A Conceptual Framework for Non-Military Investigators to Understand the Joint Roles of Medical Care in the Setting of Future Large Scale Combat Operations.

As the wars in Iraq and Afghanistan end, the US military has begun to transition to the multi-domain operations concept with preparation for large scale combat operations against a near-peer adversary. In large scale combat operations, the deployed trauma system will likely see challenges not experienced during the Global War on Terrorism. The development of science and technology will be critical to close existing capability gaps and optimize casualty survival. This review comprises a framework of deployed trauma care to provide nonmilitary investigators a general understanding of our deployed trauma care system. Trauma care begins at the Role 1 which encompasses all care from the point of injury and the battalion aid station, through transport to the Role 2 or forward staged mobile surgical team such as a Forward Resuscitative Surgical Detachment. Role 1 point of injury care approximates the care delivered by Emergency Medical Services (EMS) personnel. The Battalion Aid Station approximates the care available at a freestanding emergency center with significant differences in training level of the providers, number of beds, and diagnostic capabilities. Role 2 medical care is part of an area support medical company with surgical capabilities. The Role 2 represents the first role of care which provides damage control surgery. This capability approximates a small community hospital with the primary difference being limited patient holding capacity and reduced diagnostic equipment. The Role 3 field hospital is the largest military treatment facility in the deployed setting. The Role 3 approximates a civilian level 2 trauma center with smaller holding capabilities and diagnostic abilities limited to that of a computed tomography (CT) scanner and less.

Navy En-Route Care in Future Distributed Maritime Operations: A Review of Clinician Capabilities and Roles of Care.

OBJECTIVE: As the United States Navy transitions from Operation Iraqi Freedom/Operation Enduring Freedom to preparing for a near-peer competition, an increasing focus of wartime strategy relies upon a network of distributed naval assets for total sea control, known as Distributed Maritime Operations (DMO). Historically, embedded medical personnel have provided care at sea in times of war. Recent reviews of shipboard and evacuated mass casualty incidents have alluded to weaknesses in the existing Navy Medicine approach that will require advances in care provision to sustain high-quality care that would benefit from industry and civilian academic collaboration. To gain input from civilian prehospital expertise and insight, the current DMO and Navy En-Route Care (ERC) systems must be plainly described for non-Navy military and civilian leaders, clinicians, and researchers to understand. METHODS: N/A. RESULTS: In this review, we translate US Navy structure and vernacular into common civilian and non-Navy language, describe the maritime role-tiered ERC system, elucidate the medical assets on each naval warship, and discuss clinician levels and capabilities while deployed to help communicate the inherent challenges of US Navy maritime medical care during routine operations, casualty treatment, stabilization, and evacuation. CONCLUSIONS: We describe the roles of care, clinician levels, and medical assets within the Navy ERC system for researchers and military leaders who aim to mitigate the inherent challenges of future maritime trauma care in the age of Distributed Maritime Operations. This paper lays the framework of the Navy deployed medical system to enable research in maritime en-route care, and prompt inclusion of identified solutions into common use in the US Navy.

Disguised Among the Sea: The Implications of Artificial Islands on Casualty Care in the Indo-Pacific.

As reported in the 2022 Biden-Harris National Security Strategy, China is perceived as the primary U.S. competitor with the intent and means to become the world's greatest superpower. China's efforts, which are at odds with America's ambition to maintain its global influence, are complemented by ostensibly harmless "gray zone tactics," defined as coercive geopolitical, economic, military, and cyber activities below the use of kinetic military force. Such tactics may be utilized with seemingly innocuous intentions, but in reality, they can complicate U.S. combat casualty care in the event of an Indo-Pacific conflict. One tactic of particular impact is China's development of artificial islands throughout the South China Sea. By creating these islands, China is expanding its reach beyond its continental borders. These islands, alongside China's well-developed naval and missile capabilities, will cause disruptions to U.S. casualty care staging, medical resupply, and aeromedical evacuations. To mitigate those threats, the USA should implement a robust regional Combatant Command Trauma System, improve global health security cooperation with local partner nations, and implement irregular or guerilla trauma systems that meet medical needs in impromptu, clandestine settings. Operational recommendations based on these efforts could include pre-positioning tactical combat casualty care and damage control resuscitation supplies and developing with nearby host-nation evacuation platforms such as small boat operators. These solutions, among others, require years of training, relationship-building, and capability development to institute successfully. As a result, U.S. Military leaders should act now to incorporate these strategies into their irregular warfare, low-intensity conflict, and large-scale combat operation toolkits.

