Smart Medical Evacuation Support System for the Military.

Medical support in crisis situations is a major challenge. Efficient implementation of the medical evacuation process especially in operations with limited human resources that may occur during armed conflicts can limit the loss of these resources. Proper evacuation of wounded soldiers from the battlefield can increase the chances of their survival and rapid return to further military operations. This paper presents the technical details of the decision support system for medical evacuation to support this process. The basis for the functioning of this system is the continuous measurement of vital signs of soldiers via a specialized measurement module with a set of medical sensors. Vital signs values are then transmitted via the communication module to the analysis and inference module, which automatically determines the color of medical triage and the soldier's chance of survival. This paper presents the results of tests of our system to validate it, which were carried out using test vectors of soldiers' vital signs, as well as the results of the system's performance on a group of volunteers who performed typical activities of tactical operations. The results of this study showed the usefulness of the developed system for supporting military medical services in military operations.

The thin red line: Blood planning factors and the enduring need for a robust military blood system to support combat operations.

ABSTRACT: Battlefield lessons learned are forgotten; the current name for this is the Walker Dip. Blood transfusion and the need for a Department of Defense Blood Program are lessons that have cycled through being learned during wartime, forgotten, and then relearned during the next war. The military will always need a blood program to support combat and contingency operations. Also, blood supply to the battlefield has planning factors that have been consistent over a century. In 2024, it is imperative that we codify these lessons learned. The linchpins of modern combat casualty care are optimal prehospital care, early whole blood transfusion, and forward surgical care. This current opinion comprised of authors from all three military Services, the Joint Trauma System, the Armed Services Blood Program, blood SMEs and the CCC Research Program discuss two vital necessities for a successful military trauma system: (1) the need for an Armed Services Blood Program and (2) Planning factors for current and future deployed military ere is no effective care for wounded soldiers, and by extension there is no effective military medicine.

A trauma expert consensus: Capabilities are required early to improve survivability from traumatic injury.

BACKGROUND: Mortality reviews examine US military fatalities resulting from traumatic injuries during combat operations. These reviews are essential to the evolution of the military trauma system to improve individual, unit, and system-level trauma care delivery and inform trauma system protocols and guidelines. This study identifies specific prehospital and hospital interventions with the potential to provide survival benefits. METHODS: US Special Operations Command fatalities with battle injuries deemed potentially survivable (2001-2021) were extracted from previous mortality reviews. A military trauma review panel consisting of trauma surgeons, forensic pathologists, and prehospital and emergency medicine specialists conducted a methodical review to identify prehospital, hospital, and resuscitation interventions (e.g., laparotomy, blood transfusion) with the potential to have provided a survival benefit. RESULTS: Of 388 US Special Operations Command battle-injured fatalities, 100 were deemed potentially survivable. Of these (median age, 29 years; all male), 76.0% were injured in Afghanistan, and 75% died prehospital. Gunshot wounds were in 62.0%, followed by blast injury (37%), and blunt force injury (1.0%). Most had a Maximum Abbreviated Injury Scale severity classified as 4 (severe) (55.0%) and 5 (critical) (41.0%). The panel recommended 433 interventions (prehospital, 188; hospital, 315). The most recommended prehospital intervention was blood transfusion (95%), followed by finger/tube thoracostomy (47%). The most common hospital recommendations were thoracotomy and definitive vascular repair. Whole blood transfusion was assessed for each fatality: 74% would have required ≥10 U of blood, 20% would have required 5 to 10 U, 1% would have required 1 to 4 U, and 5% would not have required blood products to impact survival. Five may have benefited from a prehospital laparotomy. CONCLUSION: This study systematically identified capabilities needed to provide a survival benefit and examined interventions needed to inform trauma system efforts along the continuum of care. The determination was that blood transfusion and massive transfusion shortly after traumatic injury would impact survival the most. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level V.

A safety and feasibility analysis on the use of cold-stored platelets in combat trauma.

