The thin red line: Blood planning factors and the enduring need for a robust military blood system to support combat operations.

ABSTRACT: Battlefield lessons learned are forgotten; the current name for this is the Walker Dip. Blood transfusion and the need for a Department of Defense Blood Program are lessons that have cycled through being learned during wartime, forgotten, and then relearned during the next war. The military will always need a blood program to support combat and contingency operations. Also, blood supply to the battlefield has planning factors that have been consistent over a century. In 2024, it is imperative that we codify these lessons learned. The linchpins of modern combat casualty care are optimal prehospital care, early whole blood transfusion, and forward surgical care. This current opinion comprised of authors from all three military Services, the Joint Trauma System, the Armed Services Blood Program, blood SMEs and the CCC Research Program discuss two vital necessities for a successful military trauma system: (1) the need for an Armed Services Blood Program and (2) Planning factors for current and future deployed military ere is no effective care for wounded soldiers, and by extension there is no effective military medicine.

Committee on Surgical Combat Casualty Care position statement: Neurosurgical capability for the optimal management of traumatic brain injury during deployed operations.

BACKGROUND: Experiences over the last three decades of war have demonstrated a high incidence of traumatic brain injury (TBI) resulting in a persistent need for a neurosurgical capability within the deployed theater of operations. Despite this, no doctrinal requirement for a deployed neurosurgical capability exists. Through an iterative process, the Joint Trauma System Committee on Surgical Combat Casualty Care (CoSCCC) developed a position statement to inform medical and nonmedical military leaders about the risks of the lack of a specialized neurosurgical capability. METHODS: The need for deployed neurosurgical capability position statement was identified during the spring 2021 CoSCCC meeting. A triservice working group of experienced forward-deployed caregivers developed a preliminary statement. An extensive iterative review process was then conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. To provide additional context and a civilian perspective, statement commentaries were solicited from civilian clinical experts including a recently retired military trauma surgeon boarded in neurocritical care, a trauma surgeon instrumental in developing the Brain Injury Guidelines, a practicing neurosurgeon with world-renowned expertise in TBI, and the chair of the Committee on Trauma. RESULTS: After multiple revisions, the position statement was finalized, and approved by the CoSCCC membership in February 2023. Challenges identified include (1) military neurosurgeon attrition, (2) the lack of a doctrinal neurosurgical capabilities requirement during deployed combat operations, and (3) the need for neurosurgical telemedicine capability and in-theater computed tomography scans to triage TBI casualties requiring neurosurgical care. CONCLUSION: Challenges identified regarding neurosurgical capabilities within the deployed trauma system include military neurosurgeon attrition and the lack of a doctrinal requirement for neurosurgical capability during deployed combat operations. To mitigate risk to the force in a future peer-peer conflict, several evidence-based recommendations are made. The solicited civilian commentaries strengthen these recommendations by putting them into the context of civilian TBI management. This neurosurgical capabilities position statement is intended to be a forcing function and a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level V.

Therapeutic Interventions and Outcomes in Civilian and Military Isolated Gunshot Wounds to the Head: A Department of Defense Trauma Registry and ACS TQIP-matched Study.

OBJECTIVE: The purpose of this study was to compare therapeutic strategies and outcomes, following isolated gunshot wounds of the head, between military and civilian populations. BACKGROUND: Recent military conflicts introduced new concepts in trauma care, including aggressive surgical intervention in severe head trauma. METHODS: This was a cohort-matched study, using the civilian Trauma Quality Improvement Program (TQIP) database of the American College of Surgeons (ACS) and the Department of Defense Trauma Registry (DoDTR), during the period 2013 to 2016. Included in the study were patients with isolated gunshots to the head. Exclusion criteria were dead on arrival, civilians transferred from other hospitals, and patients with major extracranial associated injuries (body area Abbreviated Injury Scale >3). Patients in the military database were propensity score-matched 1:3 with patients in the civilian database. RESULTS: A total of 136 patients in the DoDTR database were matched for age, sex, year of injury, and head Abbreviated Injury Scale with 408 patients from TQIP. Utilization of blood products was significantly higher in the military population ( P <0.001). In the military group, patients were significantly more likely to have intracranial pressure monitoring (17% vs 6%, P <0.001) and more likely to undergo craniotomy or craniectomy (34% vs 13%, P <0.001) than in the civilian group. Mortality in the military population was significantly lower (27% vs 38%, P =0.013). CONCLUSIONS: Military patients are more likely to receive blood products, have intracranial pressure monitoring and undergo craniectomy or craniotomy than their civilian counterparts after isolated head gunshot wounds. Mortality is significantly lower in the military population. LEVEL OF EVIDENCE: Level III-therapeutic.

