotional disconnect, trauma symptoms, and reintegrating the family. This paper describes best practice recommendations for working with military couples, including: addressing the distinctive challenges of the military lifestyle, ensuring program delivery is seen as relevant by military couples, and providing relationship education in formats that enhance the accessibility of programs.

Smoking cessation program among naval diver trainees in the Republic of Singapore Navy.

BACKGROUND: Since 2016, the Naval Diving Unit (NDU) of the Republic of Singapore Navy (RSN) has instituted a smoking cessation trial program for their trainees, instituting a blanket ban on smoking during training hours in order to promote smoking cessation and create a smoke-free culture among its servicemen. For the rest of RSN personnel, they would attend a more costly, established Health Promotion Board (HPB) smoking cessation program, which employs social support strategies, while they undergo basic training in the Navy Military Experts Institute (NMI). METHODOLOGY: We examined the outcomes and direct costs of the NDU smoking cessation trial program, compared with the HPB smoking cessation program in NMI. The primary outcome was self-reported smoking cessation at the end of six months. PRINCIPAL FINDINGS: The NDU smoking cessation program led to 50% reduction among smokers with no additional direct costs. It is comparable to a 59% reduction of smokers among trainees in the established HPB program, which costs US$1,955 per course in 2017. The results of both programs are not significantly different (χ2 = 0.34, P-value = 0.56). Neither program?s participants raised any nicotine withdrawal issues throughout. CONCLUSION: The results of the NDU smoking cessation program suggests that it is not inferior to the established HPB smoking cessation program. More studies should be done to identify factors leading to smoking cessation success among Naval Diver trainees compared to the established program, particularly since the NDU program was less costly and had no engagement with trained counselors.

Education and Ebola: initiating the cascade of emergency healthcare training.

In response to the 2014 Ebola virus outbreak in West Africa, the UK deployed a Joint Inter-Agency Task Force to Sierra Leone. As well as constructing Ebola treatment units, the force supported a rapidly upscaled mass programme of training for host nation healthcare workers in basic knowledge of Ebola and personal protective equipment. A bespoke training course was developed in collaboration with the WHO and other partners over a period of 2 weeks, taught to 119 trainers the following week, and then cascaded to over 4000 Ebola workers over the following month. This article describes curriculum design, content delivery and assessment of this unique Training The Trainers course delivered in austere circumstances. Key learning points are highlighted and supplementary material is provided to inform future deployed clinical education initiatives.

[Specificities of war surgery, and capacities of the military health service]. / Spécificité de la chirurgie de guerre et capacités du service de santé des armées.

In view of the recent evolution of military conflicts, particularly in the Afghan theater, and the conditions in which wounded warriors are managed in the field prior to hospitalization, the authors examine the technical specificities of medical teams, based on studies of avoidable mortality. War surgery has become a separate specialty, following the disappearance in France of the general surgical specialty, of which it was the military coun-terpart. The authors stress the role of hemorrhaging and its treatment, based on three strategies: damage control resuscitation, blood transfusion, and early evacuation within the "golden hour ". The French Armed Forces Health Service, in a new strategic plan, is refocusing its activity on war traumatology, through better education and training of medical-surgical teams and by opening up its scholarship structures to the French civilian public health service sector.

Identifying training deficiencies in military pilots by applying the human factors analysis and classification system.

Without accurate analysis, it is difficult to identify training needs and develop the content of training programs required for preventing aviation accidents. The human factors analysis and classification system (HFACS) is based on Reason's system-wide model of human error. In this study, 523 accidents from the Republic of China Air Force were analyzed in which 1762 human errors were categorized. The results of the analysis showed that errors of judgment and poor decision-making were commonly reported amongst pilots. As a result, it was concluded that there was a need for military pilots to be trained specifically in making decisions in tactical environments. However, application of HFACS also allowed the identification of systemic training deficiencies within the organization further contributing to the accidents observed.

Go for Green® Nutrition Program: Translating Evidence Into Practice.

