A Serious Game for Enhancing Rescue Reasoning Skills in Tactical Combat Casualty Care: Development and Deployment Study.

BACKGROUND: Serious games (SGs) have emerged as engaging and instructional digital simulation tools that are increasingly being used for military medical training. SGs are often compared with traditional media in terms of learning outcomes, but it remains unclear which of the 2 options is more efficient and better accepted in the process of knowledge acquisition. OBJECTIVE: This study aimed to create and test a scenario-based system suitable for enhancing rescue reasoning skills in tactical combat casualty care. METHODS: To evaluate the effectiveness of the SGs, a randomized, observational, comparative trial was conducted. A total of 148 members from mobile medical logistics teams were recruited for training. Pre- and posttraining assessments were conducted using 2 different formats: a video-based online course (n=78) and a game simulation (n=70). We designed 3 evaluation instruments based on the first 2 levels of the Kirkpatrick model (reaction and learning) to measure trainees' satisfaction, knowledge proficiency, and self-confidence. RESULTS: There were 4 elements that made up the learning path for the SGs: microcourses (video-based online courses), self-test, game simulation, and record query. The knowledge test scores in both groups were significantly higher after the intervention (t154=-6.010 and t138=-7.867, respectively; P<.001). For 5 simulation cases, the average operation time was 13.6 (SD 3.3) minutes, and the average case score was 279.0 (SD 57.6) points (from a possible total of 500 points), with a score rate of only 44% (222/500 points) to 67% (336/500 points). The results indicated no significant difference in trainees' satisfaction between the 2 training methods (P=.04). However, the game simulation method outperformed the video-based online course in terms of learning proficiency (t146=-2.324, P=.02) and self-perception (t146=-5.492, P<.001). CONCLUSIONS: Despite the high satisfaction reported by trainees for both training methods, the game simulation approach demonstrated superior efficiency and acceptance in terms of knowledge acquisition, self-perception, and overall performance. The developed SG holds significant potential as an essential assessment tool for evaluating frontline rescue skills and rescue reasoning in mobile medical logistics teams.

Blood far forward: A cross-sectional analysis of prehospital transfusion practices in the Canadian Armed Forces.

BACKGROUND: Canadian Armed Forces (CAF) operate in environments that challenge patient care, especially trauma. Military personnel often find themselves in remote settings without conventional healthcare facilities. Treating traumatic injuries, particularly hemorrhagic shock, often necessitates prehospital blood transfusion. This study aims to present an overview of the current CAF prehospital transfusion practices. Furthermore, the study compared current and developing protocols against expert-recommended guidelines. METHODS: A cross-sectional survey design was employed to describe and compare CAF prehospital blood transfusion practices and protocols against expert recommendations. Topics included protocols, equipment, and procedures. An online survey targeted medical leadership and providers within CAF, with data collected from August 15 to December 15, 2023. Results were summarized descriptively. This study received approval from the Unity Health Toronto Research Ethics Board (REB 23-087). RESULTS: Units and teams with prehospital blood transfusion capabilities were contacted, achieving a 100 % response rate. Within CAF, Canadian Special Operations Forces Command (CANSOFCOM), Mobile Surgical Resuscitation Team (MSRT), and Canadian Medical Emergency Response Team (CMERT) possess these capabilities, established between 2013 and 2018. These programs are crucial for military operations. CAF has access to standard blood components, cold Leuko-Reduced Whole Blood (LrWB), and factor concentrates from Canadian Blood Services (CBS), available for both domestic and international missions given adequate planning and favorable conditions. Key findings indicate high adherence to recommended practices, some variability in the transfusion process, and potential benefits of standardizing prehospital transfusion practices. CONCLUSIONS: This study provided insights into CAF's implementation of prehospital transfusion practices, highlighting high adherence to national expert recommendations and the importance of structured protocols in military prehospital trauma management. IMPLICATIONS OF KEY FINDINGS: CAF's approach and adoption of prehospital transfusion protocols lay a strong foundation for managing trauma patients in remote settings and for expanding prehospital transfusion capabilities across CFHS deployed assets. Further research is needed to advance military trauma care by adapting prehospital blood transfusion to dynamic tactical landscapes and evolving technologies.

