Developing Military Doctors: An Institutional Approach to Medical Force Readiness in Graduate Medical Education.

Military physicians are required to not only meet civilian accreditation standards upon completion of their Graduate Medical Education (GME) training programs but also be proficient in the military-unique aspects of their field, including medical care in austere environments and management of combat casualties. They must also be familiar with the administrative and leadership aspects of military medicine, which are often absent from the training curriculum. The San Antonio Uniformed Services Health Education Consortium Military Readiness Committee, by incorporating questions of military relevance into each GME program's mandatory Annual Program Evaluation, identified curricular gaps upon which military readiness training objectives and opportunities were developed. These activities included a lecture series on the sustainment of medical and military readiness, an interactive procedural skills training event, trainee involvement in operational pre-deployment exercises, and the development of an elective operational rotation in Honduras. The Military Readiness Committee provides a model for other military GME institutions to develop training goals and opportunities to strengthen the preparedness of their trainees for military service.

Critical Care Education and Skills Validation Course for Internal Medicine Physicians in the Military.

INTRODUCTION: Military internist and internal medicine (IM) subspecialist physicians must be prepared to function in both traditional inpatient and outpatient settings, as well as manage critically ill patients within a deployed austere environment. As many critical care procedures are not performed on a routine basis in general IM practice, many active duty IM physicians experience skills degradation and lack confidence in performing these procedures. In order to address this perceived deficiency, the U.S. Army and Air Force Internal Medicine Education and Skills Validation Course was developed to provide essential training in critical care procedures for active duty military IM physicians and subspecialists. MATERIALS AND METHODS: Staff internist and subspecialist physicians at multiple military treatment facilities participated in a 2-day simulation-based training course in critical care procedures included in the Army Individual Critical Task Lists and the Air Force Comprehensive Medical Readiness Program. Educational content included high-yield didactic lectures, multi-disciplinary Advanced Cardiac Life Support/Advanced Trauma Life Support high-fidelity simulation scenarios, and competency training/validation in various bedside procedures, including central venous and arterial line placement, trauma-focused ultrasound exam, airway management and endotracheal intubation, chest tube thoracotomy, and mechanical ventilation, among others. RESULTS: A total of 87 staff IM physicians participated in the course with an average of 2-4 years of experience following completion of graduate medical education. Upon course completion, all participants successfully achieved rigorous, checklist-based, standardized validation in all the required procedures. Survey data indicated a significant improvement in overall skills confidence, with 100% of participants indicating improvement in their ability to function independently as deployed medical officers. CONCLUSIONS: Broad implementation of this program at military hospitals would improve pre-deployment critical care procedural readiness in military IM physicians.

Treating COVID-19 Acute Severe Hypoxemic Respiratory Failure: First Case Report Utilizing Dexamethasone, Remdesivir, and Convalescent Plasma in Operation Inherent Resolve.

Coronavirus 2019 (COVID-19) has spread across the globe with a concerningly high infectivity resulting in the World Health Organization deeming it a pandemic. It has resulted in thousands of deaths and placed enormous strain on communities, healthcare systems and healthcare workers as they battle shortages of ventilators, supplies, and difficulties in protecting patients and hospital staff alike. Challenges in managing the disease have led to new treatment and management strategies as healthcare teams struggle to adapt. We present the first case of COVID-19 managed in the austere deployed environment of Operation Inherent Resolve in which the patient was treated with dexamethasone, remdesivir, COVID-19 convalescent plasma, positive pressure ventilation, and proning. We discuss some of the inherent and unique challenges of caring for a patient in this resource constrained environment with a brief review of the literature on the treatment and management.

Long-Term Outcomes of Thoracic Trauma in U.S. Service Members Involved in Combat Operations.

