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.

Association between the number of individuals injured in a traumatic event and posttraumatic stress disorder among hospitalized trauma patients.

Posttraumatic stress disorder (PTSD) often occurs following mass casualty events, yet the connection between the number of individuals injured in an event and PTSD risk in smaller-scale events (i.e., involving one or several injured persons) remains unclear. We conducted a registries-based study cross-referencing three databases across the continuum of care for military trauma patients hospitalized for traumatic injuries. The study population was categorized into three groups based on the number of injured individuals involved (i.e., single injured person, two to four [2-4] injured people, and five or more [≥ 5] injured people), and PTSD prevalence was assessed using long-term disability claim diagnoses. Overall, 4,030 military personnel were included (age at injury: Mdn = 20 years), and 18.3% were subsequently diagnosed with PTSD, with the highest prevalence in events involving ≥ 5 injured individuals (35.8%). Regression analyses adjusted for potential confounders revealed that being injured in an event with 2-4 injured persons, OR = 1.68, 95% CI [1.31, 2.15], or ≥ 5 injured persons, OR = 2.36, 95% CI [1.79, 3.13], was associated with increased odds of developing PTSD compared to being the sole injured person. The findings suggest a direct association between the number of injured individuals in an event and PTSD prevalence among traumatic injury survivors. The results underscore the importance of early diagnosis and interventions to prevent PTSD in individuals injured in multicasualty and mass casualty events.

Adopting a culture of remote damage control resuscitation in the military: Insights from the Israel defense forces decade of experience.

BACKGROUND: Remote damage control resuscitation (RDCR) aims to apply the principles of damage control resuscitation to prehospital and austere care, emphasizing early control of compressible hemorrhage, balanced volume resuscitation, and the prevention or correction of coagulopathy, acidosis, hypothermia, and hypocalcemia. Over the past decades, the Israel Defense Forces Medical Corps (IDF-MC) has made significant efforts to integrate the principles of RDCR into prehospital trauma care in the military. STUDY DESIGN AND METHODS: In this article, we reflect on the implementation of RDCR in the prehospital setting by the IDF-MC, sharing successes, challenges, considerations on guideline changes, and their assessment over time. RESULTS: The implementation of RDCR has resulted in changes in clinical practice guidelines and training programs, with increased awareness and adoption of RDCR principles among both medical and non-medical military personnel. The implementation of these principles and adherence to guideline changes have been analyzed using the Israel Defense Forces Trauma Registry. DISCUSSION: By sharing our experiences, we hope to provide valuable insights for other military and civilian organizations seeking to adopt similar protocols for prehospital care. Continuous evaluation and refinement of guidelines and training programs will be essential for ongoing implementation and advancement of RDCR in the prehospital setting.

Prehospital Tranexamic Acid Administration in Pediatric Trauma Patients: A Propensity-Matched Analysis of the Israeli Defense Forces Registry.

OBJECTIVES: Tranexamic acid (TXA) administration confers a survival benefit in bleeding trauma patients; however, data regarding its use in pediatric patients are limited. This study evaluates the prehospital treatment with TXA in pediatric trauma patients treated by the Israel Defense Forces Medical Corps (IDF-MC). DESIGN: Retrospective, cohort study using the Israel Defense Forces registry, 2011-2021. PATIENTS: Pediatric trauma patients less than 18 years old. We excluded patients pronounced dead at the scene. INTERVENTIONS: None. SETTING: All cases of pediatric trauma in the registry were assessed for treatment with TXA. Propensity score matching was used to assess the association between prehospital TXA administration and mortality. MEASUREMENTS AND MAIN RESULTS: Overall, 911 pediatric trauma patients were treated with TXA by the IDF-MC teams; the median (interquartile) age was 10 years (5-15 yr), and 72.8% were male. Seventy patients (7.6%) received TXA, with 52 of 70 (74%) receiving a 1,000 mg dose (range 200-1,000 mg). There were no prehospital adverse events associated with the use of TXA (upper limit of 95% CI for 0/70 is 4.3%). Compared with pediatric patients who did not receive TXA, patients receiving TXA were more likely to suffer from shock (40% vs 10.7%; p < 0.001), sustain more penetrating injuries (72.9% vs 31.7%; p < 0.001), be treated with plasma or crystalloids (62.9% vs 11.4%; p < 0.001), and undergo more lifesaving interventions (24.3% vs 6.2%; p < 0.001). The propensity score matching failed to identify an association between TXA and lesser odds of mortality, although a lack of effect (or even adverse effect) could not be excluded (non-TXA: 7.1% vs TXA: 4.3%, odds ratio = 0.584; 95% CI 0.084-3.143; p = 0.718). CONCLUSIONS: Although prehospital TXA administration in the pediatric population is feasible with adverse event rate under 5%, more research is needed to determine the appropriate approach to pediatric hemostatic resuscitation and the role of TXA in this population.