Advancing Combat Casualty Care Statistics and Other Battlefield Care Metrics.

Aggregate statistics can provide intra-conflict and inter-conflict mortality comparisons and trends within and between U.S. combat operations. However, capturing individual-level data to evaluate medical and non-medical factors that influence combat casualty mortality has historically proven difficult. The Department of Defense (DoD) Trauma Registry, developed as an integral component of the Joint Trauma System during recent conflicts in Afghanistan and Iraq, has amassed individual-level data that have afforded greater opportunity for a variety of analyses and comparisons. Although aggregate statistics are easily calculated and commonly used across the DoD, other issues that require consideration include the impact of individual medical interventions, non-medical factors, non-battle-injured casualties, and incomplete or missing medical data, especially for prehospital care and forward surgical team care. Needed are novel methods to address these issues in order to provide a clearer interpretation of aggregate statistics and to highlight solutions that will ultimately increase survival and eliminate preventable death on the battlefield. Although many U.S. military combat fatalities sustain injuries deemed non-survivable, survival among these casualties might be improved using primary and secondary prevention strategies that prevent injury or reduce injury severity. The current commentary proposes adjustments to traditional aggregate combat casualty care statistics by integrating statistics from the DoD Military Trauma Mortality Review process as conducted by the Joint Trauma System and Armed Forces Medical Examiner System.

Maritime Applications of Prolonged Casualty Care Sepsis on a Destroyer During Distributed Maritime Operations.

During distributed maritime operations, individual components of the naval force are more geographically dispersed. As the U.S. Navy further develops this concept, smaller vessels may be operating at a significant time and distance away from more advanced medical capabilities. Therefore, during both current and future contested Distributed Maritime Operations, Role 1 maritime caregivers such as Independent Duty Corpsman will have to manage patients for prolonged periods of time. This manuscript presents an innovative approach to teaching complex operational medicine concepts (including Prolonged Casualty Care [PCC]) to austere Role 1 maritime caregivers using a hypothetical scenario involving a patient with sepsis and septic shock. The scenario incorporates the Joint Trauma System PCC Clinical Practice Guidelines (CPG) and other standard references. The scenario includes a stem clinical vignette, expected clinical changes for the affected patient at specific time points (e.g., time 0, 1, 2, and 48h), and expected interventions based on the PCC CPG and available shipboard equipment. Epidemiology of sepsis in the deployed environment is also reviewed. This process also identifies opportunities to improve training, clinical skills sustainment, and standard shipboard medical supplies.

Drawing and storing blood using a 3D printed bottle cap and a disinfected 500 mL drinking bottle: A proof-of-concept study.

BACKGROUND: Today, with wars raging in Ukraine and the Middle East, the demand for blood is high. Despite this, few companies produce the necessary equipment to draw, store, and transfuse whole blood. This study evaluated the safety and performance of a 3D printed bottle cap in conjunction with a water bottle and some available consumables to draw and store fresh whole blood. STUDY DESIGN AND METHODS: Bags of saline, and freshly donated whole blood, was transferred to the water bottle through a 3D printed bottle cap and stored for 72 h. An identical setup, transferring saline to a Terumo blood collection bag was used as control. Performance and safety were evaluated by calculating infusion rate and observing for backflow, respectively. The blood was also tested for hemolysis and bacterial growth at four sampling points. RESULTS: The cap-and-bottle setup was faster than control in terms of flow rate when transferring saline (1.53 vs. 1.81 mL/s, p < .001), and non-inferior to saline control when transfusing blood (1.53 vs. 1.49 mL/s, p = .641). We did not observe any risks of causing the donor iatrogenic harm, and there was no evidence of increased hemolysis. However, there were traces of bacterial contamination in three of six bottles. CONCLUSION: This study indicates that drawing blood is both feasible and safe, utilizing a 3D printed cap and bottle setup. Flow rate was faster than control, and mechanical properties of the blood were not affected. We were unable to determine the source of bacterial contamination in the blood.

