Expert Consensus Panel Recommendations for Selection of the Optimal Supraglottic Airway Device for Inclusion to the Medic's Aid Bag.

INTRODUCTION: Airway obstruction is the second leading cause of potentially survivable death on the battlefield. The Committee on Tactical Combat Casualty Care (CoTCCC) has evolving recommendations for the optimal supraglottic airway (SGA) device for inclusion to the medics' aid bag. METHODS: We convened an expert consensus panel consisting of a mix of 8 prehospital specialists, emergency medicine experts, and experienced combat medics, with the intent to offer recommendations for optimal SGA selection. Prior to meeting, we independently reviewed previously published studies conducted by our study team, conducted a virtual meeting, and summarized the findings to the panel. The studies included an analysis of end-user after action reviews, a market analysis, engineering testing, and prospective feedback from combat medics. The panel members then made recommendations regarding their top 3 choices of devices including the options of military custom design. Simple descriptive statistics were used to analyze panel recommendations. RESULTS: The preponderance (7/8, 88%) of panel members recommended the gel-cuffed SGA, followed by the self-inflating-cuff SGA (5/8, 62%) and laryngeal tube SGA (5/8, 62%). Panel members expressed concerns primarily related to the (1) devices' tolerance for the military environment, and (2) ability to effectively secure the gel-cuffed SGA and the self-inflating-cuff SGA during transport. CONCLUSIONS: A preponderance of panel members selected the gel-cuff SGA with substantial feedback highlighting the need for military-specific customizations to support the combat environment needs.

A Descriptive Analysis of the Execution of the Expert Field Medical Badge Competition with Mitigation Measures during the COVID-19 Pandemic.

OBJECTIVE: Introduction: In September 2020, the 2nd Stryker Brigade Combat Team of the 4th Infantry Division at Fort Carson, CO, executed an Expert Field Medical Badge (EFMB) event, unique in its implementation of Coronavirus Disease 2019 (COVID-19) mitigation measures. We conducted a descriptive analysis of our experience to inform future EFMB events. METHODS: We planned and resourced the EFMB competition in accordance with the Army Medical Department Center and School Pamphlet 350-10. We additionally defined adjustments to each event based upon the installation's COVID-19 Health Protection Condition (B, B+, or C) to set conditions for us to execute training regardless of shifts in the public health posture. We further implemented mitigation measures to include a 72-hour restriction of movement for all candidates and cadre prior to competition start, strict use of face coverings, and two daily temperature and symptom screenings. We recorded numbers of candidates and cadre withdrawing from the competition each day and the reasons for withdrawal. RESULTS: Of the 66 evaluators, 179 support personnel, and 113 candidates, 2 personnel withdrew for reasons related to COVID-19 mitigation measures. A single cadre member entered a quarantine for the development of a sore throat during the competition. One candidate withdrew after disclosing failure to comply with the 72-hour restriction of movement prior to competition start. Another candidate withdrew prior to start due to an injury sustained during land navigation. Of the remaining 111 candidates, 22 (20%) earned the EFMB. Most failures occurred due to the Army Physical Fitness Test (APFT, 33) and land navigation (44). DISCUSSION: Our competition provides proof in principle that large-scale events to train individual skills such as EFMB are feasible in conjunction with COVID-19 public health measures. Our experience highlights the imperative of prior preparation of candidates in particular for the APFT and land navigation.

Task Force Contain: A Descriptive Analysis of Brigade Combat Team COVID-19 Operations.

