Irregular warfare must combine good medicine, with both good tactics and good strategies: Position paper by the French Special Operations Forces Medical Command.

INTRODUCTION: Military operations are no longer limited to the application of counterterrorism and counterinsurgency strategies; they are now characterized by hybrid, irregular, and unconventional features. While some authors have indicated the need for medical support to adapt to these new modes of military operations, they have focused mainly on the tactical level of care on the battlefield. As Sun Tzu states, "Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat," further proposals are still needed on the application of both medical tactics and medical strategies in irregular warfare. METHODS: Medical experts from the French Special Operations Forces (SOF) Medical Command have identified specific medical challenges that special operations face in the context of the current transformation of armed confrontations into irregular warfare. RESULTS: This position paper presents original tactical medical proposals for improving medical support in irregular warfare, ranging from the definition of a Primary-Alternate-Contingency-Emergency medical plan to the promotion of telemedical support. Original strategic medical proposals have highlighted the importance of recognizing medical issues in irregular warfare, including the medical actions carried out through and with local partners and the multiple approaches to countering medical threats. CONCLUSION: The SOF medical community must be closely involved with and facilitate the responses to the shift to irregular warfare. International collaboration and interoperability are more necessary than ever, as they will enable a more effective combination of good medicine with both good tactics and good strategies. These perspectives can also be extended to improve medical care in the conventional armed forces and austere civilian settings. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Profile of injuries in recent warfare.

BACKGROUND: The epidemiology of French military severe trauma patients injured during recent military operations remains poorly described, even if French operations, casualties sustained, and care rendered in a different trauma system are distinct from others. This study aimed at describing the characteristics of these patients upon arrival at hospital in France and during hospital stay. METHODS: This 5-year retrospective cohort study included all French military servicemen injured during military operations and admitted to the intensive care unit. Data on the characteristics upon arrival at the Percy hospital in France and during hospital stay were obtained from a national civilian trauma registry. RESULTS: Of 1,990 military trauma patients injured in military operations, 39 were finally admitted to the intensive care unit of the Percy hospital and included in the analysis. Traumas were related to battle injuries and nonbattle injuries in 27 and 12 patients, respectively. Ninety-eight wounds were described: torso (n = 32), limbs (n = 32), head and neck (n = 25), and spine (n = 9). The mechanism of injury was explosion in 19 patients, gunshot wound in 8 patients, motor vehicular crash in 7 patients, or other mechanisms in 5 patients. The median Injury Severity Score was 25.5 (interquartile range, 14-34). CONCLUSION: This study highlights the small number of military severe trauma patients injured in recent warfare and their characteristics. The use of dedicated systemic military trauma registries could improve the specific epidemiological knowledge on recent warfare and help better prepare for future conflicts that may include major engagements and large-scale combat operations. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level V.

Prolonged tactical tourniquet application for extremity combat injuries during war against terrorism in the Sahelian strip.

PURPOSE: This study reports on complications following extended tourniquet application in patients with combat extremity injuries treated by the French Military Health Service in the Sahelian strip. METHODS: A retrospective review was performed in a French forward medical treatment facility deployed in Gao, Mali, between 2015 and 2020. All patients treated for an extremity injury with the application of at least one tourniquet for a minimum of 3 h were included. Prehospital data were injury pattern, associated shock, tourniquet location, and duration. Subsequent complications and surgical procedures performed were analyzed. RESULTS: Eleven patients with a mean age of 27.4 years (range 21-35 years) were included. They represented 39% of all patients in whom a tourniquet was applied. They had gunshot wounds (n = 7) or multiple blast injuries (n = 4) and totaled 14 extremity injuries requiring tourniquet application. The median ISS was 13 (interquartile range: 13). Tourniquets were mostly applied proximally on the limb for a mean duration of 268 min (range 180-360 min). Rhabdomyolysis was present in all cases. The damage control surgeries included debridement, external fixation, vascular repair, and primary amputation. Ten injuries were complicated by compartment syndrome requiring leg or thigh fasciotomy in the field or after repatriation. Two severely injured patients died of their wounds, but the others had a favorable outcome even though secondary amputation was sometimes required. CONCLUSIONS: Extended and proximal tourniquet applications led to significant morbidity related to compartment syndrome and rhabdomyolysis. Hemorrhagic shock, mass casualty incident, and tactical constraints often precluded revising the temporary tourniquet applied under fire.