When Minutes Matter: A Comparison of Whole Blood Collection Techniques.

BACKGROUND: Fast and reliable blood collection is critical to emergency walking blood banks (WBB) because mortality significantly declines when blood is quickly administered to a warfighter with hemorrhagic shock. Phlebotomy for WBB is accomplished via either the "straight stick" (SS) or "ruggedized lock" (RL) method. SS comprises a 16-gauge phlebotomy needle connected to a blood collection bag via tubing. The RL device collects blood through the same apparatus, but has a capped, intravenous (IV) catheter between the needle and the donor's arm. This is the first study to compare these two methods in battlefield-relevant metrics. METHODS: Military first responders and licensed medical providers (N=86) were trained in SS and RL as part of fresh whole blood training exercises. Outcomes included venipuncture success rates, time to IV access, blood collection times, total time, and user preferences, using a within-subjects crossover design. Data were analyzed using ANOVA and nonparametric statistics at p<0.05. RESULTS: SS outperformed RL in first venipuncture success rates (76% vs. 64%, p=0.07), IV access times (448 [standard error of the mean; SE 23] vs. 558 [SE 31] s, p<0.01), and blood collection bag fill times (573 [SE 48] vs. 703 [SE 44] s, p<0.05), resulting in an approximate 3.5-minute faster time overall. Survey data were mixed, with users perceiving SS as simpler and faster, but RL as more reliable and secure. CONCLUSION: SS is optimal when timely collection is imperative, while RL may be preferable when device stability or replacing the collection bag is a consideration.

Maritime Applications of Prolonged Casualty Care: A Series Introduction.

The current United States Navy and North Atlantic Treaty Organization (NATO) maritime strategy is coalescing around the concept of Distributed Maritime Operations (DMOs) to prepare for future large-scale combat operations with peer or near-peer competitors. As a result, individual components of naval forces will be more geographically dispersed and oper- ating at a significant time and distance from higher levels of medical care. We developed a series of educational scenarios informed by real-world events to enhance the ability of Role 1 medical caregivers to apply the principles of Prolonged Ca- sualty Care during current routine, crisis, and contingency DMOs.

Effectiveness of Mobile Applications for Trauma Care in Combat Casualty Simulations Throughout the Continuum.

INTRODUCTION: The U.S. Military uses handwritten documentation throughout the continuum of combat casualty care to document from point-of-injury, during transport and at facilities that provide damage control resuscitation and surgery. Proven impractical due to lack of durability and legibility in arduous tactical environments, we hypothesized that mobile applications would increase accuracy and completeness of documentation in combat casualty simulations. METHODS: We conducted simulations across this continuum utilizing 10 two-person teams consisting of a Medic and an Emergency or Critical Care Nurse. Participants were randomized to either the paper group or BATDOK and T6 Health Systems mobile application group. Simulations were completed in both the classroom and simulated field environments. All documentation was assessed for speed, completeness, and accuracy. RESULTS: Participant demographics averaged 10.8 ± 5.2 y of military service and 3.9 ± 0.6 h of training on both platforms. Classroom testing showed a significant increase in completeness (84.2 ± 8.1% versus 77.2 ± 6.9%; P = 0.02) and accuracy (77.6 ± 8.1% versus 68.9 ± 7.5%; P = 0.01) for mobile applications versus paper with no significant difference in overall time to completion (P = 0.19). Field testing again showed a significant increase in completeness (91.6 ± 5.8 % versus 70.0 ± 14.1%; P < 0.01) and accuracy (87.7 ± 7.6% versus 64.1 ± 14.4%; P < 0.01) with no significant difference in overall time to completion (P = 0.44). CONCLUSIONS: In deployed environments, mobile applications have the potential to improve casualty care documentation completeness and accuracy with minimal additional training. These efforts will assist in meeting an urgent operational need to enable our providers.