INTRODUCTION: Go for Green® (G4G) is an evidence-based, multi-component nutrition program for military dining facilities (DFAC) to improve nutritional fitness among Service Members. The program evolved from supporting "fueling" during initial Army training into a robust intervention across all U.S. Military branches. The current G4G program consists of eight program requirements to optimize the nutrition environment, including traffic light labeling, nutritious menus, choice architecture, food promotion, marketing, and staff training. The evolution of the G4G program, development of standardized program requirements, and lessons learned are described. MATERIALS AND METHODS: The latest scientific evidence, best practices in health promotion and nutrition education, results and data from G4G implementation in the military community support the current version of G4G. Feedback and observations from program developers, military branch foodservice headquarters, installation leadership, and local G4G DFAC teams provided insight into implementation challenges, successes, facilitators, and barriers. RESULTS: The G4G program has evolved and expanded from its initial inception over 10 years ago to its current version. Research studies, nutrition science, and feedback from military community stakeholders have informed programmatic changes and improvements. CONCLUSIONS: G4G 2.0 is a robust, innovative, multi-component, performance nutrition program with clear program element requirements. Value was added to elevate the G4G program by setting program requirements, expanding program components, and establishing a centralized resource hub. Performance nutrition initiatives in local military DFAC for dining facilities, such as G4G 2.0, has great potential to impact the health and well-being of Service Members.

Mental health training with soldiers four months after returning from Iraq: randomization by platoon.

Military personnel report significant and increasing mental health problems in the months following return from combat. Nevertheless, studies have not assessed the impact of mental health training with this at-risk population. The present study evaluated the efficacy of a prototype mental health training module designed for U.S. soldiers 3-6 months after returning from combat; the module was a component of the Battlemind Training system. Soldiers (N = 1,645) were randomly assigned by platoon to 1 hour of training or a survey-only control group. Baseline surveys were conducted immediately before training; a training satisfaction survey was administered immediately after training, and a follow-up survey was administered 6 months later. Immediate postsession surveys were conducted with 681 subjects, and follow-up surveys were conducted with 542 soldiers. The Battlemind Training module received positive ratings from participants, and those who received it reported significantly better adjustment in terms of posttraumatic stress disorder symptoms, depression, and life satisfaction at follow-up compared to those in the survey-only control group. Changes in attitudes about the stigma of seeking mental health care were found immediately posttraining, but not at follow-up. The findings demonstrate that brief mental health training can be effective in reducing mental health systems with at-risk occupational groups.

Third location decompression for individual augmentees after a military deployment.

BACKGROUND: Third location decompression (TLD) refers to the initial process, undertaken by military personnel at the end of an operational deployment, whereby adjustment from military operations commences. TLD has been shown to be useful for personnel in formed units (FU). AIMS: To examine the subjective utility of TLD for personnel deployed as individual augmentees (IAs) by comparing their experience with FU personnel. METHODS: One hundred and twenty-nine IAs and 121 FU personnel completed a short survey at the end of the decompression period asking about operational exposures, perceived usefulness, stigma, concerns about readjustment and post-traumatic stress symptoms (PTSS). RESULTS: The strongest predictor of perceived utility was the desire to participate prior to arrival at the facility. FU personnel were more likely to want to participate in TLD than IAs (60% versus 30%); however, on completion, IAs reported high usefulness ratings with 78% of IAs and 84% of FU personnel finding it useful or a little useful. More FU personnel reported substantial PTSS, reporting that high numbers of PTSS were associated with finding the briefings that dealt with traumatic stress useful. Personnel reporting substantial operational exposures also reported greater levels of PTSS. CONCLUSIONS: IAs found TLD to be as useful as FU personnel; therefore, exclusion from the TLD process is not warranted. Military commanders should consider restricting TLD to both IA and FU personnel deemed to be at increased risk of a difficult adjustment due to greater operational exposure. Our data suggest that smaller numbers of IA personnel would fall into this group.

