The Tägerwilen II report: Recommendations from the NATO Prehospital Care Improvement Initiative Task Force.

BACKGROUND: The Committee of the Chiefs of Military Medical Services (COMEDS) initiated the Prehospital Care Improvement Initiative Task Force (PHCII TF) to advise on how to improve prehospital care within NATO nations. The Task Force consisted of the NATO Military Health Care Working Group and its subordinated expert panels, including the Blood Panel, the Emergency Medicine Panel and the Special Operations Forces Medicine Panel. METHOD: The PHCII TF identified four key prehospital care themes for exploration: 1) Tactical Casualty Care, 2) Blood Far Forward), 3) Forward Surgical Capabilities), and 4) Prolonged Casualty Care. A consensus experimentation workshop explored the four themes, utilizing a modified Delphi technique and Utstein rotations during syndicate work, resulting in 83 consensus statements. The consensus statements were further evaluated on six criteria: actionable, measurable, urgent, interoperability, low risk/threat and impact. RESULTS: The 83 consensus statements, when weighted against the six criteria, resulted in 15 recommendations, focusing on standardization of training, ensuring provision of evidence-based practices and removing legislative barriers to improve prehospital care. CONCLUSION: The recommendations on these four themes reflect the most significant priorities in improving prehospital care, and must be incorporated in the on-going revision of NATO doctrine.

The impact of simulation-based training on medical students' whole blood transfusion abilities.

BACKGROUND: Whole blood transfusion has been found to increase the likelihood of patient survival within both military and civilian medicine contexts. However, no whole blood transfusion training curriculum currently exists within undergraduate or graduate medical education in the United States. The purpose of our study was to: (1) determine the impact of simulation-based training on medical students' abilities to conduct whole blood transfusions; and (2) determine the impact of simulation-based training on medical students' confidence in conducting whole blood transfusions. STUDY DESIGN AND METHODS: We assessed 157 third-year military medical students' ability to conduct whole blood transfusion before and after Operation Gunpowder, a 2-day high-fidelity prolonged casualty care simulation. We conducted a paired samples t-test to compare the students' pre- and post-simulation performance scores as well as self-reported confidence and stress ratings. RESULTS: There was a significant difference in students' scores at the beginning of the course (M = 20.469, SD 6.40675) compared to their scores at the end of the course (M = 30.361, SD = 2.10053); t(155) = -18.833, p < .001. The effect size for this analysis (d = 6.56) was large. There was a significant difference (p < .001) between the pre- and post-ratings for all self-reported confidence and stress survey items. DISCUSSION: Our results suggest that simulation-based training is an effective means of training medical students to conduct whole blood transfusiontraining in a limited resource simulated environment where blood inventories may be limited.

Deploying whole blood to the battlefield-The Israel Defense Forces Medical Corps initial experience during the 2023 war.

BACKGROUND: Military and prehospital medical organizations invest significant resources to advance the treatment of trauma patients aiming to reduce preventable deaths. Focus is on hemorrhage control and volume resuscitation with blood products, with adoption of Remote Damage Control Resuscitation (RDCR) guidelines. The Israel Defense Forces Medical Corps (IDF-MC) has been using tranexamic acid and freeze-dried plasma (FDP) as part of its RDCR protocol for more than a decade. In recent years, low-titer group O whole blood (LTOWB) has been integrated, on IDF evacuation helicopters and expanded to mobile ambulances, complementing FDP use in treating trauma patients in state of profound shock. STUDY DESIGN AND METHODS: During the war that erupted in October 2023, the IDF-MC made a decision to bring LTOWB forward, and to equip every combat brigade level mobile intensive care units with LTOWB, onboard armored vehicles. The goal was to make whole blood available as close as possible to the point of injury and within minutes from time of injury. RESULTS AND DISCUSSION: We describe the IDF-MCs' efforts to bring LTOWB to the front lines and present four cases in which LTOWB was administered. All patients were young male, with significant blood loss following penetrating injuries. One patient died in the operating room, following hospital arrival and emergency thoracotomy. The others survived. Our initial experience with bringing LTOWB as close as possible to the point of injury during high intensity fighting is encouraging, showing patient benefit along with logistic feasibility. After action reports and data collection will continue.