Manual Pressure Points Technique for Massive Hemorrhage Control-A Prospective Human Volunteer Study.

BACKGROUND: While commonly thought to be effective for management of limb and junctional hemorrhage, the manual pressure points technique was excluded from leading prehospital guidelines over a decade ago following the publication of a single human-volunteers study presenting unfavorable results. This work aimed to re-assess the efficacy and feasibility of the femoral and supraclavicular pressure points technique for temporary hemorrhage control distal to the pressure point. METHODS: A prospective, non-randomized, human volunteer, controlled environment study. In the study 35 healthy male combat medics (age 21.1 ± 1.3 years) received brief training after which they were requested to apply pressure in the femoral and supraclavicular points in attempts to stop regional blood flow, measured distally by Doppler ultrasound. Success rates in achieving flow cessation in under 2 minutes, time required for achievement of flow cessation, and cumulative flow cessation duration within a 3-minute follow-up after initial success were measured. RESULTS: For the supraclavicular point, success rates were 97.1% with a mean time to success of 12.5 (±20.9) seconds, lasting for 76.2% (±23.7) of the follow-up time. For the femoral point, success rates were 100% with a mean time to success of 5.5 (±4.3) seconds, lasting for 98.7% (±3.8) of the follow-up time. CONCLUSIONS: Manual pressure on the femoral and supraclavicular points is an applicable and efficient method for temporary hemorrhage control distal to the pressure point. As such, with additional study, this method may be considered for re-introduction to prehospital care guidelines and training programs.

Qualifying coronavirus disease 2019 convalescent plasma donors in Israel.

BACKGROUND AND OBJECTIVES: Passive immunization using investigational COVID-19 convalescent plasma (CCP) is a promising therapeutic strategy and could improve outcome if transfused early and contain high levels of anti-SARS-CoV-2 antibodies. We report the management of a national CCP collection and distribution program in Israel. MATERIALS AND METHODS: From 1 April 2020 to 15 January 2021, 4020 volunteer donors donated 5221 CCP units and 837 (20.8%) donors donated more than once. Anti-nucleocapsid IgG antibodies were determined using chemiluminescent immunoassay method (Abbott). A statistical model based on repeated IgG tests in sequential donations was created to predict the time of antibody decline below sample/cut-off (S/CO) level of 4.0. RESULTS: Ninety-six percent of CCP donors suffered a mild disease or were asymptomatic. Older donors had higher antibody levels. Higher antibody levels (S/CO ≥4) were detected in 35.2% of the donors. Low positive (S/CO ≥1.4-3.99) were found in 37%, and 27.8% had undetectable antibodies (S/CO ≤1.4). The model predicted decrease antibody thresholds of 0.55%/day since the first CCP donation, providing guidance for the effective timing of future collections from donors with high antibody levels. CONCLUSIONS: An efficient CCP collection and distribution program was achieved, based on performing initial and repeated plasma collections, preferably from donors with higher antibody levels, and only antibody-rich units were supplied for therapeutic use. The inventory met the quantity and quality standards of the authorities, enabled to respond to the growing demand of the medical system and provide a product that may contribute to improve prognosis in patients with COVID-19.