Hazardous Non-Combat Exposures in the U.S. Department of Defense.

Hazardous non-combat exposures are inherent to military service and occur in three settings: installation workplaces, installation environments, and deployment environments. Few military clinicians receive training in how to recognize, assess, and manage patients with these exposures, and systems improvements are needed to support clinicians with respect to exposure recognition and management. This commentary highlights key concepts surrounding military non-combat exposures by discussing three case examples of exposures occurring in each of these settings. In the workplace, well-coordinated, interdisciplinary occupational health teams improve identification of exposure-related illnesses, and these teams may be further supported by the development of automated clinical decision-support systems. Installation environmental exposures are characterized by high perceived risk, uncertainty in estimating actual risk, and a wide range of stakeholders including military family members and individuals in the surrounding community. Recognizing environmental exposure concerns, gathering a thorough environmental exposure history, and practicing exposure risk communication are vital skills to address these situations. During deployments, exposures may initially be perceived as low risk but then become a concern years later. A functional understanding of the capabilities and limitations of exposure monitoring and potential health effects of exposures helps the military clinician effectively communicate potential health risks to line leaders. For any of these exposure settings, service public health centers and OEM specialty leaders and consultants are available for consultation.

Vitamin C supplementation reduces the odds of developing a common cold in Republic of Korea Army recruits: randomised controlled trial.

INTRODUCTION: The Republic of Korea (ROK) military has a high incidence of respiratory diseases at training centres. Vitamin C has been reported to reduce the incidence of colds. For the purpose of preventing soldiers' respiratory diseases, this study aimed to investigate whether vitamin C intake can prevent common colds in the ROK Army soldiers. METHODS: This was a randomised, placebo-controlled, and double-blind trial of soldiers who enlisted in the Korea Army Training Centre for 30 days from 12 February to 13 March 2018. The study participants were divided into groups (vitamin C vs placebo). The military medical records were searched to determine whether the participants had a common cold. Multiple logistic regression analysis was performed to identify the association between vitamin C intake and diagnosis of common colds. In addition, subgroup analysis on the relationship between vitamin C intake and common cold according to smoking status, training camp and physical rank was conducted. RESULTS: A total of 1444 participants were included in our study. Of these participants, 695 received vitamin C (6000 mg/day, vitamin C group), while 749 participants received placebo (0 mg/day, placebo group). The vitamin C group had a 0.80-fold lower risk of getting a common cold than did the placebo group. Subgroup analyses showed that this effect was stronger among subjects in camp A, among never smokers and among those in physical rank 3. CONCLUSION: Vitamin C intake provides evidence to suggest that reducing the common colds in Korean Army soldiers. Our results may serve as a basis for introducing military healthcare policies that can provide vitamin C supplementation for military personnel in basic military training.

Task Force Contain: A Descriptive Analysis of Brigade Combat Team COVID-19 Operations.

BACKGROUND: In March 2020, a Fort Carson brigade combat team established Task Force (TF) Contain in response to the Coronavirus Disease 2019 (COVID-19) pandemic. We offer a descriptive analysis of the TF Contain execution. METHODS: This study comprises a descriptive analysis of the design and execution of COVID-19 response by an infantry brigade combat team. Specific analyses include patient flow and mitigation measures; task organization; and definition of commander decision points as associated with separate lines of effort. RESULTS: TF Contain defined separate teams to address each component of the COVID-19 response, each assigned to subordinate battalions. Team Trace augmented the installation medical activity tracing interviews and data collection. Team Isolation provided lodging and life support; whereas, Team Transportation provided movement assets for soldiers requiring restriction of movement related to COVID-19. Team Clean executed disinfection operations at geographic locations determined to be associated with transmission events. Team Oversight enforced standards of mask wear and social distancing throughout the installation. Team Overflow analyzed installation infrastructure for contingency planning in the event more facilities became necessary for soldiers in isolation or quarantine. Finally, Team Testing augmented medical department activity (MEDDAC) medical manpower to staff providers and medics for support testing operations. CONCLUSIONS: Few personnel assigned to this organization had pre-existing experience or training related to infectious disease prevention or epidemiology. Nevertheless, this organization demonstrated the capacity of the military decision-making and operations processes to build robust procedures in response to public health threats.