BACKGROUND: Damage-control resuscitation has come full circle, with the use of whole blood and balanced components. Lack of platelet availability may limit effective damage-control resuscitation. Platelets are typically stored and transfused at room temperature and have a short shelf-life, while cold-stored platelets (CSPs) have the advantage of a longer shelf-life. The US military introduced CSPs into the battlefield surgical environment in 2016. This study is a safety analysis for the use of CSPs in battlefield trauma. METHODS: The Department of Defense Trauma Registry and Armed Services Blood Program databases were queried to identify casualties who received room-temperature-stored platelets (RSPs) or both RSPs and CSPs between January 1, 2016, and February 29, 2020. Characteristics of recipients of RSPs and RSPs-CSPs were compared and analyzed. RESULTS: A total of 274 patients were identified; 131 (47.8%) received RSPs and 143 (52.2%) received RSPs-CSPs. The casualties were mostly male (97.1%), similar in age (31.7 years), with a median Injury Severity Score of 22. There was no difference in survival for recipients of RSPs (88.5%) versus RSPs-CSPs (86.7%; p = 0.645). Adverse events were similar between the two cohorts. Blood products received were higher in the RSPs-CSPs cohort compared with the RSPs cohort. The RSPs-CSPs cohort had more massive transfusion (53.5% vs. 33.5%, p = 0.001). A logistic regression model demonstrated that use of RSPs-CSPs was not associated with mortality, with an adjusted odds ratio of 0.96 (p > 0.9; 95% confidence interval, 0.41-2.25). CONCLUSION: In this safety analysis of RSPs-CSPs compared with RSPs in a combat setting, survival was similar between the two groups. Given the safety and logistical feasibility, the results support continued use of CSPs in military environments and further research into how to optimize resuscitation strategies. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Family Physician's Satisfaction Report: Military 2021 vs. Civilian 2020 and 2022.

INTRODUCTION: In the Medscape 2020 Compensation Report, family physicians ranked low for feeling fairly compensated, choosing their specialty again and choosing medicine again. However, the Medscape data may not represent military family physicians. METHODS: A large survey was emailed to 2,562 military family physicians via a military professional organization list-serve from February to April 2021. The inquiry included 6 statements pertaining to professional satisfaction. The main outcome measures were proportions of "agree" and "strongly agree." The proportions were compared to the Medscape Compensation Report 2020 and 2022. Statistical analysis was completed with a two-tailed Z-score for 2 populations. RESULTS: Sixty-one percent of military family physicians feel fairly compensated compared to 54% of civilian family physicians in 2020 and 55% in 2022 (P = .065, .119). Eighty-six percent of military family physicians would reselect medicine compared to 74% of civilian family physicians in 2020 and 73% in 2022 (P < .001 for both). Eighty percent of military family physicians would reselect their specialty again compared to 70% of civilians in 2020 and 68% in 2022 (P = .004, P = .001, respectively). CONCLUSIONS: Military family physicians were more likely to choose medicine generally and family medicine specifically again. Military family physicians and civilian family physicians do not statistically differ in feeling fairly compensated. A strong majority of military family physicians are satisfied with their military-sponsored medical education.

[Microbiological challenges in the treatment of war injuries]. / Mikrobiologische Herausforderungen bei der Versorgung von Kriegsverletzungen.

The treatment of war injuries represents a continuing and recurrent challenge in modern reconstructive surgery. Previously, tumor resections and sepsis-related resections were mainly responsible for lengthy bone defects in Germany. In recent years another picture has increasingly emerged, particularly caused by the medical support of Ukraine. Aspects of military surgery are also becoming more important in civil hospitals, especially in the treatment of gunshot and explosion injuries. In Germany, war injuries are currently secondarily treated, as the distribution of patients is carried out according to the cloverleaf principle, weeks or months after the occurrence of the primary injury. In addition to complex bone and soft tissue defects of the extremities following such injuries, which often affect neural and vascular structures, reconstruction is often complicated by an increasing spectrum of multidrug-resistant pathogens. The definition of microbiological terms, such as contamination, colonization, critical colonization, local and systemic infections are important in the clinical routine in order to initiate a targeted treatment, especially in treatment with antibiotics. Wound swabs for determination of the spectrum of pathogens and the optimal testing of resistance are important for selecting the appropriate antibiotic agents. The concept of antibiotic stewardship (ABS) is established in many hospitals to improve the quality of antibiotic treatment and to minimize the formation of resistance. The selection of the method of reconstruction depends on the condition of the patient, the overall clinical constellation and the function to be expected after completion of treatment. The treatment of injuries due to violence and terrorism necessitates clear concepts and an interdisciplinary approach, especially with respect to microbiological challenges and increasing resistance situations.

'Delivering effective Defence Healthcare Engagement during Short-Term Training Team deployments: Guidance from on-the-ground Practitioners'.

Defence Engagement (DE) has grown to become one of the key operational outputs of UK Defence. Defence Engagement (Health) (DE(H)) is a subcategory of DE, in which Defence Medical Services (DMS) personnel and assets are used to achieve influence and promote the UK's national interests. For most DMS personnel, their involvement in DE(H) will be as part of a Short-Term Training Team (STTT). STTTs are deployed to Host Nations (HNs) to work alongside a Partner Force, training, mentoring and supporting them to enhance their own capabilities. This article aims to guide junior members of the DMS in how they might approach an STTT from a DE(H) perspective. The article will draw primarily on the recent operational experiences of the authors across multiple STTTs in a variety of HNs.