The value of tracheostomy of critically ill COVID-19 patients - A multicentral study.

PURPOSE: Tracheostomy is an aerosol-generating procedure, thus performing it during the COVID-19 pandemic arises considerations such as the most appropriate timing and the patients to whom it is suitable. Medical teams lack sufficient data to assist determining whether or not to conduct tracheostomy, its short- and long-term implications are not fully understood. This study aims to shed light on the critically ill COVID-19 patients that require tracheostomy, and to investigate its value. METHODS: A retrospective multicentral case-control study of 157 hospitalized critically ill COVID-19 patients, among whom 30 patients went through tracheostomy and consisted of our study group. RESULTS: The mean age was similar between study and control groups (68.9 ± 12.7 years vs 70.5 ± 15.8 years, p = 0.57), as well as comorbidity prevalence (56.7% vs 67.7%, p = 0.25). Patients in the study group were hospitalized for longer duration until defined critically ill (5 ± 4.3 vs 3 ± 3.9 days; p = 0.01), until admitted to the intensive care unit (6 ± 6.6 vs 2.5 ± 3.7 days respectively; p = 0.005), and until discharged (24 ± 9.7 vs 10.7 ± 9.1 days, p < 0.001). Mortality rate was lower in the study group (30% vs 59.8%, p = 0.003). Kaplan Meier survival analysis revealed a statistically significant difference in survival time between groups (Log rank chi-sq = 20.91, p < 0.001) with mean survival time of 41 ± 3.1 days vs 21 ± 2.2 days. Survival was significantly longer in the study group (OR = 0.37, p = 0.004). CONCLUSION: Tracheostomy allows for more prolonged survival for gradually deteriorating critically ill COVID-19 patients. This should be integrated into the medical teams' considerations when debating whether or not to conduct tracheostomy.

Military medical research in the IDF: an array of fields and interests.

BACKGROUND: War is as old as history. Some may say it is older. The first Biblical war, dated 1880-1875 BCE, is depicted in the book of Genesis between nine kings in the vicinity of the Jordan river near Jericho. By the end of the war, Abraham (Abram) gets involved in saving his nephew Lot. In addition to war, military medicine also has its roots in historical times. Hippocrates (460-377 BCE), the father of medicine, derived his medical knowledge from the battlefield, and Sushruta [1], the father of plastic surgery, mentioned the physician's preventive role in noting environmental hazards: "A common practice of the enemy is to poison the wells on the roadside, the articles of food, the shades of trees, and the fuel and forage for cattle; hence, it is incumbent on a physician marching with the troops to inspect, examine, and purify these before using any of them, in case they are poisoned." The Greeks stated new ideas of military health, pointing to fitness promotion, gymnastics, and healthy diets to prevent illness. Over the centuries, from Alexander the Great to Napoleon's army and wars in the 20th century, military conflicts have led to the death of hundreds of millions of people from trauma and war-related disease. Amazingly analyses of the 18th and 19th centuries have shown that 80% of the soldiers died from disease, and historians and military personnel agree that during armed conflicts in known history, only a minority of soldiers perished by the sword. In Israel, the Israel Defense Forces-Medical Corps (IDF-MC) holds a unique position embedded in military and civilian national medicine. All medical personnel (e.g., physicians, nurses, technicians, veterinarians) who work in the IDF-MC receive their diplomas from civilian universities, train in civilian hospitals, and continue to practice in the national health system. The majority of these professionals continue to work in different civilian medical platforms in Israel after finishing their mandatory service. The IDF-MC's primary mission is to provide optimal medical care to IDF soldiers at all times (including wartime), to prevent disease and promote health, advance military medicine, and aid the civilian sector as ordered by the Government of Israel. In this special issue of Israel Medical Association Journal (IMAJ) is to expose readers to the continuous efforts of the IDF-MC to fulfill its mission by promoting research in multiple medical fields, including trauma, ambulatory care, health administration. In addition, in this issue of IMAJ, authors discuss the unique collaboration with the civilian system during the coronavirus disease 2019 (COVID-19) pandemic. Trauma and trauma-related injuries are the main focus of military medical research. Ben-Avi and colleagues [2] described outcomes of emergent exploratory thoracotomies on military casualties and addresses parameters that may impact the survival of these casualties. Minervini [3] further discussed the issue. Bez et al. [4] researched the impact of isolated versus non-isolated traumatic brain injuries on injury identification and decision-making by care providers in austere scenarios. Tsur and co-authors [5] described the characteristics of a unique type of terror attack: vehicle ramming. Additional examples of treatments provided in the military prehospital arena were analyzed by Nakar and colleagues [6] who discussed how to assess pain medications administered to trauma casualties in the past two decades by IDF-MC care providers. Rittblat et al. [7] further described the use of freeze-dried plasma, a blood component used in the prehospital arena and administered via intraosseous vascular access. The IDF-MC is a continuously changing organization emphasizing the adoption of advanced technologies and devices. Chen et al. [8] presented a blinded study on the use of point-of-care ultrasound and remote telementored ultrasound by inexperienced operators, and Sorkin et al. [9] described the BladeShield 101: a novel device for the battlefield designed to continuously measure vital signs and medical treatment provided and to transfer data through roles of care. In this special issue of IMAJ, authors also discusse gender-related aspects at the core of medical treatment. Segal et al. [10] examined whether missed injuries were related to the medical provider's gender, while Gelikas et al. [11] assessed whether treatment with analgesia was associated with casualty gender in the military prehospital trauma setting Over the past two and a half years, the COVID-19 pandemic has been a significant part of our lives. During these years, medical systems and teams throughout Israel and around the world struggled to adapt to this new disease and save lives fighting the pandemic. Geva et al. [12] and Shental et al. [13] discussed the impact of COVID-19 on the IDF medical system, lessons learned during the outbreak, and effects of different diseases during these times on medical treatment provided by the IDF to soldiers.