Evaluation of hemostatic capacities among commando candidates: Would their blood suit a hemorrhagic war-injured patient in case of blood donation on the battlefield?

BACKGROUND: In case of a warm fresh whole blood transfusion on the battlefield, the blood donation usually occurs just after a combat phase and often after several days on the fields. To explore the hemostatic capacity of such blood, we analyzed the blood of volunteers attending the commando course of the French Navy, considering this course as an experimental model, placing them into the same physiological conditions as those faced by deployed fighters. METHODS: Venous blood was collected at the beginning of the course, mimicking their baseline status, and a second time 6 weeks later, from the remaining candidates, during the actual commando training, mimicking the stress conditions. For each candidate, we observed the differences between the two blood samples. RESULTS: Of the 112 men that attended the first day of the course, only 17 remained 6 weeks later. In the second blood samples, we noted significant increased leucocytes and platelets counts and significant decreased hematocrit and hemoglobin levels. Thrombin generation assays showed significantly lower normalized peak heights (-31%), lower normalized endogenous thrombin potential values (-29%), and lower velocity index (-35%). Normalized lag time and time to peak did not differ. Viscoelastometric testing revealed a significant increasing in clot firmness as assessed by maximum amplitude and amplitude at 6 minutes. The clot speed was significantly increased. CONCLUSION: This work brings new data on coagulation during prolonged and considerable physical exercise. No obvious deleterious modification of hemostatic properties was observed. The decrease of the endogenous thrombin potentials may reflect a better ability to control the thrombin generation once started. Altogether, these results suggest that this blood could suit well a hemorrhagic war-injured patient. LEVEL OF EVIDENCE: Prospective observational cohort study, Level III.

Point-of-care ultrasound for treatment and triage in austere military environments.

BACKGROUND: Assessment and triage in an austere environment represent a major challenge in casualty care. Modern conflicts involve a significant proportion of multiple wounds, either superficial or penetrating, which complicate clinical evaluation. Furthermore, there is often poor accessibility to computed tomography scans and a limited number of surgical teams. Therefore, ultrasound (US) represents a potentially valuable tool for distinguishing superficial fragments or shrapnels from penetrating trauma requiring immediate damage-control surgery. METHODS: This retrospective observational multicenter study assessed casualties treated for 8 months by five medical teams deployed in Africa and Middle East. Two experts, who were experienced in military emergency medicine but did not take part in the missions, carried out an independent analysis for each case, evaluating the contribution of US to the following five items: triage categorization, diagnosis, clinical severity, prehospital therapeutic choices, and priority to operation room. Consensus was obtained using the Delphi method with three rounds. RESULTS: Of 325 casualties, 189 underwent US examination. The mean injury severity scale score was 25.6, and 76% were wounded by an improvised explosive device. Ultrasound was useful for confirming (23%) or excluding (63%) the suspected diagnosis made in the clinical assessment. It also helped obtain a diagnosis that had not been considered for 3% of casualties and was responsible for a major change in procedure or therapy in 4%. Ultrasound altered the surgical priority in 43% of cases. For 30% of cases, US permitted surgery to be temporarily delayed to prioritize another more urgent casualty. CONCLUSION: Ultrasound is a valuable tool for the management of mass casualties by improving treatment and triage, especially when surgical resources are limited. In some situations, US can also correct a diagnosis or improve prehospital therapeutic choices. Field medical teams should be trained to integrate US into their prehospital protocols. LEVEL OF EVIDENCE: Case series (no criterion standard), level V.