INTRODUCTION: Nearly 10% of all combat injuries during the most recent conflicts in Iraq and Afghanistan involve thoracic trauma. The long-term outcomes of these combat-related injuries with respect to lung function have not been fully evaluated. Limited research in civilian polytrauma patients have shown significant obstructive physiology in nearly half of their population without clear etiology. We sought to further characterize the extent to which these active duty service members (ADSM) are chronically affected by their thoracic injuries. MATERIALS AND METHODS: We conducted a retrospective chart review and analysis of ADSM who sustained thoracic injuries while deployed in support combat operations from 2003 to 2013. Using the Department of Defense Trauma Registry, 2,049 patients were found to have sustained thoracic trauma during these conflicts, of which we were able to identify 298 patients with postinjury pulmonary function testing (PFT) available for analysis. Following standardization of these tests using the established reference values, PFT was compared to a representative population of ADSM. Additional analysis was completed to detect incidence of abnormal PFTs when compared to both type of injury (burn, blunt, penetrating, and other) and also Injury Severity Score. RESULTS: In our patient population, there was a significant increase in abnormal PFTs when compared to a representative population. Of these, 31.8% of patients displayed obstructive physiology versus 3.7% in the control (P < 0.001), 24.5% displayed restrictive or restrictive pattern (those without full lung volumes available utilizing forced vital capacity) versus 4.9% (P < 0.0001), and 7.9% displaying mixed pattern. Further, increasing rates of abnormal PFTs were identified in comparison to Injury Severity Score (odds ratio 1.03). There was no significant increase in abnormal PFTs when stratified by type of injury. Finally, there was no significant change identified in pulmonary function before and after injury in our limited population of 19 patients. CONCLUSIONS: There is a significant increase in the percent of abnormal PFTs in ADSM following thoracic injury when compared to patients with similar risk factors and baseline health. It is unclear why the rates of obstruction are high in our population as previous research has not definitively shown increased rates of asthma in previously deployed, uninjured ADSM; however, this finding is consistent with limited previous research in civilian trauma patients. Further research into the long-term outcomes of thoracic trauma and occupational exposures of combat is paramount for improved outcomes going forward.

Intermittent gastric feeds lower insulin requirements without worsening dysglycemia: A pilot randomized crossover trial.

INTRODUCTION: We hypothesized that critically ill medical patients would require less insulin when fed intermittently. METHODS: First, 26 patients were randomized to receive intermittent or continuous gastric feeds. Once at goal nutrition, data were collected for the first 4-hr data collection period. Next, the enteral feed type was switched, goal nutrition was repeated, and a second 4-h data collection period was completed. The primary endpoint was the total amount of insulin infused; secondary endpoints were glucose concentration mean, maximum, minimum, and standard deviation, as well as episodes of hypoglycemia. RESULTS: Sixteen of the 26 patients successfully completed the protocol. One patient experienced a large, rapid, and sustained decline in insulin requirement from liver failure, creating a bias of lesser insulin in the intermittent arm; this patient was removed from the analysis. For the remaining 15 patients, the average total amount of insulin infused was 1.4 U/patient/h less following intermittent feeds: P =0.027, 95% confidence interval (0.02, 11.17), and effect size 0.6. Secondary endpoints were statistically similar. CONCLUSIONS: Critically ill medical patients who require an insulin infusion have a reduced insulin requirement when fed intermittently, whereas dysglycemia metrics are not adversely affected. A larger clinical study is required to confirm these findings.

The use of lobectomy for management of clinically significant pulmonary vein stenosis and occlusion refractory to percutaneous intervention.

Pulmonary vein stenosis (PVS) is a serious complication of radiofrequency ablation (RFA) for the treatment of atrial fibrillation. The prevalence of this complication was reported to be as high as 42% in 1999 when RFA was first implemented [1]. However, with improvements in operator technique including wide area circumferential ablation, antral isolation, and the use of intracardiac ultrasound, the incidence of symptomatic severe PVS following RFA ranges from 0% to 2.1% while the incidence of symptomatic pulmonary vein occlusion (PVO) following RFA was found to be 0.67% [2-8]. Despite a decrease in the incidence of clinically significant PVS following RFA, there have been increased reports of complications associated with PVS to include hemoptysis, scarring, lung infarction, and intraparenchymal hemorrhage [9]. Studies have shown that PVS is often misdiagnosed as pneumonia, pulmonary embolism, and lung cancer and as a result, patients are often subjected to unnecessary diagnostic procedures [2,10]. The current first line treatment for this condition is percutaneous balloon angioplasty with stenting; however, there are studies that have shown that there is a relatively high rate of restenosis despite optimal medical therapy [2-3,10,11]. Three case reports have described the use of lobectomy to treat patients with persistent respiratory symptoms in the setting of severe PVO with good outcomes [12-14]. We present a case of iatrogenic PVO and ipsilateral severe PVS following RFA who underwent attempted lobectomy for persistent exertional dyspnea and persistent hypoperfusion of the left upper lung lobe despite percutaneous intervention and six months of optimal medical therapy. The lobectomy was aborted due to the presence of a significant fibrothorax, and the patient continues to have significant exercise limitation despite participation in pulmonary rehabilitation.