The 2014 West Africa Ebola crisis: lessons from UK Defence Healthcare Engagement in Sierra Leone.

The 2014 West Africa Ebola virus disease outbreak prompted the deployment to Sierra Leone of non-governmental organisations and the UK Joint Inter-Agency Taskforce including personnel from the UK Defence Medical Services (DMS). Some of these military personnel partnered with the Republic of Sierra Leone Armed Forces (RSLAF) as an example of Defence Healthcare Engagement (DHE).UK DMS mentors assisted RSLAF to plan and upscale Ebola treatment units. Use of military analysis and planning tools facilitated robust and flexible plans to be produced while under significant time and resource constraints. Macrosimulation exercises enabled large numbers to be trained and standard operating procedures to be developed.Fundamental to success was a mutual respect between the DHE partners while maintaining host nation primacy throughout. DHE in this example offered advantages over non-governmental organisations. Transferable lessons for future DHE from the RSLAF-UK DMS partnership are described in this paper.

[Challenge of limb care after violence and war with a special focus on imaging procedures]. / Herausforderung der Extremitätenversorgung nach Gewalt und Krieg mit besonderer Betrachtung bildgebender Verfahren.

BACKGROUND: Injury patterns in the area of the extremities following violence and war harbor many special features and require special attention. Destructive and complex defect injuries are often present, which necessitate elaborate and special reconstruction approaches, predominantly as part of a staged and multistaged procedure. RESEARCH QUESTION: In this context, special attention must be paid to the diagnostic options as an essential aspect, as a clear diagnosis means that targeted treatment steps can be planned and implemented. MATERIAL AND METHOD: The authors' experience in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia, as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of interdisciplinary cooperation with radiological and, in particular, nuclear medicine disciplines are taken into account in the daily routine. RESULTS AND DISCUSSION: Extremity injuries in the context of violence and war are accompanied by complex bone and surrounding soft tissue defects due to the high energy impact. The principles of reconstruction familiar from everyday life can only be transferred one-to-one to a limited extent. The treatment pathways are often very long and complex and the questions of infection and tissue vitality must be answered again and again in stages. Interdisciplinary collaboration with the disciplines specialized in imaging procedures, particularly in the field of nuclear medicine, is one of the key building blocks for a successful treatment pathway.

[Initial in-hospital treatment of patients with penetrating trauma due to violence and war]. / Innerklinische Erstversorgung von Patienten mit penetrierendem Trauma nach Gewalt und Krieg.

BACKGROUND: Current political and social developments have brought the topics of violence, in this context attributable to terrorism and sabotage, and since February 2022 awareness of war in particular has again greatly increased. This article aims to present the contextualized dealing with penetrating injuries in terms of initial in-hospital treatment. OBJECTIVE: The question remains to be answered as to what extent penetrating injuries require special attention and to what extent the treatment priorities, options and strategies as well as surgical treatment require adaptation of the usual approach in routine clinical practice in Germany. MATERIAL AND METHOD: The experience of the authors in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of a comprehensive systematic literature review and current data from a national evaluation on the topic of preparing hospitals in Germany for such scenarios are taken into account. RESULTS AND DISCUSSION: The clinical systems need to be well-prepared for such casualties, especially if they require treatment in large numbers. This is precisely so because the majority of patients are in a relevantly threatening situation (usually in the sense of a hemorrhage), treatment must be very urgently provided and in such scenarios a lack of resources must always be overcome, at least temporarily, especially for example for blood transfusions.

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.

An Analysis of Tube Thoracostomy in Combat Implications for Improved Prehospital Recognition and Treatment.