Social Determinant of Unconventional Resilience Tactical Engagement with Bonding Patterns.

Building upon our strategic framework and operational model, we will discuss findings from our ethnographic study, entitled: "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams (SOSTs)," to explain the tactical nature and importance of social determinants within our new characterization of unconventional resilience. Our fourth paper in this series, will explain how bonding patterns establish the quality of intra- and interpersonal connections that create a tensive conduit for the pressure of performance within our operational model, allowing for dynamic freedom of maneuver to take place in ambiguity. We will use qualita- tive quotes to illustrate various ways SOST medics relate to themselves, other people, and the Special Operations Forces (SOF) culture. To achieve our goals, we will: 1) provide an in- troduction to social determinants as tactical engagement with unconventional resilience; 2) define the social determinant of bonding patterns as extrapolated from qualitative data as well as use qualitative data to thematize various types of bonding patterns; and 3) relate tactical engagement with bonding pat- terns to our metaphor of bag sets. We conclude by gesturing to the importance of bonding patterns in orienting SOF medics' proprioception and kinesthesia in the SOF performance space.

Social Determinant of Unconventional Resilience: Tactical Engagement with Impression Management.

Building upon our operational model, we will discuss findings from our ethnographic study titled "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams" to establish that impression management allows Special Operation Forces (SOF) medics to navigate implicit social status symbols to either degrade or optimize performance. We will use qualitative quotes to explore how Special Operations Surgical Team (SOST) medics engage in impression management to establish individual, team, and/or organizational competency to deal with ambiguity. To achieve our goals, we will: 1) provide a background on impression management and perception of competency; 2) define the social determinant of impression management extrapolated from qualitative data as well as use qualitative data to thematize various types of impression management; and 3) relate tactical engagement with impression to our metaphor of bag sets. We conclude by gesturing to the importance of impression management in orienting SOF medics' proprioception and kinesthesia in the SOF performance space.

Social Determinant of Unconventional Resilience: Tactical Engagement in Medical-Martial Creativity.

Building on our strategic framework and operational model, we will discuss findings from our ethnographic study entitled, "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams (SOST)." Our goal is to establish that medical-martial creativity supports Special Operation Forces (SOF) medics' ability to fluidly modulate pressure amid real-time military medical decision-making in austere environments. We will use qualitative quotes to explore how SOST medics express medical-martial creativity in support of unconventional resilience. We continue to highlight tactical engagement by using bag sets as a metaphor for understanding the practical performance of this social determinant. To achieve our goals, we will: 1) define the social determinant of medical-martial creativity and provide a brief background on creativity; 2) thematize various ways in which medical-martial creativity is optimized or degraded; and 3) relate tactical engagement with medical-martial creativity to our metaphor of bag sets. We conclude by gesturing to how medical-martial creativity enables SOF medics' ingenuity, which allows them to freely maneuver complex real-time decision-making to support SOF mission success.

Yugoslav Guerrilla Hospital Design Features and Operation in World War II.

In the most austere combat conditions, Yugoslav guerillas of World War II (WWII) demonstrated an innovative and effective hospitalization system that saved countless lives. Yugoslav Partisans faced extreme medical and logistical challenges that spurred innovation while waging a guerrilla war against the Nazis. Partisans used concealed hospitals ranging between 25 to 215 beds throughout the country with wards that were often subterranean. Concealment and secrecy prevented discovery of many wards, which prototypically contained two bunk levels and held 30 patients in a 3.5 × 10.5-meter space that included storage and ventilation. Backup storage and treatment facilities provided critical redundancy. Intra-theater evacuation relied on pack animals and litter bearers while partisans relied on Allied fixed wing aircraft for inter-theater evacuation.

Unconventional Resilience: An Operational Model.