Upper airway wheezing: Inducible laryngeal obstruction vs. excessive dynamic airway collapse.

There are multiple causes of dyspnea upon exertion in young, healthy patients to primarily include asthma and exercise-induced bronchospasm. Excessive dynamic airway collapse (EDAC) describes focal collapse of the trachea or main bronchi with maintained structural integrity of the cartilaginous rings. It is commonly associated with pulmonary disorders like bronchiectasis, chronic obstructive pulmonary disease and asthma. It is believed to result secondary to airway obstruction in these conditions. While uncommon in young, healthy adults, it has recently been found as a cause of dyspnea in this population. Inducible laryngeal obstruction (ILO) is an umbrella term that describes an induced, intermittent upper airway impediment. While ILO is found in 10% of young patients with exertional dyspnea, it is primarily inspiratory in nature due to paradoxical closure of the glottis or supraglottis. This report highlights the presentation of a United States Army soldier who after a deployment was given a diagnosis of asthma, later found to have ILO and was subsequently diagnosed with concurrent EDAC. We follow up with a literature review and discussion of symptomatology, diagnosis, exercise bronchoscopy, and treatment modalities for both EDAC and ILO.

Comparison of Forced and Slow Vital Capacity Maneuvers in Defining Airway Obstruction.

BACKGROUND: Obstructive lung disease is diagnosed by a decreased ratio of FEV1 to the vital capacity (VC). Although the most commonly used VC is FVC, American Thoracic Society guidelines suggest alternative VCs, for example, slow VC (SVC), may offer a more-accurate evaluation of breathing capacity. There is recent evidence that using only FEV1/FVC underrecognizes obstruction in subjects at high risk and who are symptomatic. Previous studies have indicated that healthy individuals show a minimum difference between FVC and SVC; however, testing of individuals with asthma and who are symptomatic indicates that SVC can be markedly larger than FVC. OBJECTIVE: To evaluate the differences among SVC, FVC, and SVC-based measurements in the diagnosis of symptomatic obstructive lung disease. METHODS: A retrospective analysis was performed of spirometry and plethysmography measurements from studies conducted between 2011 to 2015. We established a pulmonary function database that incorporated predictive equations from the National Health and Nutrition Examination Survey III (NHANES III). The SVC to FVC difference was calculated. FEV1/SVC was compared with FEV1/FVC by using NHANES III lower limit of normal values. RESULTS: A total of 2,710 studies with 2,244 subjects were reviewed. Spirometric obstruction, as defined by NHANES III, was identified in 26.1% of the studies (707/2,710). The mean (± SD) difference between SVC and FVC was 375.0 ± 623.0 mL and 258.8 ± 532.5 mL in those with and those without obstruction, respectively. Subgroup and multivariate analysis demonstrated age, body mass index, and FEV1 associated contributions to the difference between SVC and FVC. By using FEV1/SVC, the prevalence of obstruction increased from 26.1 to 45.0% (1,219/2,710) and identified 566 additional studies of subjects with obstruction. Fifty-four percent of the subjects with newly-identified obstructive lung disease (305/566) had smoking histories, and 67.4% (345/512) received medications for obstructive lung disease. CONCLUSIONS: The isolated use of FVC-based diagnostic algorithms did not recognize individuals with symptomatic obstructive lung disease. Recognizing the difference between SVC and FVC measurements in subjects will improve testing and diagnosis of obstructive lung disease.