On the front lines of patient safety: implementation and evaluation of team training in Iraq.

BACKGROUND: Team training has been identified as a key strategy for reducing medical errors and building a culture of safety in health care. Communication and coordination skills can serve as barriers to potential errors, as in the modern deployed U.S. Military Healthcare System (MHS), which emphasizes rapid movement of critically injured patients to facilities capable of providing definitive care. A team training intervention--TeamSTEPPS--was implemented on a large scale during one of the most intense phases of the conflict in Iraq. This evaluation of the program constituted the first undertaken in a combat theater of operations. IMPLEMENTING TEAMSTEPPS IN IRAQ: The Baghdad combat support hospital (CSH) conducted continuous operations from a fixed facility for a 13-month deployment--between November 2007 and December 2008. The TeamSTEPPS implementation in Iraq began at this facility and spread throughout the combat theater of operations. Teamwork training was implemented in two primary training sessions, followed up with reinforcement of team behaviors on the unit by hospital leadership. RESULTS: A total of 153 patient safety reports were submitted during the 13 months reviewed, 94 before TeamSTEPPS implementation and 59 afterwards. After training, there were significant decreases in the rates of communication-related errors, medication and transfusion errors, and needlestick incidents. There was a significant decrease in the rate of incidents coded communication as the primary teamwork skill that could have potentially prevented the event. CONCLUSIONS: Process improvement programs such as TeamSTEPPS implementation can be conducted under the extremely austere conditions of a CSH in a combat zone. Teamwork training decreased medical errors in the CSH while deployed in the combat theater in Iraq.

The Role 3 Multinational Medical Unit at Kandahar Airfield 2005-2010.

In late 2005, Canadian Forces Health Services (CFHS) was tasked with the command of the NATO Role 3 Multinational Medical Unit (R3MMU) on Kandahar Airfield in southern Afghanistan. Preparations drew on past experience and planning. Eight complete hospital contingents were trained and deployed in rotation. Near-reality simulation training was undertaken with the combat brigade, including complete deployment of the field hospital in the exercise area. Standard operating procedures (SOP) were developed and applied by each rotation so successfully that they were adopted by the new command in late 2009. The Canadian period at R3MMU had the highest survival rate ever recorded for victims of war. Lessons learned are being applied among victims of the conflict and trauma. The experience of the R3MMU was used to successfully deploy a hospital as part of the earthquake relief effort in Haiti in 2010.The training protocols and SOP are being applied to disaster preparedness in Canadian civilian hospitals.

Training Australian military health care personnel in the primary care of maxillofacial wounds from improvised explosive devices.

Severe facial wounds frequently result from improvised explosive devices (IEDs) as the face is still vulnerable despite advances in personal protection of soldiers. In contrast to the poor outcomes with civilian maxillofacial trauma management methods initially employed by the US Army for maxillofacial wounds from IEDs, advances in wound management methods for such injuries by the US Army have resulted in significant improvements in appearance and function. This article describes the features of a short course in the primary management of combat related maxillofacial wounds for deployed health care personnel who may not be facial specialists, including contemporary treatment techniques for those confronting wounds from IEDs which are explained in this course.

How we teach military medicine to medical cadets at Phramongkutklao College of Medicine.