Battlefield pain summit 2022: Expert consensus statements.

BACKGROUND: Battlefield pain occurs in combat casualties who experience multiple severe injuries. The nature of battlefield scenarios requires a distinct approach to battlefield pain research. A battlefield pain summit was thus convened to identify shortcomings in the current understanding of battlefield pain management, review the current state of battlefield pain research, and shape the direction of future research. METHODS: On January 10 to 11, 2022, a hybrid in-person and virtual meeting hosted by the US Army Institute of Surgical Research defined research priorities for the Combat Casualty Care Research Program's Battlefield Pain research portfolio. Summit participants identified the following key focus areas under the umbrella of battlefield pain research: battlefield injury patterns; use of ketamine and nonopioid analgesics; analgesic delivery systems; the impact of analgesia on performance, cognition, and survival; training methods; battlefield regional anesthesia; and research models. Preliminary statements presented during the summit were refined and rank ordered through a Delphi process. RESULTS: Consensus was achieved on 7 statements addressing ideal analgesic properties, delivery systems, operational performance concerns, and pain training. Ketamine was identified as safe and effective for battlefield use, and further research into nonopioid analgesics represented a high priority. CONCLUSION: The 7 consensus statements that emerged from this battlefield pain summit serve as a template to define the near-term research priorities for military-specific battlefield pain research.

Committee on Surgical Combat Casualty Care position statement on the use of single surgeon teams and invited commentaries.

BACKGROUND: Over the last 20 years of war, there has been an operational need for far forward surgical teams near the point of injury. Over time, the medical footprint of these teams has decreased and the utilization of mobile single surgeon teams (SSTs) by the Services has increased. The increased use of SSTs is because of a tactical mobility requirement and not because of proven noninferiority of clinical outcomes. Through an iterative process, the Committee on Surgical Combat Casualty Care (CoSCCC) reviewed the utilization of SSTs and developed an expert-opinion consensus statement addressing the risks of SST utilization and proposed mitigation strategies. METHODS: A small triservice working group of surgeons with deployment experience, to include SST deployments, developed a statement regarding the risks and benefits of SST utilization. The draft statement was reviewed by a working group at the CoSCCC meeting November 2021 and further refined. This was followed by an extensive iterative review process, which was conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. The final draft was voted on by the entire CoSCCC membership. To inform the civilian trauma community, commentaries were solicited from civilian trauma leaders to help put this practice into context and to further the discussion in both military and civilian trauma communities. RESULTS: After multiple revisions, the SST statement was finalized in January 2022 and distributed to the CoSCCC membership for a vote. Of 42 voting members, there were three nonconcur votes. The SST statement underwent further revisions to address CoSCCC voting membership comments. Statement commentaries from the President of the American Association for the Surgery for Trauma, the chair of the Committee on Trauma, the Medical Director of the Military Health System Strategic Partnership with the American College of Surgeons and a recently retired military surgeon we included to put this military relevant statement into a civilian context and further delineate the risks and benefits of including the trauma care paradigm in the Department of Defense (DoD) deployed trauma system. CONCLUSION: The use of SSTs has a role in the operational environment; however, operational commanders must understand the tradeoff between tactical mobility and clinical capabilities. As SST tactical mobility increases, the ability of teams to care for multiple casualty incidents or provide sustained clinical operations decreases. The SST position statement is a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields.

Comparison of 10- versus 14-gauge angiocatheter for treatment of tension pneumothorax and tension-induced pulseless electrical activity with hemorrhagic shock: Bigger is still better.

