Battlefield Vital Sign Monitoring in Role 1 Military Treatment Facilities: A Thematic Analysis of After-Action Reviews from the Prehospital Trauma Registry.

INTRODUCTION: The Prehospital Trauma Registry (PHTR) captures after-action reviews (AARs) as part of a continuous performance improvement cycle and to provide commanders real-time feedback of Role 1 care. We have previously described overall challenges noted within the AARs. We now performed a focused assessment of challenges with regard to hemodynamic monitoring to improve casualty monitoring systems. MATERIALS AND METHODS: We performed a review of AARs within the PHTR in Afghanistan from January 2013 to September 2014 as previously described. In this analysis, we focus on AARs specific to challenges with hemodynamic monitoring of combat casualties. RESULTS: Of the 705 PHTR casualties, 592 had available AAR data; 86 of those described challenges with hemodynamic monitoring. Most were identified as male (97%) and having sustained battle injuries (93%), typically from an explosion (48%). Most were urgent evacuation status (85%) and had a medical officer in their chain of care (65%). The most common vital sign mentioned in AAR comments was blood pressure (62%), and nearly one-quarter of comments stated that arterial palpation was used in place of blood pressure cuff measurements. CONCLUSIONS: Our qualitative methods study highlights the challenges with obtaining vital signs-both training and equipment. We also highlight the challenges regarding ongoing monitoring to prevent hemodynamic collapse in severely injured casualties. The U.S. military needs to develop better methods for casualty monitoring for the subset of casualties that are critically injured.

Historical Alternans in the Emergency Department (H.A.t.E.D.) for Pain: An Analysis of Patient Pain Descriptors to Attending and Trainee Clinicians.

OBJECTIVES: The concept of "historical alternans" (HA), a teaching folklore term referring to different descriptions of patient histories to trainees versus attending clinicians, can cause disjointed care and be a source of frustration for the trainee. Increased focus on the proper evaluation and treatment of pain in the emergency department (ED) setting prompts an evaluation of the HA concept as it relates to pain. METHODS: We conducted a prospective observational pilot study comparing pain descriptions given to attending and trainee clinicians in the ED using a five-question pain description survey. Trainees included emergency medicine physician residents, emergency medicine physician assistant residents, off-service residents, and students. Trainees completed the first survey and attending clinicians repeated survey questions after at least a 10-minute washout. Surveys include descriptions of pain as part of patients' primary concern, severity indicated by a verbal numerical rating score (VNRS), and pain location, quality, and duration. RESULTS: During a 10-day period, surveys were completed for 97 patient encounters. Most trainee clinicians were emergency medicine physician residents (53%), followed by emergency medicine physician assistants (32%), students (13%), and off-service residents (2%). Pain complaints centered on the abdomen (18.5%), chest (12%), and knee (6%). Differences in pain description were found in the majority of cases (55%), with most having one categorical difference. The majority of categorical differences were VNRS (38%), although the difference in scores was not statistically significant (P = 0.20). Medical students had the highest variance in VNRS difference compared with attending clinicians. There was no significant difference in described duration (P = 0.99) or quality of pain (P = 0.99) between trainee and attending clinicians. CONCLUSIONS: Most patient encounters had at least one difference in categorical pain descriptors between trainee and attending clinicians. Although differences in severity of pain were present, they were not significant. HA does occur in the ED setting, but the magnitude of difference may be minimal.

An Analysis of Exertional Safety After Blood Donation in Active Duty Military Personnel-A Feasibility Study.

INTRODUCTION: Whole blood (WB) is the optimal resuscitation fluid in hemorrhagic shock. Military research focuses on mortality benefits of WB acquired through walking blood banks (WBBs). Few military-based studies on donation effects exist, almost exclusively performed on small special operation forces. No Department of Defense regulations for postdonation precautions in nonaviation crew members exist. Further study is warranted regarding safety and limitations in postdonation populations. MATERIALS AND METHODS: A feasibility (n = 25) prospective interventional study examined the safety of exertion (defined as a 1.6-km treadmill run at volunteers' minimum passing pace for the Army Physical Fitness Test) following 1 unit of WB donation. Subjects served as their own controls, performing baseline testing 7 days before donation, with repeat testing 1 h following donation conducted by Armed Services Blood Program personnel. Adverse events, pre- and postexertion vital signs (VS) were evaluated. RESULTS: There were no adverse events throughout testing. Only resting heart rate (68 vs. 73 beats · min-1, p < 0.01) and postexertion heart rate were significantly different among pre- and postdonation VS. Additional significant findings were time to attain postexertion normocardia (116 vs. 147 seconds, p < 0.01). A small but statistically significant change in Borg perceived exertional scores was noted (10.3 vs. 10.8, p < 0.05). CONCLUSIONS: This feasibility study demonstrates the first safety test of regular military populations performing exertion immediately following the standardized WB donation. VS changes may translate into a small but significant increase in perceived postdonation exertion. Future studies should expand duration and intensity of exertion to match combat conditions.