Isolated Versus Non-isolated Traumatic Brain Injuries Identification and Decision Making: A Comparative Study.

BACKGROUND: Traumatic brain injury (TBI) is a significant cause of death in the battlefield. TBI can be challenging to diagnose in the combat setting and remains a substantial challenge for advanced life support (ALS) providers. OBJECTIVES: To compare prehospital and hospitalization characteristics between isolated and non-isolated TBI. To examine the effects of TBI with coexisting injuries on patient evaluation and outcomes based on the Israeli Defense Forces Trauma Registry and the Israeli National Trauma Registry of soldiers hospitalized for TBI between the years 2006-2017. METHODS: A total of 885 casualties were eligible for our study, of whom 271 (30%) had isolated TBI. Only 35% of hospitalized patients with isolated TBI were defined as urgent by the ALS providers versus 67% in the non-isolated TBI group (P < 0.001). RESULTS: Overall, 29% of the TBIs in the non-isolated group were missed by the ALS providers vs. 11% in the isolated group. CONCLUSIONS: Concomitant injuries may delay the diagnosis of TBI by ALS providers. These findings should be considered in the prehospital evaluation to potentially improve the care and outcome of head injury patients.

Intraosseous administration of freeze-dried plasma in the prehospital setting.

BACKGROUND: Freeze dried plasma (FDP) is a commonly used replacement fluid in the prehospital setting when blood products are unavailable. It is normally administered via a peripheral intravenous (PIV) line. However, in severe casualties, when establishing a PIV is difficult, administration via intraosseous vascular access is a practical alternative, particularly under field conditions. OBJECTIVES: To evaluate the indications and success rate of intraosseous administration of FDP in casualties treated by the Israel Defense Forces (IDF). METHODS: A retrospective analysis of data from the IDF-Trauma Registry was conducted. It included all casualties treated with FDP via intraosseous from 2013 to 2019 with additional data on the technical aspects of deployment collected from the caregivers of each case. RESULTS: Of 7223 casualties treated during the study period, intravascular access was attempted in 1744; intraosseous in 87 of those. FDP via intraosseous was attempted in 15 (0.86% of all casualties requiring intravascular access). The complication rate was 73% (11/15 of casualties). Complications were more frequent when the event included multiple casualties or when the injury included multiple organs. Of the 11 failed attempts, 5 were reported as due to slow flow of the FDP through the intraosseous apparatus. Complications in the remaining six were associated with deployment of the intraosseous device. CONCLUSIONS: Administration of FDP via intraosseous access in the field requires a high skill level.