The first two years of the use of low titer group O whole blood during French Military overseas operations: A retrospective study.

BACKGROUND: On the battlefield, hemorrhage is the main cause of potentially preventable death. To reduce mortality due to hemorrhagic injuries, the French Military Medical Service (FMMS) has deployed low titer group O whole blood (LTOWB) since June 2021 during operation BARKHANE in the Sahel-Saharan strip. Questions persist regarding the circumstances under which the FMMS employs LTOWB during overseas operations. STUDY DESIGN: We performed a retrospective analysis of all LTOWB transfused by the FMMS during overseas operations in the Sahel-Saharan strip between June 1, 2021, and June 1, 2023. Information was collected from battlefield forward transfusion sheets. RESULTS: Over the 2-year study period, 40 units of LTOWB were transfused into 25 patients. Of the 25 patients, 18 were combat casualties and seven were transfused for non-trauma surgery. Of the 40 units of LTOWB transfused, 22 were provided during Role 2 care, 11 during tactical medical evacuation (MEDEVAC), and seven in light and mobile surgical units. Among combat casualties, LTOWB was the first blood product transfused in 13 patients. In combat casualties, 6 h post-trauma, the median ratio of plasma: red blood cells (RBCs) was 1.5, and the median equivalent platelet concentrate (PC) transfused was 0.17. No immediate adverse events related to LTOWB transfusion were reported. CONCLUSION: LTOWB is transfused by the FMMS during overseas operations from the tactical MEDEVAC until Role 2 care. Deployment of LTOWB by the FMMS enables an early high-ratio plasma/RBC transfusion and an early platelet transfusion for combat casualties.

Warzone pediatric trauma care: Lessons from civilian medical staff in Kyiv.

INTRODUCTION: The article discusses the challenges faced by civilian healthcare providers in Kyiv, Ukraine, during the conflict in treating pediatric trauma resulting from war-related incidents. METHODS: The authors share their experiences and insights from managing a series of 12 pediatric patients admitted to the Ohmatdyt children's hospital between February 25 and April 1, 2022. During this period, the hospital was under constant threat due to the military conflict. RESULTS: The patients, ranging in age from 3 months to 17 years, suffered injuries from various causes, including vehicle shootings, explosions, and other traumatic events. The interventions and timely management are discussed, and two detailed clinical cases are presented to illustrate the complexities of treating pediatric trauma in a warzone. CONCLUSION: In summary, the article sheds light on the unique challenges faced by healthcare providers in a warzone when treating pediatric trauma. It underscores the importance of timely intervention, effective triage, and the utilization of advanced medical techniques to improve patient outcomes in such challenging circumstances.

Addressing neurosurgical challenges in war conflict countries.

The Russo-Ukrainian war caused significant humanitarian and healthcare issues in the Russo-Ukrainian region, which were further aggravated by the escalation of the conflict on February 2022. Because of this ongoing confrontation between the two nations, which has its roots in geopolitical conflicts and historical events, there have been nearly 4 million refugees in only the first month, and 906 healthcare institutions have sustained significant damage. Consequently, the demand for medical services has increased, adding onto the burden of the pre-existing problems within the region's healthcare system, such as inequities, budget shortages, and corruption. With nearly 500,000 military deaths and an estimated 27,1499 civilian casualties, the war's immediate health effects are devastating. Due to inadequate disease surveillance and difficulties with immunization, the risk of infectious illnesses, particularly HIV/AIDS and tuberculosis, increased. Although there were originally few mental health problems, the long-term effects are yet unknown. Some of the indirect effects are the severe refugee situation, the burden on public infrastructure, and problems with the security of food and water. Unprecedented obstacles confronted neurosurgery in the Russo-Ukrainian region, including increased patient loads from war-related cases, resource limitations, and facility devastation. Many countries stepped up to aid in managing neurosurgeries however, the some of the problems still persisted, such as insufficient sterility and power outages. Strengthened security standards, financial incentives, telemedicine services, and cooperation with international medical organizations are the main points of recovery recommendations. Rebuilding the region's healthcare system and guaranteeing ongoing foreign support after the conflict require a comprehensive strategy that addresses both short- and long-term issues.