Procedural Volume Within Military Treatment Facilities-Implications for a Ready Medical Force.

INTRODUCTION: Consistent procedural volume is important for emergency physicians (EPs) to maintain opportunities for critical lifesaving skills. While non-EP literature demonstrates improved patient outcomes with higher volumes, few studies examine the optimal number of repetitions needed to maintain procedural competency in EP populations. The largely young, healthy active duty population that constitutes the majority of patients in military treatment facilities (MTFs) decreases the likelihood to utilize emergent procedures. Despite this likelihood, EPs are expected to maintain proficiency and readiness to perform critical procedures in deployed settings. MATERIALS AND METHODS: A retrospective analysis of de-identified data obtained through the Military Health System Mart was performed for procedural codes involving surgical airway, central venous access, and intubation. Data were sought for 2014-2016 calendar years from seven Army hospitals under the Southwest Region Medical Command. Procedural numbers were obtained for both overall volume and those performed per 1,000 encounters. Additionally, we analyzed for volume differences with the highest volume MTF (Brooke Army Medical Center [BAMC]) removed from the data set. RESULTS: A total of 1,450 procedures were performed among the MTFs analyzed, including 973 intubations, 473 central venous catheter placements, and 4 surgical airways. MTFs averaged 69.5 intubations and 38.8 venous catheters placed each year, but decreased to 28.1 intubations and 13.0 venous catheters placed annually when BAMC was removed from the data set (a 59.6 and 61.6% decrease, respectively). Monthly averages of 40.5 intubations and 19.7 central venous catheterizations per month among all included MTFs decreased to 14.0 and 6.5 when BAMC was removed. All surgical airways were performed at BAMC. Procedural frequency per 1,000 encounters was highest at BAMC, although ordinal differences were noted in the remaining six MTFs compared with overall procedural volumes. CONCLUSIONS: This retrospective analysis demonstrates a significant variation in procedural volumes across MTFs, illustrating disproportionate opportunities for procedural skill maintenance among Army EPs. Low procedural volume threatens the maintenance of critical EP skills. These numbers could also suggest low skills for other providers (such as physician assistants), further illustrating decreased skill readiness throughout the force. Further research is needed to examine procedural volumes per individual EP, as well as those performed by other providers to evaluate for overall procedural readiness across the military force.

Prehospital Use of Ketamine in the Combat Setting: A Sub-Analysis of Patients With Head Injuries Evaluated in the Prospective Life Saving Intervention Study.

OBJECTIVES: Ketamine is used as an analgesic for combat injuries. Ketamine may worsen brain injury, but new studies suggest neuroprotection. Our objective was to report the outcomes of combat casualties with traumatic brain injury (TBI) who received prehospital ketamine. METHODS: This was a post hoc, sub-analysis of a larger prospective, multicenter study (the Life Saving Intervention study [LSI]) evaluating prehospital interventions performed in Afghanistan. A DoD Trauma Registry query provided disposition at discharge and outcomes to be linked with the LSI data. RESULTS: For this study, we enrolled casualties that were suspected to have TBI (n = 160). Most were 26-year-old males (98%) with explosion-related injuries (66%), a median injury severity score of 12, and 5% mortality. Fifty-seven percent (n = 91) received an analgesic, 29% (n = 46) ketamine, 28% (n = 45) other analgesic (OA), and 43% (n = 69) no analgesic (NA). The ketamine group had more pelvic injuries (P = 0.0302) and tourniquets (P = 0.0041) compared to OA. In comparison to NA, the ketamine group was more severely injured and more likely to require LSI procedures, yet, had similar vital signs at admission and disposition at discharge. CONCLUSIONS: We found that combat casualties with suspected TBI that received prehospital ketamine had similar outcomes to those that received OAs or NAs despite injury differences.