Characteristics and development trend of war injury treatment under joint all-area combat situation / 解放军医学杂志

At the beginning of this century,breakthroughs and innovations in disruptive technologies represented by artificial intelligence have profoundly affected the development of human society and have become a central component in leading the new global military transformation.Saving the lives of the wounded and technological innovation are the driving force behind the development of military medicine.How to fight a battle and how to save people is the question that military medicine must answer.Joint all-area combat is a new military concept,representing the development direction of the future combat style,it has a strong strategic guiding significance for the future war and also puts forward higher requirements for the treatment of war injuries."Platinum ten minutes,gold one hour"is the fundamental law of the battlefield first-line time-saving treatment,the war injury treatment must serve in the joint all-area combat demand and service requirements.This paper discusses the issue of demand or war injury treatment capacity building under the joint all-area combat pasture for criticism and correction.

Bluetooth Tactical Headsets Improve The Speed of Accurate Patient Handoffs.

BACKGROUND: The Committee on En Route Combat Casualty Care recently ranked the patient handoff as their fourth research priority. Bluetooth technology has been introduced to the battlefield and has the potential to improve the tactical patient handoff. The purpose of this study is to compare the traditional methods of communication used in tactical medical evacuation by Special Operations medical personnel (radio push-to-talk [PTT] and Tactical Medic Intercom System [TM-ICS]) to Bluetooth communication. METHODS: Twenty-four simulated tactical patient handoffs were performed to compare Bluetooth and traditional methods of communication used in tactical medical evacuation. Patient scenario order and method of communication were randomized. Accuracy and time required to complete the patient handoff were determined. The study took place using a rotary-wing aircraft kept at level 2 to simulate real-world background noise. Preferred method of communication for each study participant was determined. RESULTS: There were no differences in accuracy of the received patient handoffs between groups or patient handoff transmission times at the ramp of the aircraft. However, when comparing patient handoff times to the medical team within the aircraft, Bluetooth communication was significantly faster than both TM-ICS and radio PTT, while Bluetooth PTT and radio PTT were also significantly faster than TM-ICS. Bluetooth communication was ranked as the preferred method of handoff by all study participants. CONCLUSION: The study demonstrated that utilization of Bluetooth technology for patient handover results in faster handoffs compared with traditional methods without sacrificing any accuracy in a scenario with high levels of noise.

Casualty evacuation in arctic and extreme cold environments: A paradigm shift for traumatic hypothermia management in tactical combat casualty care.

In Arctic or extreme cold environments of Alaska, trauma care is complicated by large expanses of geography and lack of forward-positioned resources. This paper presents four hypothetical vignettes highlighting austere cold medical priorities: (1) traumatic hypothermia management as part of Tactical Combat Casualty Care (TCCC) is clinically and tactically important and hypothermia needs to be reprioritized in the MARCH algorithm to MhARCH; (2) at present it is unknown which TCCC recommended medical equipment/supplies will function as designed in the extreme cold; (3) ensuring advanced resuscitative care measures are available serves as a temporal bridge until casualties can receive damage control resuscitation (DCR); and (4) current systems for managing traumatic hypothermia in TCCC and casualty evacuation (CASEVAC) are insufficient. In conclusion, numerous assessments recognise the DoD's current solutions for employing medical forces in Arctic operations are not optimally postured to save lives. There should be a joint standard for fielding an arctic supplement to current medical equipment sets. A new way of thinking in terms of an "ecosystem" approach of immediate casualty protection and movement in CASEVAC doctrine is needed to optimise these "Golden Minutes."

Slow Intravenous Infusion of a Novel Damage Control Cocktail Decreases Blood Loss in a Pig Polytrauma Model.