This is the third of nine planned papers drawn from the findings of our ethnographic study entitled "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams." Building from our strategic framework, this paper will establish that resilience is better understood as cohesive adaptation within a Special Operation Forces (SOF) cultural ecosystem. Exploring unconventional resilience as the inter-relationship across the organization, team, and individual, we will use qualitative quotes to describe the ecosystem of dynamic freedom of maneuver in ambiguity. To achieve our goals, we will: 1) compare conventional and unconventional resilience to operationalize the components of our strategic framework; 2) use qualitative quotes to show how the ecosystem of unconventional resilience functions at each level supporting our operational model; and 3) describe how the operational model of unconventional resilience links to tactical performance through five social determinants. We conclude by gesturing to how transformational change-agency applies to practical performance of all SOF medics.

Unconventional Resilience: A Strategic Framework.

This will be the second in a series of nine articles in which we discuss findings from our ethnographic study entitled "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams." Our goal in this article is to establish the practical importance of redefining resilience within a strategic framework. Our bottom-up approach to strategy development explores unconventional resilience as an integrated transformational process that promotes change-agency through the force of movement. Synthesis of empirical data derived from participant interviews and focus groups highlights conceptual attributes that make up the essential components of this framework. To achieve our goal, the authors (1) briefly remind readers how we have problematized conventional resilience; (2) explain how we analyzed qualitative quotes to extrapolate our definition of unconventional resilience; and (3) describe in detail our strategic framework. We conclude by gesturing to why this strategic framework is applicable to practical performance of all Special Operation Forces (SOF) medics.

Conventional Resilience and the Impact of Catastrophic Injury Exposure on Special Operations Surgical Teams.

This article presents a justification for using an ethnographic approach to research resilience. Our hypothesis is that the conventional resilience construct is ineffective in achieving its stated goal of mitigating diagnosable stress pathologies because it is grounded in a set of assumptions that overlook human experience when examining human performance in combat. To achieve this goal, we (1) describe the evolution of the strategic framework within which the conventional resilience construct is defined; (2) highlight certain limiting assumptions entailed in this framework; (3) explain how bottom-up ethnographic research relates the medic's practical performance to military requirements and mission capabilities; and (4) articulate the unique elements of our study that widen the aperture of the conventional resilience construct. We conclude by gesturing to initial research findings.

Brief Comparative Analysis of Trauma Care Specialties in Europe and the United States.

Understanding the variation in training and nuances of trauma provider practice between the countries in Europe and the United States is a daunting task. This article briefly reviews the key specialties of trauma care in Europe including emergency medical services (EMS), emergency medicine, anesthesia, trauma surgery, and critical care. The authors hope to inform U.S. military clinicians and medical planners of the major differences in emergency and trauma care that exist across Europe. Emergency medicine exists as both a primary specialty and a subspecialty across Europe, with varying stages of development as a specialty in each country. There is heavy physician involvement in EMS in much of Europe, with anesthesiologists having additional EMS training typically providing prehospital critical care. Because of the historical predominance of blunt trauma in Europe, in many countries, trauma surgery is a subspecialty with initial orthopedic surgery training versus general surgery. Intensive care medicine has various training pathways across Europe, but there have been great advances in standardizing competency requirements across the European Union. Finally, the authors suggest some strategies to mitigate the potential negative consequences of joint medical teams and how to leverage some key differences to advance life-saving medical interoperability across the North Atlantic Treaty Organization alliance.

An Assessment of Casualties Undergoing Delayed Surgical Intervention in the Combat Setting.