Smart Medical Evacuation Support System for the Military.

Medical support in crisis situations is a major challenge. Efficient implementation of the medical evacuation process especially in operations with limited human resources that may occur during armed conflicts can limit the loss of these resources. Proper evacuation of wounded soldiers from the battlefield can increase the chances of their survival and rapid return to further military operations. This paper presents the technical details of the decision support system for medical evacuation to support this process. The basis for the functioning of this system is the continuous measurement of vital signs of soldiers via a specialized measurement module with a set of medical sensors. Vital signs values are then transmitted via the communication module to the analysis and inference module, which automatically determines the color of medical triage and the soldier's chance of survival. This paper presents the results of tests of our system to validate it, which were carried out using test vectors of soldiers' vital signs, as well as the results of the system's performance on a group of volunteers who performed typical activities of tactical operations. The results of this study showed the usefulness of the developed system for supporting military medical services in military operations.

[Care for Seriously Injured People in Military Conflicts]. / Schwerstverletztenversorgung in kriegerischen Auseinandersetzungen.

The current war in Ukraine has drawn public attention to the treatment of war injuries. Follow-up treatment in Germany is portrayed the clover leaf of the TraumaNetzwerke DGU, is largely based on the demands of the Federal Ministries for Defence and Health and is intended to enhance resilience in war.The present article presents the special features of the care of severely injured patients during hostilities and should provide insights into the expected results of treatment and the actual procedures. We emphasise the unpredictability of the care of the severely injured during hostilities.On the basis of a search of the literature for the deployment of the German Army in Afghanistan and for the current war in Ukraine, we present the challenges and the typical patterns of injuries. We discuss the factors that can influence the procedures and the quality of the results during hostilities and how these may differ from civil polytrauma care in Germany - which is well established and standardised.Even during deployment of the Federal Army or (as planned) NATO, care of the severely injured is under standardised conditions, as based on the algorithmic ATLS care and which is concentrated on bleeding control. The corresponding equipment and personnel are well established, well prepared and well trained.However, there may be special local conditions or special deployments that make it inevitable that emergency medical care will be more delayed than in the civil system in Germany and can only take place after protracted transport. The objective is always that soldiers in combat should be able to receive medical care that is equivalent to that received by all accident victims in Germany, whatever the time and site of the accident.

[By the 200th anniversary of friedrich von esmarch (1823-1908)]. / K 200-letiyu so dnya rozhdeniya Fridrikha fon Esmarkha (1823­1908).

The world fame of Friedrich von Esmarch (1823-1908) is based on his universal effectiveness as a surgeon and innovative physician. He was primarily a military surgeon, and some ones call him the «Ambroise Pare of Germany¼. He owns numerous ideas in optimizing care for wounded and innovative developments in surgery. Friedrich von Esmarch improved methods of asepsis and antisepsis, anesthesia and sanitation in German hospitals. He is also considered as one of the pioneers in primary care. Friedrich von Esmarch is an author of more than 80 publications including a first aid textbook.

[The review of the monograph "Ambroise Paré. The first surgeon of the Kingdom" by E. E. Berger].

The review considers the approach placing famous French surgeon A. Paré into more general European context of European Renaissance of XVI century and into local context of intellectual life of Paris of this period. The refutation of widespread in history of medicine opinion about strict separation of university medicine from artisan surgery in Medieval Europe is discussed.

APPLICATION OF ARTIFICIAL INTELLIGENCE IN CIVIL AND MILITARY MEDICINE.