Is Gender a Risk Factor for Oligoanalgesia in the Military Prehospital Trauma Setting?

BACKGROUND: Pain management is fundamental in the treatment of a trauma casualty. Adequate pain management is associated with decreased long-term morbidity and chronic pain. Nonetheless, pain is frequently not documented nor adequately treated in the prehospital setting, a phenomenon described as oligoanalgesia. Gender bias has been suggested as a risk factor for oligoanalgesia. OBJECTIVES: To examine the association between casualty gender and pain management in the prehospital trauma setting. METHODS: We conducted a retrospective cohort study of the Israel Defense Forces Trauma Registry between 2015 and 2020. Univariable analysis followed by multivariable logistic regression was used to assess the association between casualty gender and pain management. For adult patients for whom gender was known, pain scores were documented. RESULTS: A total of 1044 casualties were included in the study; 894 (85.6%) were male. Females and males differed in several demographic and injury characteristics, including age in years (mean 36 vs. 27.6, P value < 0.001) and injury mechanism (16%% vs. 34.5% penetrating injury, P value < 0.001). Female casualties were less likely to be treated for pain (odds ratio [OR] 0.708, 95% confidence interval [95%CI] 0.5-1, P = 0.05). However, after adjustment for various factors, including pain severity, this association was insignificant (OR 0.748, 95%CI 0.46-1.23, P = 0.25). CONCLUSIONS: In this prehospital study, gender bias in pain management was not apparent. As women's role on the battlefield continues to increase, further studies regarding the role of gender bias in casualty care are warranted.

Emergent exploratory thoracotomy with military casualties: contemporary prehospital management and outcome (see editorial page 619).

BACKGROUND: Chest trauma is among the most common types of trauma, corresponding to 10% of trauma patients admitted to hospitals. In the military setting, thoracic trauma was reported as a significant cause of death. With well-timed treatment, chest trauma is regarded as survivable. Emergency thoracotomy (ET) is considered when the patient with trauma to the chest needs immediate resuscitation. Survival rate is reported as low as 1% in some reports and 20% in others. The survival rate depends on injury mechanism, protocols for intervention, and other decompressive procedures. OBJECTIVES: To determine parameters that may impact survival of ET. METHODS: We conducted a retrospective cohort study to compare prehospital and in-hospital data regarding ET in the emergency department (ED) versus the operating room (OR). RESULTS: Between 2009 and 2017, 6532 casualties presented to the ED; 1125 with trauma to the chest. Fifty-four of those with chest trauma underwent ET in the hospital (4.8%), 22 (41%) in the ED, and 32 (59%) in the OR. The overall mortality of the ET subgroup was 48%. With regard to thoracotomies, 19/22 of patients (86%) who underwent ET in the ED died compared to 2/28 in the OR (13%). CONCLUSIONS: Utilizing ET after chest trauma with appropriate clinical indications, well-trained personnel, and prompt transportation poses a significant challenge, but may be associated with better survival than that reported previously with military casualties. Adoption of indications and timed allocation to the OR may improve outcomes with chest trauma casualties.

Where Did the Patients Go? The IDF Medical Corps Medical Services Experience during the COVID-19 Outbreak: Lessons Learned.

