U.S. Army Medical Corps Recruitment, Job Satisfaction, and Retention: Historical Perspectives and Current Issues.

INTRODUCTION: This study was conducted to identify and understand the current factors affecting recruitment, job satisfaction, and retention of U.S. Army Medical Corps officers and provide historical background to understand if the current factors are dissimilar. MATERIALS AND METHODS: An anonymous, voluntary questionnaire was sent to U.S. Army Medical Corps officers, and responses were tabulated and analyzed. Historical research was conducted and historical analysis applied. RESULTS: Recruiting, job satisfaction, and retention among Army Medical Corps Officers have been problematic throughout the 50-year history of the all-volunteer force. Recruiting has largely been of medical students, with very limited numbers of direct accessions. At times, satisfactory overall numbers have camouflaged shortages in key go-to-war specialties. Also, satisfactory numbers in a specialty have sometimes camouflaged problems in depth of experience. Satisfaction has been seen as a problem but apparently only studied informally and/or episodically. Retention has largely been addressed through service obligations, followed by monetary bonuses, although these have to be across the Department of Defense, limiting service flexibility. There has never been consistent, longitudinal sampling of opinion among Medical Corps Officers to allow senior leaders to influence the Department of Defense policy. A recent (2016) study provides substantial data but should be repeated rather than being isolated. CONCLUSION: As the situation in the Department of Defense and Army Medical Department changes, with more focus on go-to-war specialties, the Army needs to better measure opinion among Medical Corps Officers to inform policy. These studies should be conducted regularly to generate reliable information on trends and allow prioritization of effort to areas that hamper recruiting, undermine satisfaction, and prevent retention.

New hemostatic agents in the combat setting.

BACKGROUND: Hemorrhage is a leading cause of potentially preventable death in both civilian and military trauma patients. Animal data have shown that hemostatic bandages reduce hemorrhage and improve survival. This article reports recent clinical observations regarding the efficacy and evolution of use of two new hemostatic bandages employed in the global war on terrorism. METHODS: We performed a retrospective cohort review of soldiers treated with either the QuikClot or HemCon hemostatic bandages between April and October 2006. Hemostatic dressings were placed on wounds either in the field or at the combat support hospital (CSH). RESULTS: During the 6-month study period, 1691 trauma patients were admitted to the CSH. Fifty uses of hemostatic dressings in 44 patients (2.6% of admissions) were identified. Forty patients were treated with HemCon dressings, three patients with QuikClot, and one with both QuikClot and HemCon. Eighteen percent of the dressings were used in the field, predominantly on extremity wounds (7/8). In contrast, most dressings used in the CSH were for truncal wounds (26/36 patients). Hemostatic dressings were applied to extremity wounds in prehospital and hospital settings, either alone or in conjunction with tourniquets. In surviving patients (95%), the treating surgeon determined that the hemorrhage was either stopped or greatly decreased by use of hemostatic dressings. Two of the four patients treated with QuikClot had burns from exothermic reactions, while no adverse reactions were noted with HemCon. CONCLUSIONS: Hemostatic agents stop or decrease bleeding. Whereas HemCon appears to be safe, QuikClot may produce superficial burns. These new hemostatic agents have a place in the surgical armamentarium to assist in controlling internal hemorrhage from truncal and pelvic hemorrhage, especially during damage-control surgery.

Longterm outcomes after combat casualty emergency department thoracotomy.

BACKGROUND: The incidence, survival, and blood product use after emergency department thoracotomy (EDT) in combat casualties is unknown. STUDY DESIGN: We performed a prospective and retrospective observational study of EDT at a combat support hospital in Iraq, evaluating the impact of injury mechanisms, blood product use, mortality, and longterm neurologic outcomes of survivors. RESULTS: From November 2003 to December 2007, 12,536 trauma admissions resulted in 101 EDTs (0.01%). In patients undergoing EDT, penetrating trauma from explosions and firearms accounted for the majority of injuries (93%). There were no survivors after EDT for blunt trauma (n=7). The areas of primary penetrating injury were the abdomen (30%), thorax (40%), and extremities (22%). Twelve percent (12 of 101) of all patients survived until evacuation, with the overall survival rate (8 to 26 months) of US casualties at 11% (6 of 53). There was no difference in survival seen in either injury mechanism or primary injury location. Signs of life were present in all overall survivors. Cardiopulmonary resuscitation (CPR) was performed in 92% (93 of 101) of all patients, and in 75% (9 of 12) of those evacuated. Mean (+/-SD) transfusion requirements for all patients were 15.0+/-12.7 U of RBC and 7.3+/-8.7 U of fresh frozen plasma during the initial resuscitation. Survivors demonstrated higher fresh frozen plasma:RBC ratios. All survivors were neurologically intact. CONCLUSIONS: In the combat casualty with penetrating injury, arriving with signs of life, receiving CPR, and undergoing EDT, longterm survival with normal neurologic outcomes is possible. CPR is not a contraindication to performance of EDT in penetrating injuries if signs of life are present. A large amount of blood products are used in the resuscitation of EDT patients.