BACKGROUND: Little is known regarding the effect of hemorrhagic shock on the diagnosis and treatment of tension pneumothorax (tPTX). Recently, the Tactical Combat Casualty Care guidelines included the 10-gauge angiocatheter (10-g AC) as an acceptable alternative to the 14-g AC. This study sought to compare these two devices for decompression of tPTX and rescue from tension-induced pulseless electric activity (tPEA) in the setting of a concomitant 30% estimated blood volume hemorrhage. METHODS: Following a controlled hemorrhage, carbon dioxide was insufflated into the chest to induce either tPTX or tPEA. Tension pneumothorax was defined as a reduction in cardiac output by 50%, and tPEA was defined as a loss of arterial waveform with mean arterial pressure less than 20 mm Hg. The affected hemithorax was decompressed using a randomized 14-g AC or 10-g AC while a persistent air leak was maintained after decompression. Successful rescue from tPTX was defined as 80% recovery of baseline systolic blood pressure, while successful return of spontaneous circulation following tPEA was defined as a mean arterial pressure greater than 20 mm Hg. Primary outcome was success of device. RESULTS: Eighty tPTX and 50 tPEA events were conducted in 38 adult Yorkshire swine. There were no significant differences in the baseline characteristics between animals or devices. In the tPTX model, the 10-g AC successfully rescued 90% of events, while 14-g AC rescued 80% of events (p = 0.350). In the tPEA model, the 10-g AC rescued 87% of events while the 14 AC rescued only 48% of events (p = 0.006). CONCLUSION: The 10-g AC was vastly superior to the 14-g AC for return of spontaneous circulation following tPEA in the setting of 30% hemorrhage. These findings further support the importance of larger caliber devices that facilitate rapid recovery from tPTX, particularly in the setting of polytrauma. LEVEL OF EVIDENCE: Therapeutic, level II.

Safety of Pressurized Intraosseous Blood Infusion Strategies in a Swine Model of Hemorrhagic Shock.

BACKGROUND: Current guidelines support intraosseous access for trauma resuscitation when intravenous access is not readily available. However, safety of intraosseous blood transfusions with varying degrees of infusion pressure has not been previously characterized. MATERIALS AND METHODS: Adult female Yorkshire swine (Sus scrofa; n = 36; mean (M): 80 kg, 95% CI: 78-82 kg) were cannulated and then bled approximately 30% total blood volume. Swine were randomly assigned to proximal humerus intraosseous blood infusion with either Rapid Infuser, or Pressure Bag, or Push-Pull methods (n = 12 each). Flow rates, infusion pressures, vitals, biochemical variables, and pulmonary and renal tissue pathology were contrasted between groups. RESULTS: Flow rates were greater for the Push-Pull strategy than Pressure Bag (96.5 mL/min versus 72.6 mL/min, P = 0.02) or Rapid Infuser (96.5 mL/min versus 60 mL/min, P = 0.002) strategies. The pressures generated during the Push-Pull transfusion (3058 mmHg) were greater than the other strategies (≤360 mmHg). After the observation period, plasma-free hemoglobin levels were higher in the Push-Pull strategy than in the Rapid Infuser (40 mg/dL versus 12 mg/dL, P = 0.02) or Pressure Bag (40 mg/dL versus 12 mg/dL, P = 0.01). Groups did not significantly differ in vitals, biochemical variables, or tissue pathology. CONCLUSIONS: Push-Pull conferred the highest flow rates, but with higher infusion pressures and evidence of intravascular hemolysis. Rapid Infuser and Pressure Bag infusions had no increase from baseline in plasma-free hemoglobin. Pressure Bag infusion was noted to confer an advantage in flow rates over Rapid Infuser. Intraosseous blood transfusion with pressure bags can safely bridge toward central access in the early phases of trauma resuscitation.

A Reusable Perfused Human Cadaver Model for Surgical Training: An Initial Proof of Concept Study.

OBJECTIVES: Today's surgical trainees have less exposure to open vascular and trauma procedures. Lightly embalmed cadavers may allow a reusable model that maximizes resources and allows for repeat surgical training over time. METHODS: This was a three-phased study that was conducted over several months. Segments of soft-embalmed cadaver vessels were harvested and perfused with tap water. To test durability, vessels were clamped, then an incision was made and repaired with 5-0 polypropylene. Tolerance to suturing and clamping was graded. In a second phase, both an arterial-synthetic graft and an arterial-venous anastomosis were performed and tested at 90 mmHg perfusion. In the final phase, lower extremity regional perfusion was performed and vascular control of a simulated injury was achieved. RESULTS: Seven arteries and six veins from four cadavers were explanted. All vessels accommodated suture repair over 6 weeks. There was minor leaking at all previous clamp sites. In the anastomotic phase, vessels tolerated grafting, clamping, and perfusion without tearing or leaking. Regional perfusion provided a life-like training scenario. CONCLUSIONS: Explanted vessels of soft-embalmed cadavers show adequate durability over time with realistic vascular surgery handling characteristics. This shows promise as initial proof of concept for a reusable perfused cadaver model. Further study with serial regional and whole-body perfusion is warranted.

Forward Surgical Team Experience (FSTE) Is Associated With Increased Confidence With Combat Surgeon Trauma Skills.