Artificial intelligence (AI) encompasses the advancement of computers and robots, enabling them to surpass human capabilities in various aspects. By utilizing AI, programs have the ability to autonomously analyze and interpret data, offering information and executing actions without any human involvement. The ongoing war in Ukraine showed various aspects of severe gunshot injuries because of previously unknown course of wounds after application of ballistic missiles, drones, etc., which is frequently applied by russians. In such conditions, decision-making process by military medical doctors must be quick and rational, however in case of massive casualties, combined trauma (e.g. thoracoabdominal gunshot injury) MDs might have permanent challenges to apply appropriate care options and individualized approach. The aim of this study is to start the discussion about role and possible application of AI in management of gunshot injuries in combat patients or other individuals who received wounds relating to high-energy weapon. Conclusions. Gunshot wound is a clinical challenge in many cases among patients who were injured by high-energy weapons, requiring complex and quick decisions. AI might be applied as an additional tool for the decision-making process in case of severe trauma in deployed field hospitals, or in hospitals of higher Roles (3-4). This study is to start the research discussion about the utility of AI application for the management of the injured in the war associated with high-energy weapons.

Military surgery and field surgical care in the Czech Army.

Military surgery is one of the basic branches of military medicine. It is based on the principles of surgery performed in peacetime, but is significantly different when performed under specific conditions. The aim of the article is to describe these differences and present the current state of providing surgical care in the field in the Czech Army. Medical support in the field, or the treatment and evacuation system of medical services of the armies of NATO member countries, is organized on four levels, matched by medical facilities designated as Role 1-4. Surgical care in the field usually takes place at the level of Role 2 and Role 3. While in the conditions of a foreign military mission, surgical treatment aims to achieve a definitive standard, in a typical war conflict the only goal is to save life and limb and prepare casualties for further evacuation. Additionally, triage of the wounded is an important part of health care in the field at individual levels, the importance of which increases especially in the case of mass casualties. In the military medical service of the Army of the Czech Republic, goals are defined as part of the construction and development of capabilities, which should expand and reinforce the current potential of providing surgical care in the field - currently encompassing two field hospitals capable of Role 2 or 3. The ambitious plan to construct additional field medical elements is difficult to achieve in the expected time horizon and, in addition, it also faces a significant shortage of military surgeons due to the planned scope of capacity increase. Despite all the objective difficulties, however, Czech military surgeons have a high credit in the eyes of the NATO allies, gained during the deployment of the Czech field hospital or of the Czech field surgical team within multinational military units.

'Delivering effective Defence Healthcare Engagement during Short-Term Training Team deployments: Guidance from on-the-ground Practitioners'.

Defence Engagement (DE) has grown to become one of the key operational outputs of UK Defence. Defence Engagement (Health) (DE(H)) is a subcategory of DE, in which Defence Medical Services (DMS) personnel and assets are used to achieve influence and promote the UK's national interests. For most DMS personnel, their involvement in DE(H) will be as part of a Short-Term Training Team (STTT). STTTs are deployed to Host Nations (HNs) to work alongside a Partner Force, training, mentoring and supporting them to enhance their own capabilities. This article aims to guide junior members of the DMS in how they might approach an STTT from a DE(H) perspective. The article will draw primarily on the recent operational experiences of the authors across multiple STTTs in a variety of HNs.

Engineering Features From Advanced Medical Technology Initiative Submissions to Enable Predictive Modeling for Proposal Success.