BACKGROUND: Our objective was to optimize a novel damage control resuscitation (DCR) cocktail composed of hydroxyethyl starch, vasopressin, and fibrinogen concentrate for the polytraumatized casualty. We hypothesized that slow intravenous infusion of the DCR cocktail in a pig polytrauma model would decrease internal hemorrhage and improve survival compared with bolus administration. METHODS: We induced polytrauma, including traumatic brain injury (TBI), femoral fracture, hemorrhagic shock, and free bleeding from aortic tear injury, in 18 farm pigs. The DCR cocktail consisted of 6% hydroxyethyl starch in Ringer's lactate solution (14mL/kg), vasopressin (0.8U/kg), and fibrinogen concentrate (100mg/kg) in a total fluid volume of 20mL/kg that was either divided in half and given as two boluses separated by 30 minutes as control or given as a continuous slow infusion over 60 minutes. Nine animals were studied per group and monitored for up to 3 hours. Outcomes included internal blood loss, survival, hemodynamics, lactate concentration, and organ blood flow obtained by colored microsphere injection. RESULTS: Mean internal blood loss was significantly decreased by 11.1mL/kg with infusion compared with the bolus group (p = .038). Survival to 3 hours was 80% with infusion and 40% with bolus, which was not statistically different (Kaplan Meier log-rank test, p = .17). Overall blood pressure was increased (p < .001), and blood lactate concentration was decreased (p < .001) with infusion compared with bolus. There were no differences in organ blood flow (p > .09). CONCLUSION: Controlled infusion of a novel DCR cocktail decreased hemorrhage and improved resuscitation in this polytrauma model compared with bolus. The rate of infusion of intravenous fluids should be considered as an important aspect of DCR.

Medic and Portable Pulse Oximeter Respiratory Rate Measurement Comparison to Waveform Capnography: A Prospective, Observational Study.

BACKGROUND: The second leading cause of preventable battlefield death involves airway management. Tactical combat casualty care (TCCC) guidelines emphasize combat casualty airway, breathing and respiratory evaluation, including respiratory rate (RR) measurement. The current standard of practice for the US Army medics is to measure the RR by manual counting. Manual counting methods are operator-dependent, and medics face situational stressors limiting accurate measurement of RR in combat settings. To date, no published studies evaluate alternate methods of RR measurement by medics. The purpose of this study is to compare RR assessment by medics against waveform capnography and commercial finger pulse oximeters with continuous plethysmography. MATERIALS AND METHODS: We conducted a prospective, observational study to compare Army medic RR assessments against plethysmography and waveform capnography RR. Assessments were performed prior to and following exertion at 30 and 60 seconds with both the pulse oximeter (NSN 6515-01-655-9412) and defibrillator monitor (NSN 6515-01-607-8629), followed by end-user surveys. RESULTS: Of the 40 medics enrolled over a 4-month period, most were male (85%), and reported between less than 5 years of military and medical experience. The mean manual RR reported by medics at rest did not significantly differ from waveform capnography (14.05 versus 13.98, p is equal to 0.523); however, mean manual RR reported by medics on post-exertional subjects was significantly lower than waveform capnography (25.62 versus 29.77, p is less than 0.001). Time to medic-obtained RR was slower than the pulse oximeter (NSN 6515-01-655-9412) both at rest (-7.37 seconds, p is less than 0.001) and at exertion (-6.50 seconds, p is less than 0.001). While the mean difference in RR between the pulse oximeter (NSN 6515-01-655-9412) and waveform capnography in models at rest at 30 seconds was statistically significant (-1.38, p is less than 0.001). There was no overall statistically significant differences in RR between the pulse oximeter (NSN 6515-01-655-9412) and waveform capnography in models at exertion at 30 seconds and at rest and exertion at 60 seconds. CONCLUSION: Resting RR measurement did not differ significantly; however, medic-obtained RR considerably deviated from both pulse oximeters and waveform capnography at elevated rates. Existing commercial pulse oximeters with RR plethysmography do not differ significantly from waveform capnography and should be investigated further for consideration in fielding across the force for RR assessment.