Introduction: Little is known regarding the confidence of military surgeons prior to combat zone deployment. Military surgeons are frequently deployed without peers experienced in combat surgery. We hypothesized that forward surgical team experience (FSTE) increases surgeon confidence with critical skill sets. Methods: We conducted a national survey of military affiliated personnel. We used a novel survey instrument that was piloted and validated by experienced military surgeons to collect demographics, education, practice patterns, and confidence parameters for trauma and surgical critical care skills. Skills were defined as crucial operative techniques for hemorrhage control and resuscitation. Surveyors were blinded to participants, and surveys were returned electronically via REDCap database. Data were analyzed with SPSS using appropriate models. Significance was considered p < 0.05. Results: Of 174 distributed surveys, 86 were completed. Nine individuals failed to characterize their FSTE, thus leaving a sample size of 77. At the time of first deployment, 78.4% were alone or with less experienced surgeons and 53.2% had less than 2 yr of post-residency practice. The respondents' confidence in damage control techniques and seven other trauma skills increased relative to FSTE. After adjusting for years of practice, number of trauma resuscitations performed per month and pre-deployment training, there remained a significant positive association between FSTE and confidence in damage control, thoracic surgery, extremity/junctional hemorrhage control, trauma systems administration, adult critical care and airway management. Conclusions: Training programs and years of general surgery practice do not replace FSTE among military surgeons. Pre-deployment training that mimics FST skill sets should be developed to improve military surgeon confidence and outcomes. Level of Evidence: Prognostic and Epidemiologic, Level IV.

Bigger is better: Comparison of alternative devices for tension hemopneumothorax and pulseless electrical activity in a Yorkshire swine model.

BACKGROUND: Tension pneumothorax is a cause of potentially preventable death in prehospital and battlefield settings and 14-gauge angiocatheter (14G AC) decompression remains the current treatment standard, despite its high incidence of failure. Traumatic pneumothorax is often associated with hemothorax, but 14G AC has no proven efficacy for associated hemothorax. We sought to compare the 14G AC to three alternative devices for treatment of tension hemopneumothorax (t-H/PTX) in a positive-pressure ventilation swine model. METHODS: Our tension model was modified to incorporate a persistent air leak and pleural blood. Tension physiology was achieved with escalating carbon dioxide insufflation via transdiaphragmatic trocar, and 10% estimated blood volume was instilled into each chest. Intervention was randomized between 14G AC, 10-gauge angiocatheter (10G AC), modified Veress-type needle (mVN), and 3-mm laparoscopic trocar (LT). After recovery, serial tension-induced pulseless electrical activity (PEA) events were induced and decompressed. Success of rescue, time to rescue, and physiologic data were recorded. RESULTS: One hundred ninety-five t-H/PTX and 88 PEA events were conducted in 25 swine. Laparoscopic trocar and 10G AC were more successful and had faster median time to rescue for t-H/PTX compared with 14G AC, whereas mVN performed comparably. Following PEA, 14G AC and mVN succeeded at rescue only 50% and 57% of the time, whereas 10G AC and LT had 100% success at return of spontaneous circulation. Time to successful return of circulation following PEA did not differ between devices; however, there was a noticeable difference in the rate of meaningful hemodynamic recovery following PEA favoring LT and 10G AC. There were no significant injuries noted. CONCLUSIONS: While mVN performed comparably to 14G AC, both have unacceptable failure rates. Ten-gauge AC and LT performed superiorly in both t-H/PTX and PEA. We believe there is now ample evidence supporting replacement of the 14G AC with 10G AC in current treatment recommendations.

Paying it forward: Four-year analysis of the Eastern Association for the Surgery of Trauma Mentoring Program.

BACKGROUND: Mentorship programs in surgery are used to overcome barriers to clinical and academic productivity, research success, and work-life balance. We sought to determine if the Eastern Association for the Surgery of Trauma (EAST) Mentoring Program has met its goals of fostering academic and personal growth in young acute care surgeons. METHODS: We conducted a systematic program evaluation of EAST Mentoring Program's first 4 years. Demographic information was collected from EAST records, mentorship program applications, and mentee-mentor career development plans. We reviewed the career development plans for thematic commonalities and results of a structured, online questionnaire distributed since program inception. A mixed methods approach was used to better understand the program goals from both mentee and mentor perspectives, as well as attitudes and barriers regarding the perceived success of this career development program. RESULTS: During 2012 to 2015, 65 mentoring dyads were paired and 60 completed the program. Of 184 surveys distributed, 108 were returned (57% response rate). Respondents were evenly distributed between mentees and mentors (53 vs. 55, p = 0.768). In participant surveys, mentoring relationships were viewed to focus on research (45%), "sticky situations" (e.g., communication, work-life balance) (27%), education (18%), or administrative issues (10%). Mentees were more focused on research and education versus mentors (74% vs. 50%; p = 0.040). Mentees felt that goals were "always" or "usually" met versus mentors (89% vs. 77%; p = 0.096). Two barriers to successful mentorship included time and communication, with most pairs communicating by email. Most respondents (91%) planned to continue the relationship beyond the EAST Mentoring Program and recommended the experience to colleagues. CONCLUSION: Mentee satisfaction with the EAST Mentoring Program was high. Mentoring is a beneficial tool to promote success among EAST's young members, but differences exist between mentee and mentor perceptions. Revising communication expectations and time commitment to improve career development may help our young acute care surgeons.