INTRODUCTION: The U.S. Army Telemedicine and Advanced Technology Research Center Advanced Medical Technology Initiative (AMTI) demonstrate key emerging technologies related to military medicine. AMTI invites researchers to submit proposals for short-term funding opportunities that support this goal. AMTI proposal selection is guided by a time-intensive peer review process, where proposals are rated on innovation, military relevance, metrics for success, and return on investment. Utilizing machine learning (ML) could assist in proposal evaluations by learning relationships between proposal performance and proposal features. This research explores the viability of artificial intelligence/ML for predicting proposal ratings given content-based proposal features. Although not meant to replace experts, a model-based approach to evaluating proposal quality could work alongside experts to provide a fast, minimally biased estimate of proposal performance. This article presents initial stages of a project aiming to use ML to prioritize research proposals. MATERIALS AND METHODS: The initial steps included a literature review to identify potential features. Then, these features were extracted from a dataset consisting of past proposals submissions. The dataset includes 824 proposals submitted to the AMTI program from 2010 to 2022. The analysis will inform a discussion of anticipated next steps toward developing a ML model. The following features were created for future modeling: requested funds; word count by section; readability by section; citations and partners identified; and term frequency-inverse document frequency word vectors. RESULTS: This initial process identified the top ranked words (data, health, injury, device, treatment, technology, etc.) among the abstract, problem to be solved, military relevance, and metrics/outcomes text proposal fields. The analysis also evaluated the text fields for readability using the Flesch readability scale. Most proposals text fields were categorized as "college graduate," indicating a challenging readability level. Finally, citations and partners were reviewed as an indicator of proposal successfulness. CONCLUSIONS: This research was the first stage of a larger project to explore the use of ML to predict proposal ratings for the purpose of providing automated support to proposal reviewers and to reveal the preferences and values of AMTI proposal reviewers and other decision-makers. The result of this work will provide practical insights regarding the review process for the AMTI program. This will facilitate reduction in bias for AMTI innovators and a streamlined and subjective process for AMTI administrators, which benefits the military health system overall.

The Manikin We Owe.

This poem is to provide narratives written by a student of Hospital Corpsman Basic program, describing experiences throughout the training and expressing hope in Navy Medicine. It was originally performed as a spoken-word poem at graduation in 2023 and was adopted for reading enjoyment.

Expeditionary Surgeons: Essential to Surgical Leadership in World War II and Today.

This presidential address, given during the Annual Symposium of the Excelsior Surgical Society of the American College of Surgeons, explores the origins of the expeditionary surgeon. The essential traits of such a surgeon-leader are defined using examples from history and are then used to examine the leadership of Edward D Churchill during World War II as the prototypical expeditionary surgeon. In the future, identifying key military surgical leaders as expeditionary surgeons would serve our nation's interests well in preserving our fighting force on the battlefield. Consideration should be given to formally training and designating such surgical leaders for the military and other austere settings.

Examining the Intersection of Strategic Thinking and Continuous Process Improvement Through the Lens of Military Medical Education to Build a Novel Model.

In 2020, the U.S. Air Force School of Aerospace Medicine hired its first civilian dean since its founding in 1918, tasked with building the school's first strategic plan to modernize and improve the institution. Using a combination of military continuous process improvement and academic strategic thinking, the dean produced a highly successful strategic plan. However, its resource-heavy and time-consuming methodology made it difficult to replicate. This study aimed to create a novel and streamlined strategic planning model that combined best practices from continuous process improvement and strategic thinking without redundancy. A qualitative descriptive case study was used to analyze the detailed efforts through content analysis of 150 pages of documentation. A hybrid approach to coding uncovered 44 deductive codes and 5 inductive codes from 10 strategic tools. Results indicated a converging relationship between all strategic processes tested-strategic planning, strategic thinking, and continuous process improvement and their associated tools. A five-step model called the Triple "O" OODA Loop was created, combining best practice tools from strategic planning (purpose trident and SWOT analysis or strengths, weaknesses, opportunities, and threats), strategic thinking (Hot Spots scale and GOST framework or goals, objectives, strategies, and tactics) and continuous process improvement (phases 6-8).

Complexities of autonomy in military medical ethics: A brief report.

ABSTRACT: The first Fallen Surgeons Military Educational Symposium was convened in conjunction with the the American Association for the Surgery of Trauma (AAST) 23 meeting, under the guidance of the AAST Military Liaison Committee. The daylong session included a 1.5-hour segment on military medical ethics in combat and its unique challenges. Medical ethical issues arise frequently within the military across a range of varied circumstances, from the day-to-day operations of stateside forces to the complexities of deployed troops in theaters of conflict. Given the scope of these circumstances, preparation and advanced planning are the key to addressing and resolving the ethical issues that occur. The goal of this session was to present illustrative cases, not to prescribe solutions, and to make the attendees aware of some of the challenges they may encounter when deployed.