INTRODUCTION: The US military is transitioning into a posture preparing for large-scale combat operations in which delays in evacuation may become common. It remains unclear which casualty population can have their initial surgical interventions delayed, thus reducing the evacuation demands. METHODS: We performed a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry (DODTR) focused on casualties who received prehospital care. In this, we sought to determine (1) of those who underwent operative intervention, the proportion of surgeries occurring ≥3 days post-injury, and (2) of those who underwent early versus delayed surgery, the proportions who required blood products. RESULTS: There were 6,558 US military casualties who underwent surgical intervention-6,224 early (less than 3 days from injury) and 333 delayed (≥ 3 days from injury). The median Injury Severity Score (ISS) was higher in the early cohort (10 versus 6, p is less than 0.001). Serious injuries to the head were more common in the early cohort (12% versus 5%, p is less than 0.001), as were the thorax (13% versus 9%, p=0.041), abdomen (10% versus 5%, p=0.001), extremities (37% versus 14%, p is less than 0.001), and skin (4% versus less than 1%, p=0.001). Survival to discharge was lower in the early cohort (97% versus 100%, p is less than 0.001). Mean whole blood consumption was higher in the early cohort (0.5 versus 0 units, p is less than 0.001), as was packed red blood cells (6.3 versus 0.5, p is less than 0.001), platelets (0.9 versus 0, p is less than 0.001), and fresh frozen plasma (4.5 versus 0.2, p is less than 0.001). The administration of any units of packed red blood cells and whole blood was higher for the early cohort (37% versus 7%, p is less than 0.001), as was a ≥3 units threshold (30% versus 3%, p is less than 0.001), and ≥10 units threshold (18% versus 1%, p is less than 0.001). CONCLUSIONS: Few combat casualties underwent delayed surgical interventions defined as ≥3 days post injury, and only a small number of casualties with delayed surgical intervention received blood products. Casualties who received early surgical intervention were more likely to have higher injury severity scores, and more likely to receive blood.

Analysis of the U.S. Military Trauma System in Accordance With Doctrinal Levels of Warfare.

INTRODUCTION: In recent conflicts, the Joint Theater Trauma System (JTTS) led the systematic approach to improve battlefield trauma care, substantially contributing to the unprecedented survival of combat casualties. The Joint Trauma System (JTS) was codified in 2016 to preserve the lessons learned and functions of the JTTS, including the Department of Defense Trauma Registry. Concurrently, Combatant Commands (CCMD) were directed to establish CCMD Trauma Systems (CTS) "modeled after the JTTS" and to maintain a baseline of core functions intended to rapidly scale as needed. The complex nature of both CCMDs and the military trauma system has challenged the full implementation of the CTS. Analyzing the historical experiences of the JTTS, JTS, and CTS within a military doctrinal framework might enable the further success of the military trauma system. METHODS: The strategic, operational, and tactical levels of warfare, in accordance with Joint Publication 1-0, Doctrine of the Armed Forces of the United States, and Joint Publication 3-0, Joint Operations, established the analytic framework for this study. The literature regarding the JTTS, CTS, and JTS was reviewed for relevant information concerning organizational structure and functions of trauma system performance improvement (PI) capabilities. A comprehensive analysis was performed using a thematic approach to evaluating descriptive data contained within the collected data set. Deployed trauma system PI tasks, functions, and responsibilities were identified, defined, and correlated according to the respective levels of warfare. RESULTS: The comprehensive analysis revealed both discrete and overlapping tasks, functions, and responsibilities of the trauma system PI capabilities at each of the three levels of warfare. Strategic-level actions were categorized according to 12 distinct themes: reduce mortality; strategic reporting; centralized trauma registry; strategic communications; centralized organization; direct support to CCMDs; Department of Defense policy and doctrine; strategic-level PI; clinical practice guidelines; training and readiness standards; force structure, standardization, and interoperability; and research and development. Operational-level actions were categorized according to seven distinct themes: theater trauma system policies and requirements; theater trauma system leadership; stakeholder coordination; theater communication; theater standards for readiness and skill sustainment; trauma system planning; and medical logistics support. Tactical-level actions were categorized according to seven distinct themes: trauma system personnel; PI; documentation enforcement and patient care data collection; tactical planning recommendations for employing medical assets; research support; communication and reporting; and training and skills sustainment. CONCLUSION: The deployed U.S. military trauma system requires a robust PI capability to optimize combat casualty care. Policy updates, a joint military trauma system doctrine, and force design updates are necessary for deployed military trauma system PI capabilities to function optimally across all levels of warfare.

Evidence-based principles of time, triage and treatment: Refining the initial medical response to massive casualty incidents.