Analysis of tourniquet pressure over military winter clothing and a short review of combat casualty care in cold weather warfare.

Cold weather warfare is of increasing importance. Haemorrhage is the most common preventable cause of death in military conflicts. We analysed the pressure of the Combat Application Tourniquet® Generation 7 (CAT), the SAM® Extremity Tourniquet (SAMXT) and the SOF® Tactical Tourniquet Wide Generation 4 (SOFTT) over different military cold weather clothing setups with a leg tourniquet trainer. We conducted a selective PubMed search and supplemented this with own experiences in cold weather medicine. The CAT and the SAMXT both reached the cut off value of 180mmHg in almost all applications. The SOFTT was unable to reach the 180mmHg limit in less than 50% of all applications in some clothing setups. We outline the influence of cold during military operations by presenting differences between military and civilian cold exposure. We propose a classification of winter warfare and identify caveats and alterations of Tactical Combat Casualty Care in cold weather warfare, with a special focus on control of bleeding. The application of tourniquets over military winter clothing is successful in principle, but effectiveness may vary for different tourniquet models. Soldiers are more affected and impaired by cold than civilians. Military commanders must be made aware of medical alterations in cold weather warfare.

External Hemorrhage Control Techniques for Human Space Exploration: Lessons from the Battlefield.

The past few decades of military experience have brought major advances in the prehospital care of patients with trauma. A focus on early hemorrhage control with aggressive use of tourniquets and hemostatic gauze is now generally accepted. This narrative literature review aims to discuss external hemorrhage control and the applicability of military concepts in space exploration. In space, environmental hazards, spacesuit removal, and limited crew training could cause significant time delays in providing initial trauma care. Cardiovascular and hematological adaptations to the microgravity environment are likely to reduce the ability to compensate, and resources for advanced resuscitation are limited. Any unscheduled emergency evacuation requires a patient to don a spacesuit, involves exposure to high G-forces upon re-entry into Earth's atmosphere, and costs a significant amount of time until a definitive care facility is reached. As a result, early hemorrhage control in space is critical. Safe implementation of hemostatic dressings and tourniquets seems feasible, but adequate training will be essential, and tourniquets are preferably converted to other methods of hemostasis in case of a prolonged medical evacuation. Other emerging approaches such as early tranexamic acid administration and more advanced techniques have shown promising results as well. For future exploration missions to the Moon and Mars, when evacuation is not possible, we look into what training or assistance tools would be helpful in managing the bleed at the point of injury.

The Effect of Prehospital Blood Transfusion on Patient Body Temperature from the Time of Emergency Medical Services Transfusion to Arrival at the Emergency Department.

BACKGROUND: Transfusion of blood products is life-saving and time-sensitive in the setting of acute blood-loss anemia, and is increasingly common in the emergency medical services (EMS) setting. Prehospital blood products are generally "cold-stored" at 4°C, then warmed with a portable fluid-warming system for the purpose of preventing the "lethal triad" of hypothermia, acidosis, and coagulopathy. This study aims to evaluate body temperature changes of EMS patients receiving packed red blood cells (PRBC) and/or fresh frozen plasma (FFP) when using the LifeWarmer Quantum Blood & Fluid Warming System (LifeWarmer, https://www.lifewarmer.com/). METHODS: From 1 January 2020 to 31 August 2021, patients who qualified for and received PRBC and/or FFP were retrospectively reviewed. Body-temperature homeostasis pre- and post-transfusion were evaluated with attention given to those who arrived to the emergency department (ED) hypothermic (<36°C). RESULTS: For all 69 patients analyzed, the mean initial prehospital temperature (°C) was 36.5 ± 1.0, and the mean initial ED temperature was 36.7 ± 0.6, demonstrating no statically significant change in value pre- or post-transfusion (0.2 ± 0.8, p = .09). Shock index showed a statistically significant decrease following transfusion: 1.5 ± 0.5 to 0.9 ± 0.4 (p < .001). CONCLUSION: Use of the Quantum prevents the previously identified risk of hypothermia with respect to unwarmed prehospital transfusions. The data is favorable in that body temperature did not decrease in critically ill patients receiving cold-stored blood warmed during administration with the Quantum.