BACKGROUND: Thoracic trauma occurs frequently in combat and is associated with high mortality. Tube thoracostomy (chest tube) is the treatment for pneumothorax resulting from thoracic trauma, but little data exist to characterize combat casualties undergoing this intervention. We sought to describe the incidence of these injuries and procedures to inform training and materiel development priorities. METHODS: This is a secondary analysis of a Department of Defense Trauma Registry (DoDTR) data set from 2007 to 2020 describing prehospital care within all theaters in the registry. We described all casualties who received a tube thoracostomy within 24 hours of admission to a military treatment facility. Variables described included casualty demographics; abbreviated injury scale (AIS) score by body region, presented as binary serious (=3) or not serious (<3); and prehospital interventions. RESULTS: The database identified 25,897 casualties, 2,178 (8.4%) of whom received a tube thoracostomy within 24 hours of admission. Of those casualties, the body regions with the highest proportions of common serious injury (AIS >3) were thorax 62% (1,351), extremities 29% (629), abdomen 22% (473), and head/neck 22% (473). Of those casualties, 13% (276) had prehospital needle thoracostomies performed, and 19% (416) had limb tourniquets placed. Most of the patients were male (97%), partner forces members or humanitarian casualties (70%), and survived to discharge (87%). CONCLUSIONS: Combat casualties with chest trauma often have multiple injuries complicating prehospital and hospital care. Explosions and gunshot wounds are common mechanisms of injury associated with the need for tube thoracostomy, and these interventions are often performed by enlisted medical personnel. Future efforts should be made to provide a correlation between chest interventions and pneumothorax management in prehospital thoracic trauma.

Refocusing the Military Health System to support Role 4 definitive care in future large-scale combat operations.

ABSTRACT: The last 20 years of sustained combat operations during the Global War on Terror generated significant advancements in combat casualty care. Improvements in point-of-injury care, en route care, and forward surgical care appropriately aligned with the survival, evacuation, and return to duty needs of the small-scale unconventional conflict. However, casualty numbers in large-scale combat operations have brought into focus the critical need for modernized casualty receiving and convalescence: Role 4 definitive care. Historically, World War II was the most recent conflict in which the United States fought in multiple operational theaters, with hundreds of thousands of combat casualties returned to the continental United States. These numbers necessitated the establishment of a "Zone of the Interior," which integrated military and civilian health care networks for definitive treatment and rehabilitation of casualties. Current security threats demand refocusing and bolstering the Military Health System's definitive care capabilities to maximize its force regeneration capacity in a similar fashion. Medical force generation, medical force sustainment and readiness, and integrated casualty care capabilities are three pillars that must be developed for Military Health System readiness of Role 4 definitive care in future large-scale contingencies against near-peer/peer adversaries.

APPLICATION OF ARTIFICIAL INTELLIGENCE IN CIVIL AND MILITARY MEDICINE.

Artificial intelligence (AI) encompasses the advancement of computers and robots, enabling them to surpass human capabilities in various aspects. By utilizing AI, programs have the ability to autonomously analyze and interpret data, offering information and executing actions without any human involvement. The ongoing war in Ukraine showed various aspects of severe gunshot injuries because of previously unknown course of wounds after application of ballistic missiles, drones, etc., which is frequently applied by russians. In such conditions, decision-making process by military medical doctors must be quick and rational, however in case of massive casualties, combined trauma (e.g. thoracoabdominal gunshot injury) MDs might have permanent challenges to apply appropriate care options and individualized approach. The aim of this study is to start the discussion about role and possible application of AI in management of gunshot injuries in combat patients or other individuals who received wounds relating to high-energy weapon. Conclusions. Gunshot wound is a clinical challenge in many cases among patients who were injured by high-energy weapons, requiring complex and quick decisions. AI might be applied as an additional tool for the decision-making process in case of severe trauma in deployed field hospitals, or in hospitals of higher Roles (3-4). This study is to start the research discussion about the utility of AI application for the management of the injured in the war associated with high-energy weapons.

Examining the Intersection of Strategic Thinking and Continuous Process Improvement Through the Lens of Military Medical Education to Build a Novel Model.

In 2020, the U.S. Air Force School of Aerospace Medicine hired its first civilian dean since its founding in 1918, tasked with building the school's first strategic plan to modernize and improve the institution. Using a combination of military continuous process improvement and academic strategic thinking, the dean produced a highly successful strategic plan. However, its resource-heavy and time-consuming methodology made it difficult to replicate. This study aimed to create a novel and streamlined strategic planning model that combined best practices from continuous process improvement and strategic thinking without redundancy. A qualitative descriptive case study was used to analyze the detailed efforts through content analysis of 150 pages of documentation. A hybrid approach to coding uncovered 44 deductive codes and 5 inductive codes from 10 strategic tools. Results indicated a converging relationship between all strategic processes tested-strategic planning, strategic thinking, and continuous process improvement and their associated tools. A five-step model called the Triple "O" OODA Loop was created, combining best practice tools from strategic planning (purpose trident and SWOT analysis or strengths, weaknesses, opportunities, and threats), strategic thinking (Hot Spots scale and GOST framework or goals, objectives, strategies, and tactics) and continuous process improvement (phases 6-8).