Traum'cast: an online, open-access educational video podcast series for teaching military trauma care to all healthcare providers.

The aim of this paper was to describe the development of 'Traum'cast', an ambitious project to create a high-quality, open-access, 12-week video podcast programme providing evidence-based continuing medical education for civilian and military healthcare practitioners dedicated to the management of trauma caused by weapons of war. The management of such patients became a particular public health issue in France following the 2015 terrorist attacks in Paris, which highlighted the need for all healthcare professionals to have appropriate knowledge and training in such situations. In 2016, the French Health General Direction asked the French Military Medical Service (FMMS) to create a task force and to use its unique and considerable experience to produce high-quality educational material on key themes including war injuries, combat casualty care, triage, damage control surgery, transfusion strategies, psychological injury and rehabilitation. The material was produced by FMMS and first broadcast in French and for free, on the official FMMS YouTube channel in September 2020. Traum'cast provides evidence-based continuing medical education for civilian and military healthcare practitioners. Traum'cast is an educational innovation that meets a public health requirement.

Use of ketamine for prehospital pain control on the battlefield: A systematic review.

BACKGROUND: Intravenous ketamine is commonly used for pain management in the civilian prehospital setting. Several studies have evaluated its effectiveness in the military setting. To date, there has been no report reviewing the published data on the use of ketamine in this context. The objective of this systematic review was to analyze the content and quality of published data on the use of ketamine for prehospital pain management in military trauma. METHODS: The MEDLINE database was searched for studies on ketamine use in combat prehospital settings, at point of injury or during evacuation, published between 2000 and 2019. The systematic review was conducted following PRISMA guidelines, and the protocol was registered on PROSPERO (CRD42019115728). Civilian reports and case series lacking systematic data collection were excluded. RESULTS: Eight studies were included with 2029 casualties receiving ketamine. All but one were American reports from Afghanistan and Iraq conflicts. Studies implied retrospective cohorts or prospective observational analysis. Ketamine use rose from 3.9% during the period preceding its addition to the Tactical Combat Casualty Care guidelines in 2012 to 19.8% thereafter. It was the most common analgesic administered (up to 52% of casualties) in one of the studies. Ketamine was more likely given during tactical medical evacuation when no analgesic was provided at the point of injury. The median total intravenous dose was 50 mg. Pain intensity decreased from moderate or severe to mild or none, sometimes after only one dose. In one study, ketamine administration during tactical evacuation was associated with increased systolic blood pressure as opposed to morphine. Incoherent speech, extremity movements, and hallucinations were the main adverse events reported. CONCLUSION: Published data on ketamine use in military trauma are rare and heterogeneous. Though, all studies tend to strengthen the belief in the efficacy and safety of ketamine when given at 50-mg to 100-mg intravenous for prehospital analgesia in combat casualties. LEVEL OF EVIDENCE: Systematic Review, Level IV.

Terrorist threat: Creating a nationwide damage control training program for non-trauma care providers.

INTRODUCTION: The current terrorist threat challenges nations to train numerous non-trauma care providers with different backgrounds in damage control (DC) strategies. The purpose of this work was to propose a specific DC training program. METHODS: A Task Force of 16 civilian and military physicians met for a 24-hour session, to propose the construction of a DC training program for non-specialised caregivers. RESULTS: Existing DC training programs are heterogeneous, mainly theoretical and almost only for physicians. A program entitled Damage Control for Terrorist Attack Victims (DC-TAV) was then proposed. Identified training targets were care providers from prehospital and hospital staffs, with no experience in trauma care. The training objectives were the improvement of individual and collective skills in managing terrorist attacks casualties. The tools selected for training concerned e-learning on a dedicated digital teaching platform (including a core section of four modules with types and mechanisms of injury, basic DC techniques, triage, organisation of emergency medical response and two complementary modules for doctors with DC resuscitation including remote transfusion and DC surgery), hands-on workshops with procedural simulation and full-scale simulation exercises, technical (tourniquets, haemostatic gauzes, needle thoracostomy, chest tube drainage, management of airway, coniotomy) and non-technical (leadership, communication, coordination and triage, decision-making, appropriate use of resources) skills. Finally, an evaluation of the DC-TAV program was planned. CONCLUSIONS: The DC-TAV program is an ambitious, civilian-military, nationwide and long-term program, based on a harmonised standard of care and including multidimensional training. Further studies are required to assess its efficacy.