Effect of recombinant factor VIIa as an adjunctive therapy in damage control for wartime vascular injuries: a case control study.

OBJECTIVES: Military casualties with vascular injuries often present with severe acidosis and coagulopathy that can negatively influence limb salvage decisions. We previously reported the value of a damage control resuscitation (DCR) strategy that can correct physiologic shock during simultaneous vascular reconstruction. The effect of recombinant factor VIIa (rFVIIa) on the repair of injured vessels and vascular grafts when used as an adjunctive therapy during DCR is unclear in the setting of wartime vascular injuries. The primary aim of this study was to assess the effect of rFVIIa use during DCR for vascular trauma and the impact on vessel repair. METHODS: A retrospective two cohort case control study was performed using the Joint Theater Trauma Registry to identify patients with major vascular injury and DCR. Group 1 (n = 12) had DCR and repair of the injured vessels. Group 2 (n = 41) included early rFVIIa as an adjunctive therapy with DCR to control bleeding and perform simultaneous vascular reconstruction. RESULTS: Age, injury severity score, presenting physiology, and operative time were similar between groups. Postoperative data show that early physiologic recovery from acidosis, coagulopathy, and anemia was associated with rFVIIa and DCR. Extremity graft failures in groups 1 and 2 (follow-up range, 10-26 months) were either from early thrombosis (1 vs. 5 p = 1), graft dehiscence (1 vs. 2 p = 0.55), or infection (1 vs. 1 p = 0.41) and were the result of inadequate soft tissue coverage or technical factors that eventually resulted in eight (15%) amputations. All cause mortality (group 1: 0% vs. group 2: 7.3%, p = 1) and amputation rates (group 1: 25% vs. groups 2: 12.2%, p = 0.36) were similar between the two groups. CONCLUSIONS: DCR using rFVIIa is effective for controlling hemorrhage and reversing coagulopathy for severe vascular injuries. Early graft failures seem unrelated to rFVIIa use in the setting of wartime vascular injuries. No differences in amputation rate or mortality were seen. Although rFVIIa may be a useful damage control adjunct during vessel repair, the overall impact of this strategy on long-term outcomes such as mortality and limb salvage remains to be determined.

Damage control resuscitation for vascular surgery in a combat support hospital.

BACKGROUND: Hemorrhage from extremity wounds is a leading cause of potentially preventable death during modern combat operations. Optimal management involves rapid hemostasis and reversal of metabolic derangements utilizing damage control principles. The traditional practice of damage control surgery favors a life over limb approach and discourages elaborate, prolonged vascular reconstructions. We hypothesized that limb preservation could be successful when the damage control approach combines advanced resuscitative strategies and modern vascular techniques. METHODS: Trauma Registry records at a Combat Support Hospital from April to June 2006 were retrospectively reviewed. Patients with life-threatening hemorrhage (defined as >4 units of packed red blood cells) who underwent simultaneous revascularization for a pulseless extremity were included. Data collection included the initial physiologic parameters in the emergency department (ED), total and 24-hour blood product requirements, and admission physiology and laboratory values in the intensive care unit (ICU). Outcome measures were survival, graft patency, and amputation rate at 7 days. RESULTS: Sixteen patients underwent 20 vascular reconstructions for upper (3) or lower extremity (17) wounds. Patients were hypotensive (blood pressure 105/60 +/- 29/18), acidotic (pH 7.27 +/- 0.1; BD -7.50 +/- 5.5), and coagulopathic (international normalized ratio 1.3 +/- 0.4) on arrival to the ED and essentially normal upon admission to the ICU, 4 hours later. Vein grafts (19/20, 95%) were used preferentially. Prosthetic grafts (1), shunting and delayed repair (4) or amputation (1) were infrequent. Heparin was not used or limited to a half dose (5/20, 25%). Tourniquets (12/16, 75%) and fasciotomies (13/16, 81%) were routine. Most (75%) received recombinant factor VIIa in the ED and in the operating room. All survived with normalized physiology on arrival in the ICU. Twenty-four-hour crystalloid use averaged 7.1 +/- 3.2 L, whereas packed red blood cells averaged 23 +/- 18 units, and 88% were massively transfused. Median operative time was 4.5 hours (range, 1.7-8.4 hours). CONCLUSIONS: Aggressive damage control resuscitation maneuvers in critically injured casualties successfully permitted prolonged, complex extremity revascularization with excellent early limb salvage and graft patency. Recombinant VIIa and liberal resuscitation with fresh whole blood, plasma, platelets and cryoprecipitate, while minimizing crystalloid, allowed limb salvage and did not result in early graft failures.