BACKGROUND: Coronavirus disease 2019 (COVID-19) led to two nationwide lockdowns in Israel, reducing both supply and demand for medical services in the Israel Defense Force (IDF). IDF soldiers serve on bases within Israel, and most of them return home at the end of the day, similar to other armies in the world. OBJECTIVES: To analyze the health services provided by the IDF with regard to policy changes during lockdowns. METHODS: We compared medical encounters between different services provided by the IDF Medical Corps. We related them to specific time periods: pre-first lockdown, first lockdown (and corresponding timeframes of the previous 3 years), between lockdowns, second lockdown, and post-second lockdown. RESULTS: Compared to past periods, we found a similar reduction of 27-30% in primary care medical encounter rates during the two lockdowns: 42-43% in sick days and 50-54% in referrals to the emergency department. Referral rates to all specialist medical encounters and elective surgeries decreased significantly during the first lockdown period and increased 1.2-3.5 times during the second lockdown. CONCLUSIONS: A continuance of the shift to telehealth is required to withstand a future lockdown, with a full supply of secondary medical services attuned to core medical issues relevant for combat personnel. A liberal sick leave policy is required to eliminate unnecessary in-person visits, thus reducing the risk of infection.

Patterns in vehicle-ramming attacks.

BACKGROUND: Vehicle-ramming attacks have become a common tactic for terror organizations worldwide. However, the medical implications of vehicle-ramming attacks remain unknown. OBJECTIVES: To investigate the characteristics of vehicle-ramming attack incidents and casualties in order to assist in guiding the policy of medical organizations. METHODS: In this study we included all vehicle-ramming attacks recorded in the Israel Defense Forces-Trauma Registry between 2015 and 2019. Records were screened using text mining of incident, casualty, and injury descriptions. The selected records were examined manually to ensure that they were vehicle-ramming attacks. Incident and casualty data were retrieved from the trauma registry. RESULTS: During the years 2015-2019, a total of 36 vehicle-ramming attacks with 113 casualties were documented in the trauma registry. The median number of casualties, urgent casualties, and fatalities per incident was 3 (interquartile range [IQR] 2-5), 1 (IQR 1-2), and 1 (IQR 1-1), respectively. Of the incidents, 15 (42%) had three or more casualties. The most prevelant day of the week was Friday with 9 incidents (25%). Within the day, 21 incidents (58%) occurred between the hours of 12:00 and 18:00. Commonly injured body regions were lower extremities (55%), head (28%), and upper extremities. Ten victims (9%) died before arriving at a hospital. CONCLUSIONS: Vehicle-ramming attacks tend to have multiple casualties, be deadly, occur more often on Fridays and in the afternoon, and result mostly in injuries to the extremities and the head. These findings could guide policymaking to improve medical response to vehicle-ramming attacks.

Lessons from outbreaks of COVID-19 at Israeli military bases.

BACKGROUND: To mitigate the spread of coronavirus disease 2019 (COVID-19), national guidelines, in accordance with international health authorities, mandated 14 days of quarantine for every close contact of a confirmed COVID-19 patient. Although health benefits are obvious, consequences are profound, especially for organizations required to maintain operational preparedness. OBJECTIVES: To present the Israel Defense Force (IDF) experience with outbreaks regarding quarantined individuals. To weigh the consequences of quarantined individuals needed for workforce and operation. METHODS: All positive COVID-19 cases in the IDF, as measured by a positive rRT-PCR test result, between 29 February and 18 May 2020 were evaluated. Numbers of positive individuals, quarantined individuals, and confirmatory exams conducted were collected. We compared the events in four units with the largest outbreaks and assessed the impact of confirmed cases, tests conducted, and workforce loss due to quarantine. RESULTS: Of the 187 soldiers who tested positive for COVID-19, source of infection was traced to 140 soldiers (75%). Almost no medical treatment was delivered, and hospitalization was rare. We found a median of 15.2% (interquartile range 5.3-34) for decline in unit workforce due to quarantine measures. Maximum reduction reached 47% of the workforce in one unit. CONCLUSIONS: Despite a relatively small number of confirmed cases, units underwent a substantial change in mode of operation due to the toll of quarantined individuals. In certain populations and organizations, perhaps a more liberal application of isolation and contact tracing is suitable due to the heavy economic burden and consequences in term of operational readiness.