Relative device stability of anterior versus axillary needle decompression for tension pneumothorax during casualty movement: Preliminary analysis of a human cadaver model.

BACKGROUND: Tension pneumothorax (tPTX) remains a significant cause of potentially preventable death in military and civilian settings. The current prehospital standard of care for tPTX is immediate decompression with a 14-gauge 8-cm angiocatheter; however, failure rates may be as high as 17% to 60%. Alternative devices, such as 10-gauge angiocatheter, modified Veress needle, and laparoscopic trocar, have shown to be potentially more effective in animal models; however, little is known about the relative insertional safety or mechanical stability during casualty movement. METHODS: Seven soft-embalmed cadavers were intubated and mechanically ventilated. Chest wall thickness was measured at the second intercostal space at the midclavicular line (2MCL) and the fifth intercostal space along the anterior axillary line (5AAL). CO2 insufflation created a PTX, and needle decompression was then performed with a randomized device. Insertional depth was measured between hub and skin before and after simulated casualty transport. Thoracoscopy was used to evaluate for intrapleural placement and/or injury during insertion and after movement. Cadaver demographics, device displacement, device dislodgment, and injuries were recorded. Three decompressions were performed at each site (2MCL/5AAL), totaling 12 events per cadaver. RESULTS: Eighty-four decompressions were performed. Average cadaver age was 59 years, and body mass index was 24 kg/m. The CWT varied between cadavers because of subcutaneous emphysema, but the average was 39 mm at the 2MCL and 31 mm at the 5AAL. Following movement, the 2MCL site was more likely to become dislodged than the 5AAL (67% vs. 17%, p = 0.001). Median displacement also differed between 2MCL and 5AAL (23 vs. 2 mm, p = 0.001). No significant differences were noted in dislodgement or displacement between devices. Five minor lung injuries were noted at the 5AAL position. CONCLUSION: Preliminary results from this human cadaver study suggest the 5AAL position is a more stable and reliable location for thoracic decompression of tPTX during combat casualty transport. LEVEL OF EVIDENCE: Therapeutic study, level III.

Metabolic and nutritional support of the enterocutaneous fistula patient: a three-phase approach.

BACKGROUND: The care and outcome of enterocutaneous fistula (ECF) have improved greatly over several decades due to revolutionary advances in nutrition, along with dramatic improvements in the treatment of sepsis and the critically ill. However, as the collective experience with damage control surgery has matured, the frequent development of enteroatmospheric fistula (EAF) in the "open abdomen" patient has emerged as an even more vexing problem. Despite our best efforts, ECF and especially EAF continue to be highly morbid conditions, and sepsis and malnutrition remain the leading causes of death. Aggressive nutritional and metabolic support is the most significant predictor of outcome with ECF and EAF. RESULTS: Discussion of the historical advances in nutritional therapy and their impact on ECF, as well as review of the classification of ECF and EAF, provides a framework for the suggested phased strategy that specifically targets the nutritional and metabolic needs of the ECF/EAF patient. These three phases include (1) diagnosis, resuscitation, and early interval nutrition; (2) definition of fistula anatomy, drainage of collections, nutritional assessment and monitoring, and placement of feeding access; and (3) definitive nutritional management, including pharmacologic adjuncts. Early nutritional support with parenteral nutrition followed by transition to enteral nutrition is advocated, including the merits of delivery of enteral nutrition via the fistula itself, known as fistuloclysis. CONCLUSION: Aggressive nutritional therapy is necessary to reverse the catabolic state associated with ECF/EAF patients. Once established, it allows proper time, preparation, and planning for definitive management of the fistula, and in many cases provides the support for spontaneous closure.