Fixed Wing Tactical Aircraft for Air Medical Evacuation in Sahel.

OBJECTIVE: The medical support of military operations over a 5 million km2 area in the Sahel-Saharan strip has justified the use of a medical fixed wing aircraft. Two CASA CN 235 aircraft currently perform medical evacuation (medevac) from the point of injury to forward surgical structures and then to the international airport before strategic medevac to France. METHODS: A retrospective observational study including all flights performed from January 2013 to December 2017 by the medical CASA located in Mali. RESULTS: Three thousand three flight hours were achieved. Four hundred twenty-four medevacs were performed for 898 patients. Seventy-five percent were evacuated from forward surgical structures. Their initial categorization included 10% Alpha, 23% Bravo, and 67% Charlie. Mechanical ventilation was performed for 5%; 34.5% had common medical or surgical pathologies, 34.2% were combat casualties mostly by explosion, and 18.7% were nonbattle injuries. No difficulties related to the aeronautical environment were reported by the teams. CONCLUSION: Tactical medevac with fixed wing aircraft has become a crucial link in the French medical evacuation chain in remote areas. Military emergency medical teams were able to provide in-flight intensive care before and after damage control surgery. Discussions are underway to consider possible doctrinal and logistical evolutions.

Association of Prehospital Time to In-Hospital Trauma Mortality in a Physician-Staffed Emergency Medicine System.

Importance: The association between total prehospital time and mortality in physician-staffed trauma systems remains uncertain. Objective: To describe the association of total prehospital time and in-hospital mortality in prehospital, physician-staffed trauma systems in France, with the hypothesis that total prehospital time is associated with increased mortality. Design, Setting, and Participants: This cohort study was conducted from January 2009 to December 2016. Data for this study were derived from 2 distinct regional trauma registries in France (1 urban and 1 rural) that both have a physician-staffed emergency medical service. Consecutive adult trauma patients admitted to either of the regional trauma referral centers during the study period were included. Data analysis took place from March 2018 to September 2018. Main Outcomes and Measures: The association between death and prehospital time was assessed with a multivariable model adjusted with confounders. Total prehospital time was the primary exposure variable, recorded as the time from the arrival of the physician-led prehospital care team on scene to the arrival at the hospital. The main outcome of interest was all-cause in-hospital mortality. Results: A total of 10 216 patients were included (mean [SD] age, 41 [18] years; 7937 men [78.3%]) affected by predominantly nonpenetrating injuries (9265 [91.5%]), with a mean (SD) Injury Severity Score of 17 (14) points. Of the patients, 6737 (66.5%) had at least 1 body region with an Abbreviated Injury Scale score of 3 or more. A total of 1259 patients (12.4%) presented in shock (with systolic pressure <90 mm Hg) and 2724 (26.9%) with severe head injury (Abbreviated Injury Scale score ≥3 points). On unadjusted analysis, increasing prehospital times (in 30-minute categories) were associated with a markedly and constant increase in the risk of in-hospital death. The odds of death increased by 9% for each 10-minute increase in prehospital time (odds ratio, 1.09 [95% CI, 1.07-1.11]) and after adjustment by 4% (odds ratio, 1.04 [95% CI, 1.01-1.07]). Conclusions and Relevance: In this study, an increase in total prehospital time was associated with increasing in-hospital all-cause mortality in trauma patients at a physician-staffed emergency medical system, after adjustment for case complexity. Prehospital time is a management objective in analogy to physiological targets. These findings plead for a further streamlining of prehospital trauma care and the need to define the optimal intervention-to-time ratio.