Where There's a War, There's a Way: A Brief Report on Tactical Combat Casualty Care Training in a Multinational Environment.

BACKGROUND: With most combat deaths occurring in prehospital settings, the US Armed Forces focuses on life-threatening conditions at or near the point of injury. Tactical Combat Casualty Care (TCCC) guidelines are required for all US Servicemembers. Multinational militaries lack this requirement, and international partner forces often have limited prehospital medical training. METHODS: From November 2019 to March 2020, military members assigned to the Role 2E at the Hamid Kazai International Airport (HKIA) North Atlantic Treaty Organization (NATO) base conducted multinational TCCC training. The standardized Joint Trauma System (JTS) TCCC curriculum consisted of two-day classroom instruction and situational training exercises. Competency was assessed through verbalized and demonstrated knowledge. After Action Reviews (AAR) were completed. RESULTS: Twelve multinational TCCC training courses trained 590 military Servicemembers and civilians from 10 countries, ranging from 16 to 62 participants (avg class size = 35). Portugal and Turkey represented the two largest participating nations with 219 and 133, respectively. Student feedback determined optimal group ratios for instruction. AARs were reviewed to categorize best practices. CONCLUSION: Multinational TCCC standardization will save lives. Most nations lack TCCC training requirements. Thus, providing opportunities for standardized training for HKIA residents helped established a multinational baseline of medical interoperability. Utilizing this curriculum in multinational environments can replicate these results. International adoption of TCCC is dynamic and ongoing and should be promulgated to reduce preventable deaths.

Design and implementation of integrated simulation training system of tactical combat casualty care for mobile medical detachments / 医疗卫生装备

Objective To design an integrated simulation training system of tactical combat casualty care for mobile medical detachments to realize training of mass casualty treatment at wartime.Methods An integrated simulation training system of tactical combat casualty care for mobile medical detachments was developed with UE4 unreal engine and Vue.js framework for developing visual interface scenes,3D modeling for building war simulation scenarios,Java programming language for writing backend logic code and MySQL database for data recording.There were four functional modules involved in the system developed for micro class,self-assessment,game simulation and record query.Results The system developed realized integrated training for attending class,practice,test and review,and enhanced the efficacy for training of tactical combat casualty care.Conclusions The system developed contributes to increasing the combat casualty care capability of mobile medical detachments.

Unit Collective Medical Training in the 75th Ranger Regiment.

The 75th Ranger Regiment's success with eliminating preventable death on the battlefield is innate to the execution of a continuous operational readiness training cycle that integrates individual and unit collective medical training. This is a tactical solution to a tactical problem that is solved by the entire unit, not just by medics. When a casualty occurs, the unit must immediately respond as a team to extract, treat, and evacuate the casualty while simultaneously completing the tactical mission. All in the unit must maintain first responder medical skills and medics must be highly proficient. Leaders must be prepared to integrate casualty management into any phase of the mission. Leaders must understand that (1) the first casualty can be anyone; (2) the first responder to a casualty can be anyone; (3) medical personnel manage casualty care; and (4) leaders have ownership and responsibility for all aspects of the mission. Foundational to training is a command-directed casualty response system which serves as a forcing function to ensure proficiency and mastery of the basics. Four programs have been developed to train individual and collective tasks that sustain the Ranger casualty response system: (1) Ranger First Responder, (2) Advanced Ranger First Responder, (3) Ranger Medic Assessment and Validation, and (4) Casualty Response Training for Ranger Leaders. Unit collective medical training incorporates tactical leader actions to facilitate the principles of casualty care. Tactical leader actions are paramount to execute a casualty response battle drill efficiently and effectively. Successful execution of this battle drill relies on a command-directed casualty response system and mastery of the basics through rehearsals, repetition, and conditioning.