A predictive model for massive transfusion in combat casualty patients.

BACKGROUND: Massive transfusion (MT) is associated with increased morbidity and mortality in severely injured patients. Early and aggressive use of blood products in these patients may correct coagulopathy, control bleeding, and improve outcomes. However, rapid identification of patients at risk for MT has been difficult. We postulated that evaluation of clinical variables routinely assessed upon admission would allow identification of these patients for earlier, more effective intervention. METHODS: A retrospective cohort study was conducted at a single combat support hospital to identify risk factors for MT in patients with traumatic injuries. Demographic, diagnostic, and laboratory variables obtained upon admission were evaluated. Univariate and multivariate analyses were performed. An algorithm was formulated, validated with an independent dataset and a simple scoring system was devised. RESULTS: Three thousand four hundred forty-two patient records were reviewed. At least one unit of blood was transfused to 680 patients at the combat support hospital. Exclusion criteria included age less than 18 years, transfer from another medical facility, designation as a security internee, or incomplete data fields. The final number of patients was 302, of whom 26.5% (80 of 302) received a MT. Patients with MT had higher mortality (29 vs. 7% [p < 0.001]), and an increased Injury Severity Score (25 +/- 11.1 vs. 18 +/- 16.2 [p < 0.001]). Four independent risk factors for MT were identified: heart rate >105 bpm, systolic blood pressure <110 mm Hg, pH <7.25, and hematocrit <32.0%. An algorithm was created to analyze the risk of MT (area under the curve [AUC] = 0.839). In an independent data set of 396 patients the ability to accurately identify those requiring MT was 66% (AUC = 0.747). CONCLUSIONS: Independent predictors for MT were identified in a cohort of severely injured patients requiring transfusions. Patients requiring a MT can be identified with variables commonly obtained upon hospital admission.

The effectiveness of a damage control resuscitation strategy for vascular injury in a combat support hospital: results of a case control study.

OBJECTIVES: Major vascular injury is a leading cause of potentially preventable hemorrhagic death in modern combat operations. An optimal resuscitation approach for military trauma should offer both rapid hemorrhage control and early reversal of metabolic derangements. The objective of this report is to establish the use and effectiveness of a damage control resuscitation (DCR) strategy in the setting of wartime vascular injury. METHODS: A retrospective two-cohort case control study was performed using the Joint Theater Trauma Registry to identify patients with an extremity vascular injury treated at two different points in time: group 1 (n = 16) from April to June 2006 when DCR concepts were put into practice and group 2 (n = 24) 1 year later in a period when DCR strategies were not employed. RESULTS: Baseline demographics, injury severity, admission physiology, and operative details were similar between groups 1 and 2. Group 1 patients received more total blood products (23 vs. 12 units, p < 0.05), fresh frozen plasma (16 vs. 7 units, p < 0.01), cryoprecipitate (11 vs. 1.2 units, p < 0.05), whole blood (19% vs. 0%, p = 0.06), and early recombinant factor VIIa (75% vs. 0%, p < 0.001) than group 2 patients. Group 1 patients had a more complete early physiologic recovery after vascular reconstruction (heart rate: 38 vs. 12, p < 0.001; systolic blood pressure, 39 vs. 14, p < 0.001; base deficit: 7.36 vs. 2.72, p < 0.001; International Normalized Ratio, 0.3 vs. 0.1, p < 0.001). There was no significant difference in early amputation rates (group 1: 6.2% vs. group 2: 4.2%) or 7-day mortality (0% in both groups). CONCLUSIONS: This study was the first to use the Joint Theater Trauma Registry for follow-up on an established clinical practice guideline. DCR goals appear now to be met during the management of acute wartime vascular injuries with effective correction of physiologic shock. The overall impact of this resuscitation strategy on long-term outcomes such as limb salvage and mortality remains to be determined.