Phramongkutklao College of Medicine has a unique curriculum for "Military Medicine." Military Medicine involves prevention, threat assessment, evacuations and clinical management of diseases and injuries resulting from military occupational exposures. The Military Medicine curriculum covers all the entities of knowledge of Military Sciences, Combat Medical Skills, Military Preventive Medicine, Military Applied Physiology and Military Contingency Medicine. The highlight of the curriculum is "Operation Petcharavut" that represents simulated battlefield operations, involving multidisciplinary clinical integration and military regulation. In this course, medical cadets review all the knowledge that they have learnt and in addition, Medical Platoon leader strategies, Advanced Cardiac Life support and Phramongkutklao Traumatic Life support, crucial medical practices. Medical cadets would experience simulated patients with minimal injuries to critical wounds and complications including combat stress syndromes in various situations, from advancing to retreating units and from Battalion Aid Station to Division Medical Operations Center, whether during day or night. Since the medical cadets experience all Military Medicine courses from the second to the sixth year class and pass all medical knowledge-based examinations, Phramongkutklao College of Medicine expects all graduates to be excellent in not only all standard requirements of the medical professional set forth by the Medical Council of Thailand but also ready to serve the nation effectively in the Royal Thai Armed Forces.

The Rise of the Stop the Bleed Campaign in Italy.

BACKGROUND: The B-Con Basic 1.0 protocol is a medical training designed to teach how to control massive external haemorrhages in emergency conditions. Spread throughout the United States since 2013, thanks to the Stop the Bleed campaign, it has seen a progressive international spread during 2016-2018. We report here data from the first 18 months of our training in Italy. METHODS: Since January 2017, military Operators enlisted to the Volunteer Military Corps of the Italian Red Cross and registered to the ACS B-Con instructor database have provided B-Con courses. These instructors have provided extensive training, involving learners among military and civilian populations, especially health professionals and students. Further, they have obtained a formal adhesion to the National Stop the Bleed Day 2018. RESULTS: Through August 2018, we trained 1186 learners in Italy on the B-Con protocol. The learners were mainly military personnel and law enforcement agents (620 [52%]) but also students and civilian health personnel (566 [48%]). CONCLUSION: The B-Con protocol has been very well received in Italy by military and police personnel. Good results have been assessed among civilian health professionals and medical students, especially by those operators involved in the field of emergency medicine.

High Tourniquet Failure Rates Among Non-Medical Personnel Do Not Improve with Tourniquet Training, Including Combat Stress Inoculation: A Randomized Controlled Trial.

BACKGROUND: The rate of failing to apply a tourniquet remains high. HYPOTHESIS: The study objective was to examine whether early advanced training under conditions that approximate combat conditions and provide stress inoculation improve competency, compared to the current educational program of non-medical personnel. METHODS: This was a randomized controlled trial. Male recruits of the armored corps were included in the study. During Combat Lifesaver training, recruits apply The Tourniquet 12 times. This educational program was used as the control group. The combat stress inoculation (CSI) group also included 12 tourniquet applications, albeit some of them in combat conditions such as low light and physical exertion. Three parameters defined success, and these parameters were measured by The Simulator: (1) applied pressure ≥ 200mmHg; (2) time to stop bleeding ≤ 60 seconds; and (3) placement up to 7.5cm above the amputation. RESULTS: Out of the participants, 138 were assigned to the control group and 167 were assigned to the CSI group. The overall failure rate was 80.33% (81.90% in the control group versus 79.00% in the CSI group; P value = .565; 95% confidence interval, 0.677 to 2.122). Differences in pressure, time to stop bleeding, or placement were not significant (95% confidence intervals, -17.283 to 23.404, -1.792 to 6.105, and 0.932 to 2.387, respectively). Tourniquet placement was incorrect in most of the applications (62.30%). CONCLUSIONS: This study found high rates of failure in tourniquet application immediately after successful completion of tourniquet training. These rates did not improve with tourniquet training, including CSI. The results may indicate that better tourniquet training methods should be pursued.Tsur, AM, Binyamin, Y, Koren, L, Ohayon, S, Thompson; P, Glassberg, E. High tourniquet failure rates among non-medical personnel do not improve with tourniquet training, including combat stress inoculation: a randomized controlled trial. Prehosp Disaster Med. 2019;34(3):282-287.