BACKGROUND: In March 2020, a Fort Carson brigade combat team established Task Force (TF) Contain in response to the Coronavirus Disease 2019 (COVID-19) pandemic. We offer a descriptive analysis of the TF Contain execution. METHODS: This study comprises a descriptive analysis of the design and execution of COVID-19 response by an infantry brigade combat team. Specific analyses include patient flow and mitigation measures; task organization; and definition of commander decision points as associated with separate lines of effort. RESULTS: TF Contain defined separate teams to address each component of the COVID-19 response, each assigned to subordinate battalions. Team Trace augmented the installation medical activity tracing interviews and data collection. Team Isolation provided lodging and life support; whereas, Team Transportation provided movement assets for soldiers requiring restriction of movement related to COVID-19. Team Clean executed disinfection operations at geographic locations determined to be associated with transmission events. Team Oversight enforced standards of mask wear and social distancing throughout the installation. Team Overflow analyzed installation infrastructure for contingency planning in the event more facilities became necessary for soldiers in isolation or quarantine. Finally, Team Testing augmented medical department activity (MEDDAC) medical manpower to staff providers and medics for support testing operations. CONCLUSIONS: Few personnel assigned to this organization had pre-existing experience or training related to infectious disease prevention or epidemiology. Nevertheless, this organization demonstrated the capacity of the military decision-making and operations processes to build robust procedures in response to public health threats.

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.

Telemedicine at the Joint Readiness Training Center: Expanding Forward Medical Capability.

INTRODUCTION: The US Army's transition from counterinsurgency operations to preparation for large-scale combat operations is likely to bring unique access to care challenges on the battlefield. Ruggedized computer systems exist that allow forward medical personnel to establish telehealth connections with rear-based specialists. We describe our use of one such device during simulated force on force operations at the Joint Readiness Training Center (JRTC). METHODS: Our infantry brigade combat team brought a telehealth device to JRTC 20-02. The device comprised a mobile laptop and peripheral medical devices. We used the Warfighter Information Network-Tactical Increment 2 Tactical Communications Node (TCN) to establish communication between the device and external entities. We sought to establish connectivity in the Fort Polk, LA, cantonment area as part of reception, staging, onward movement, and integration operations. RESULTS: We successfully executed video calls from the field utilizing the telehealth device at the JRTC rear aid station and the local military treatment facility on Fort Polk, LA. We also executed calls to our home station military treatment facility on Fort Carson, CO. Each of these calls lasted approximately five minutes with sustained high-quality video and audio feeds. CONCLUSIONS: Our experience provides proof of concept that telehealth may enable rear-based medical personnel to expand the medical capabilities of medics based forward in the battlespace. Telehealth devices may prove feasible for use with strictly tactical communications architecture in the kinetic setting of large scale combat operations.

A Descriptive Analysis of Notional Casualties Sustained at the Joint Readiness Training Center: Implications for Health Service Support during Large-Scale Combat Operations.

INTRODUCTION: The Joint Readiness Training Center (JRTC) offers a laboratory for study of combat casualty care delivery during brigade-sized collective training exercises. We describe the casualty outcomes during largescale combat operations as part of a JRTC rotation. METHODS: During JRTC rotation 20-02, 2/4 Infantry Brigade Combat Team (IBCT) participated in force on force operations as part of a joint and multinational task force. Medical assets available included a Role II associated with the Brigade Support Medical Company and Role I facilities associated with six subordinate battalion elements. Observers, coaches, and trainers (OCTs) categorized all casualties as killed in action (KIA) or wounded in action (WIA). OCTs categorized WIA casualties as died of wounds (DOW) based upon time elapsed from time of injury to transportation to successive roles of care within time standards, dependent upon the severity of injuries. We portrayed our DOW rates using descriptive statistics. RESULTS: Force on force operations spanned 14 days. The task organization comprised 3,820 persons. Casualties included 642 KIA and 1061 WIA. Of the WIA, 502 (47.3%) dies from their wounds. The primary reason for DOW was evacuation delay from point of injury (POI) to military treatment facility (MTF) (443 casualties, 88.2%). An additional 40 casualties DOW at the Role 1 (8.0%) and 10 died at Role II (2.0%). Nine casualties (1.8%) DOW due to improper care rendered. DISCUSSION: Casualty DOW during simulated large-scale combat operations are overwhelmingly due to evacuation delays from POI. Medical readiness for near-peer force on force operations depends upon shared understanding across medical and non-medical personnel of casualty movement through echelons of care on the battlefield.