Trends in prehospital pain management: two decades of point-of-injury care.

BACKGROUND: Pain control in trauma is an integral part of treatment in combat casualty care. More soldiers injured on the battlefield need analgesics for pain than life-saving interventions (LSIs). Early treatment of pain improves outcomes after injury, while inadequate treatment leads to higher rates of post-traumatic stress disorder (PTSD). OBJECTIVES: To describe the experience of the Israel Defense Forces (IDF) Medical Corps with prehospital use of analgesia. METHODS: All cases documented in the IDF-Trauma Registry between January 1997 and December 2019 were examined. Data collection included analgesia administered, mechanism of injury, wound distribution, and life-saving interventions performed. RESULTS: Of 16,117 patients, 1807 (11.2%) had at least one documented analgesia. Demographics included 91.2% male; median age 21 years. Leading mechanism of injury was penetrating (52.9%). Of injured body regions reported, 46.2% were lower extremity wounds. Most common types of analgesics were morphine (57.2%) and fentanyl (27%). Over the two decades of the study period, types of analgesics given by providers at point of injury (POI) had changed. Fentanyl was introduced in 2013, and by 2019 was given to 39% of patients. Another change was an increase of casualties receiving analgesia from 5-10% until 2010 to 34% by 2019. A total of 824 LSIs were performed on 556 patients (30.8%) receiving analgesia and no adverse events were found in any of the casualties. CONCLUSIONS: Most casualties at POI did not receive any analgesics. The most common analgesics administered were opioids. Over time analgesic administration has gained acceptance and become more commonplace on the battlefield.

Rates of Missed Injuries in the Prehospital Setting Are Unrelated to the Gender of the Medical Provider: A Retrospective Study.

BACKGROUND: Medical organizations worldwide aim for equity and diversity in the medical profession to improve care quality. Data on whether the caregiver gender affects outcomes in the prehospital setting are essential but scarce compared to available in-hospital studies. OBJECTIVES: To analyze the rates of missed injuries in the prehospital setting and determine whether these rates were associated with the gender of the on-field physician or paramedic. METHODS: A retrospective record review was conducted, which included trauma records documented in two trauma registries, the prehospital Israel Defense Forces-Trauma Registry (IDF-TR), and the in-hospital Israeli National Trauma Registry (INTR). Missed injuries were defined as injuries documented in the INTR but not in the IDF-TR. A multivariable regression analysis was performed to assess the association between provider's gender and missed injuries. RESULTS: Of 490 casualties, 369 (75.3%) were treated by teams that included only male paramedics or physicians. In 386 (78.8%) cases, a physician was a part of the prehospital team. In all, 94 (19.2%) casualties sustained injuries that were missed by the prehospital medical team. Missed injuries were not associated with the gender of the paramedic or physician (odds ratio 1.242, 95% confidence interval 0.69-2.193). CONCLUSIONS: No association was found between the gender of the medical provider in the prehospital setting and the rate of missed injuries. These results should encourage prehospital emergency medical systems to aim for a balanced and diverse caregiver population.

BladeShield 101: A Novel Prehospital Digital Wearable Combat Casualty Card.

BACKGROUND: The Israeli Defense Forces-Medical Corps (IDF-MC) focuses on reducing preventable death by improving prehospital trauma care. High quality documentation of care can serve casualty care and to improve future care. Currently, paper casualty cards are used for documentation. Incomplete data acquisition and inadequate data handover are common. To resolve these deficits, the IDF-MC launched the BladeShield 101 project. OBJECTIVES: To assess the quality of casualty care data acquired by comparing standard paper casualty cards with the BladeShield 101. METHODS: The BladeShield 101 system consists of three components: a patient unit that records vital signs and medical care provided, a medical sensor that transmits to the patient unit, and a ruggedized mobile device that allows providers to access and document information. We compared all trauma registries of casualties treated between September 2019 and June 2020. RESULTS: The system was applied during the study period on 24 patients. All data were transferred to the military trauma registry within one day, compared to 72% (141/194) with a paper casualty card (P < 0.01). Information regarding treatment time was available in 100% vs. 43% (P < 0.01) of cases and 98% vs. 67% (P < 0.01) of treatments provided were documented comparing BladeShield 101 with paper cards, respectively. CONCLUSIONS: Using an autonomous system to record, view, deliver, and store casualty information may resolve most current information flow deficits. This solution will ultimately significantly improve individual patient care and systematic learning and development processes.