Ethnicity greatly influences cytokine gene polymorphism distribution.

Polymorphisms in the regulatory regions of cytokine genes are associated with high and low cytokine production and may modulate the magnitude of alloimmune responses following transplantation. Ethnicity influences allograft half-life and the incidence of acute and chronic rejection. We have questioned whether ethnic-based differences in renal allograft survival could be due in part to inheritance of cytokine polymorphisms. To address that question, we studied the inheritance patterns for polymorphisms in several cytokine genes (IL-2, IL-6, IL-10, TNF-alpha, TGF-beta, and IFN-gamma) within an ethnically diverse study population comprised of 216 Whites, 58 Blacks, 25 Hispanics, and 31 Asians. Polymorphisms were determined by allele-specific polymerase chain reaction and restriction fragment length analysis. We found striking differences in the distribution of cytokine polymorphisms among ethnic populations. Specifically, significant differences existed between Blacks and both Whites and Asians in the distribution of the polymorphic alleles for IL-2. Blacks, Hispanics and Asians demonstrated marked differences in the inheritance of IL-6 alleles and IL-10 genotypes that result in high expression when compared with Whites. Those of Asian descent exhibited an increase in IFN-gamma genotypes that result in low expression as compared to Whites. In contrast, we did not find significant ethnic-based differences in the inheritance of polymorphic alleles for TNF-alpha. Our results show that the inheritance of certain cytokine gene polymorphisms is strongly associated with ethnicity. These differences may contribute to the apparent influence of ethnicity on allograft outcome.

Sentinel lymph node evaluation is technically feasible and may improve staging in colorectal cancer.

PURPOSE: The accurate nodal staging of colorectal cancer (CRC) is important to identify those patients who may benefit from adjuvant chemotherapy. Some have suggested that identification of sentinel lymph nodes (SLN) may improve staging in CRC. We sought to determine: the feasibility of identifying SLN in CRC utilizing isosulfan blue dye; the accuracy of the identified SLN in predicting the status of the remainder of the lymph nodes in CRC; and whether a more thorough evaluation of SLN with serial step sectioning and immunohistochemistry would more accurately stage patients with CRC. METHODS: A pilot trial was initiated at Walter Reed Army Medical Center (WRAMC), and 17 patients with masses on colonoscopy and subsequent tissue diagnosis of CRC were enrolled. Patients underwent standard surgical resection of their CRC with wedge of mesentery containing draining lymph nodes. Isosulfan blue dye was injected around the tumor subserosally/submucosally before dividing the mesenteric portion of the resection (n = 7) or ex vivo (n = 10). Sentinel lymph nodes were defined as all nodes staining blue and were dissected from the mesentery in the operating room. The SLN were sent separately for standard bivalving and hematoxylin and eosin staining (H&E) followed by serial step sectioning and immunohistochemistry (IHC) staining for cytokeratin. RESULTS: Seventeen patients (6 men, 11 women) were enrolled. The average preoperative carcinoembryonic antigen (CEA) was 5.9 (range, 1.2 to 18.9), and the average postoperative CEA was 2.8 (range, 0.7 to 9.1). One patient had a T1 tumor, 6 patients had T2 tumors, and 10 patients had T3 tumors on final pathology. Five cancers were well differentiated, 11 were moderately differentiated, and 1 was poorly differentiated. In all 17 cases, SLN were identified. A mean of 5.5 SLN was found per specimen (range, 2 to 11) with no difference noted between injection techniques (in vivo vs ex vivo). An additional 12 nonsentinel lymph nodes (range, 1 to 29) were identified per specimen. Ten patients had negative SLN and non-SLN. Seven patients were found to have positive SLN (3 by H&E, 2 by serial step sectioning, and 2 by IHC only). CONCLUSIONS: The isosulfan blue technique is technically feasible to allow identification of sentinel lymph nodes. In this study, no false-negative SLN occurred. A total of 7 patients had positive SLN; more importantly, 4 patients were upstaged as a result of serial step sectioning and immunohistochemistry staining. We hypothesize that this method may help pathologists find appropriate lymph nodes for more detailed analysis. As a result, patients may be more accurately staged and counseled for adjuvant chemotherapy, which has been shown to improve survival in node-positive CRC. Further studies should be undertaken to test these preliminary findings.