BACKGROUND: The overall approach to massive casualty triage has changed little in the past 200 years. As the military and civilian organizations prepare for the possibility of future large-scale combat operations, terrorist attacks and natural disasters, potentially involving hundreds or even thousands of casualties, a modified approach is needed to conduct effective triage, initiate treatment, and save as many lives as possible. METHODS: Military experience and review of analyses from the Department of Defense Trauma Registry are combined to introduce new concepts in triage and initial casualty management. RESULTS: The classification of the scale of massive casualty (MASCAL) incidents, timeline of life-saving interventions, immediate first pass actions prior to formal triage decisions during the first hour after injury, simplification of triage decisions, and the understanding that ultra-MASCAL will primarily require casualty movement and survival needs with few prehospital life-saving medical interventions are discussed. CONCLUSION: Self aid, bystander, and first responder interventions are paramount and should be trained and planned extensively. Military and disaster planning should not only train these concepts, but should seek innovations to extend the timelines of effectiveness and to deliver novel capabilities within the timelines to the greatest extent possible.

The doctrinal basis for medical stability operations.

This article describes possible roles for the military in the health sector during stability operations, which exist primarily when security conditions do not permit the free movement of civilian actors. This article reviews the new U.S. Army Field Manuals (FMs) 3-24, Counterinsurgency and FM 3-07, Stability Operations, in the context of the health sector. Essential tasks in medical stability operations are identified for various logical lines of operation including information operations, civil security, civil control, support to governance, support to economic development, and restoration of essential services. Restoring essential services is addressed in detail including coordination, assessment, actions, and metrics in the health sector. Coordination by the military with other actors in the health sector including host nation medical officials, other United States governmental agencies, international governmental organizations (IGOs), and nongovernment organizations (NGOs) is key to success in medical stability operations.

Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018.

TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.

The SOF Truths for Army Special Operations Forces Surgical Teams.

The US Army Special Operations Command and Army Medical Command are at a critical junction in Army medical training. Army Special Operations Forces (ARSOF) will receive Forward Resuscitative Surgical Teams (FRSTs) in the near future and must establish a training model to enable successful support for ARSOF operations. The military has been directed by Congress through the 2017 National Defense Authorization Act to embed trauma combat casualty care teams in civilian trauma centers. ARSOF FRSTs should be embedded in the nation's leading civilian trauma centers to build and sustain true expertise in delivering trauma care on the battlefield. The SOF Truths provide valuable insights into the required conditions for success of this new training paradigm.

Diagnosis of diverticulitis by bedside ultrasound in the Emergency Department.

This case report describes a potential novel indication for the use of bedside ultrasound in the Emergency Department. The patient in this case had some of the signs and symptoms of diverticulitis. The "pseudo-kidney" sign, which was thought to represent acute diverticulitis, was appreciated on a rapid, bedside ultrasound and confirmed by computed tomography. Knowledge of the sonographic appearance of diverticulitis may aid emergency physicians in making this diagnosis promptly, and facilitate the appropriate disposition.

Comparison of Preloaded Bougie versus Standard Bougie Technique for Endotracheal Intubation in a Cadaveric Model.

INTRODUCTION: We compared intubating with a preloaded bougie (PB) against standard bougie technique in terms of success rates, time to successful intubation and provider preference on a cadaveric airway model. METHODS: In this prospective, crossover study, healthcare providers intubated a cadaver using the PB technique and the standard bougie technique. Participants were randomly assigned to start with either technique. Following standardized training and practice, procedural success and time for each technique was recorded for each participant. Subsequently, participants were asked to rate their perceived ease of intubation on a visual analogue scale of 1 to 10 (1=difficult and 10=easy) and to select which technique they preferred. RESULTS: 47 participants with variable experience intubating were enrolled at an emergency medicine intern airway course. The success rate of all groups for both techniques was equal (95.7%). The range of times to completion for the standard bougie technique was 16.0-70.2 seconds, with a mean time of 29.7 seconds. The range of times to completion for the PB technique was 15.7-110.9 seconds, with a mean time of 29.4 seconds. There was a non-significant difference of 0.3 seconds (95% confidence interval -2.8 to 3.4 seconds) between the two techniques. Participants rated the relative ease of intubation as 7.3/10 for the standard technique and 7.6/10 for the preloaded technique (p=0.53, 95% confidence interval of the difference -0.97 to 0.50). Thirty of 47 participants subjectively preferred the PB technique (p=0.039). CONCLUSION: There was no significant difference in success or time to intubation between standard bougie and PB techniques. The majority of participants in this study preferred the PB technique. Until a clear and clinically significant difference is found between these techniques, emergency airway operators should feel confident in using the technique with which they are most comfortable.