Inclusion of extranodal extension in the lymph node classification of cutaneous squamous cell carcinoma of the head and neck.

BACKGROUND: The prognostic performance of the recently updated American Joint Committee on Cancer lymph node classification of cutaneous head and neck squamous cell carcinoma (HNSCC) has not been validated. The objective of this study was to assess the prognostic role of extranodal extension (ENE) in cutaneous HNSCC. METHODS: This was a retrospective analysis of 1258 patients with cutaneous HNSCC who underwent surgery with or without adjuvant therapy between 1995 and 2019 at The University of Texas MD Anderson Cancer Center. The primary outcome was disease-specific survival (DSS). Local, regional, and distant metastases-free survival were secondary outcomes. Recursive partitioning analysis (RPA) and a Cox proportional hazards regression model were used to assess the fitness of staging models. RESULTS: No significant differences in 5-year DSS were observed between patients with pathologic lymph node-negative (pN0) disease (67.4%) and those with pN-positive/ENE-negative disease (68.2%; hazard ratio, 1.02; 95% CI, 0.61-1.79) or between patients with pN-positive/ENE-negative disease and those with pN-positive/ENE-positive disease (52.7%; hazard ratio, 0.57; 95% CI, 0.31-1.01). The RPA-derived model achieved better stratification between high-risk patients (category III, ENE-positive with >2 positive lymph nodes) and low-risk patients (category I, pN0; category II, ENE-positive/pN1 and ENE-negative with >2 positive lymph nodes). The performance of the RPA-derived model was better than that of the pathologic TNM classification (Akaike information criterion score, 1167 compared with 1176; Bayesian information criterion score, 1175 compared with 1195). CONCLUSIONS: The number of metastatic lymph nodes and the presence of ENE are independent prognostic factors for DSS in cutaneous HNSCC, and incorporation of these factors in staging systems improves the performance of the American Joint Committee on Cancer lymph node classification.

Post-expiry stability of freeze-dried plasma under field conditions - Can shelf life be extended?

BACKGROUND: This prospective study evaluated the effect of routine, uncontrolled, Israeli field storage conditions on the safety and efficacy of Lyo-Plas N Freeze-Dried Plasma (FDP) at the end of the manufacturer's shelf life, and up to 24 months post expiry. Clotting factors V, VIII and XI, proteins S, C, fibrinogen, PTT, ATIII, VWF, and INR as well as TEG, DDM, residual moisture, pH, and sterility of FDP returned from field units after uncontrolled storage were evaluated. STUDY DESIGN AND METHODS: Parameters measured at the end of manufacturer shelf life, as well as 6, 12, 18, and 24 months after expiry, were compared to those of freshly supplied FDP doses. RESULTS: Changes were found when comparing freshly supplied FDP to all field-stored groups in INR, PT, PTT, pH, fibrinogen, and factor VIII. A significant change was also seen in Factor XI in the 12, 18, and 24 months post-expiry samples, Factor V and R in the 24 months post-expiry samples, MA in the 12, 24 months post-expiry group, and Protein C in the 18 months post-expiry group. An increase in the residual moisture from 0.90% in freshly supplied FDP to 1.35% in 24 months post-expiry FDP.; all p < .05. No growth was found in sterility analysis. CONCLUSION: Despite uncontrolled field storage conditions, the findings demonstrate that the safety and efficacy of FDP units, stored in uncontrolled conditions are only slightly affected, even beyond their expiration date. This information allows consideration of possibly extending the shelf life.