Misuse of Tourniquets in Ukraine may be Costing More Lives and Limbs than they Save.

Hands-on training and social media sites have heavily emphasized the use of tourniquets to treat limb injuries during the Ukraine war. Tourniquet overuse or misuse can lead to significant tragedy-limb loss, physiologic complications, and even death. Casualty evacuation in Ukraine often exceeds 6 hours, and the liberal use of limb tourniquets may have unintentionally increased morbidity. Tourniquet application was appropriate in 24.6% of the wounded with tourniquets in one recent publication by a Ukrainian vascular surgeon. The longer a limb tourniquet is in place raises the risk of compartment syndrome, vascular thrombosis, rhabdomyolysis, and irreversible myonecrosis resulting in major tissue loss and often necessitating limb amputation. If bleeding is controlled with a tourniquet, attempts to remove the tourniquet as early as possible to avoid the negative consequences are essential. Training in tourniquet use without explaining possible limb loss and other complications resulting from tourniquets left in situ more than 2 hours makes use risky. Tourniquets should be loosened at one hour if the tactical situation allows, and the injury assessed to determine if major bleeding persists or to determine if other methods of hemostasis would be effective. Ukraine must improve the training so that everyone becomes aware of the risks of prolonged or improper tourniquet use. This tourniquet training information must be transmitted to military medical leaders, Ukrainian military medics, civilian volunteers, volunteers in Ukraine, and NATO trainers in allied countries conducting medical training for Ukrainian soldiers. A trauma registry and tracking through echelons of care can enhance performance improvement through timely feedback.

Arming Hospital Ships of the Future: Hybrid Wars Require a Major Change.

INTRODUCTION: It is time to provide heavier defense systems to U.S. Navy hospital ships. They serve vital functions in both the military and emergency management spaces. They provide medical support for combat operations and can also convey the empathy and generosity of the American people when used in humanitarian assistance and disaster relief response. Hospital ships are often key to success in scenarios that require the international deployment of resources and medical expertise. Hospital ships serve a dual purpose and hence are subject to regulations that do not address all wartime mission requirements and necessary defensive capabilities. The current U.S. Navy's interpretation of the Geneva Conventions regarding the visibility, lack of defensive capabilities, and inability to use encrypted communications needlessly endangers medical platforms and personnel in the modern environment. METHODS: The authors (including senior author F.M.B.-a recognized (International Health Law expert) reviewed relevant literature and have evaluated the policies of belligerent parties in past and current conflicts. These increasingly appear to target civilian infrastructure including medical facilities and may increase the risk to hospital ships. This demonstrable current hybrid warfare appears to include purposeful attacks on health care facilities and as such hospital ships should have additional defensive measures. RESULTS: Hybrid warfare and its focus on civilian infrastructure and health care targets are highly visible in the acts of both state and non-state actors and may encourage others to purposefully target health care facilities and personnel. Evidence of this is seen in the current Russian invasion of Ukraine, where since the invasion a year ago 1,218 Ukrainian health facilities have been damaged, including 540 damaged hospitals, 173 of which were totally destroyed and turned into "piles of stones." CONCLUSIONS: In today's conflicted global environment, the clear identification of hospital ships leaving them relatively undefended and denying encrypted communication is the folly of a bygone era. Hospital ships may be targeted because they are brightly lit soft targets that can deliver a large payoff by their destruction. It is time to adapt to the global reality and move on from the tradition of painting hospital ships white, adorning them with red crosses, keeping them unarmed, maintaining open communications, and illuminating them at night. The increasing threats from hybrid warfare and unprincipled adversaries to medical platforms and providers of health care demonstrate that hospital ships must be capable of self-defense. The U.S. Navy is designing new platforms for medical missions and the debate, no matter how uncomfortable, must now occur among major decision-makers to make them more tactical and defensible.

Effective Humanitarian Work: Teaching Medical Skill Sets in Ukraine.

The senior authors traveled to Ukraine to teach specific skills to Ukrainian physicians and other medical professionals, utilizing a 2-day ATLS course, workshops in point-of-care ultrasonography (POCUS), lectures and webinars on damage control resuscitation, damage control surgery, and transfusion of whole blood. The authors have focused on providing skill sets that Ukrainian doctors can utilize within their existing system to improve immediate patient care for casualties resulting from the unanticipated Russian invasion and improve outcomes. Given the resource limitations and differences of the Ukrainian healthcare systems, the authors believe Western-based professionals who come to Ukraine to help for short periods should resist the temptation to offer western solutions that may not work in Ukraine. Major improvements in Ukrainian health care will require long-term efforts in teaching but also need to include increased efforts to improve hospitals, clinics, staffing, education, supplies, and equipment. Those who travel to help in Ukraine can still teach short courses that provide skills that Ukrainian doctors and nurses can use within their existing healthcare system to improve the quality of patient care in the immediate period of crisis and hopefully improve outcomes in the near term. It is not a reasonable expectation to think that the delivery of 2-day courses such as ATLS or POCUS will significantly change the country-wide delivery of healthcare. This sort of practice change requires the engagement of medical and political leaders and a sustained reform effort over years, not days or weeks. Supportive countries and non-governmental organizations need to prepare for a long and extensive investment in improving Ukrainian healthcare.

Russia's Hybrid Warfare in Ukraine Threatens Both Healthcare & Health Protections Provided by International Law.

Hybrid Warfare is on display because of the unjustified Russian invasion of Ukraine. This is characterized by numerous crimes against civilians as seen vividly during the occupation of the town of Bucha where rape, torture, murder, and looting seem to reflect Russian military policy, leadership, and command guidance. Of particular concern is the threat to hospitals and health care as well as vital life support. Numerous hospitals have been damaged and destroyed. Hospitals are not tactical military targets and targeting health care facilities and personnel ignores traditional jus in bello and ignores numerous conventions established to stabilize the global order. The Russian-proclaimed "special operation" in Ukraine has been characterized by barbarian warfare in which the Russian military uses weapons against the civilian population and civilian infrastructure. The aggressors have embarked on a purposeful terror campaign through infrastructure attacks, which are of little military value except to demoralize the nation's people. This is evident with Russian missile and drone attacks on electric, water, and health care in Ukraine. Warfare now and in the future may be increasingly aimed at demoralizing civilian populations and reducing the will of the people and their government to resist. The Ukrainian invasion clearly shows that this use of hybrid warfare should be met with a strong reaction of the international community at the earliest possible stage, especially the supposedly peace-loving neutral countries, or else the future is expanded unlawful and barbaric military conflict.

Improving Pandemic Response With Military Tools: Using Enhanced Intelligence, Surveillance, and Reconnaissance.

The coronavirus disease 2019 (COVID-19) pandemic rocked the world, spurring the collapse of national commerce, international trade, education, air travel, and tourism. The global economy has been brought to its knees by the rapid spread of infection, resulting in widespread illness and many deaths. The rise in nationalism and isolationism, ethnic strife, disingenuous governmental reporting, lockdowns, travel restrictions, and vaccination misinformation have caused further problems. This has brought into stark relief the need for improved disease surveillance and health protection measures. National and international agencies that should have provided earlier warning in fact failed to do so. A robust global health network that includes enhanced cooperation with Military Intelligence, Surveillance, and Reconnaissance (ISR) assets in conjunction with the existing international, governmental, and nongovernment medical intelligence networks and allies and partners would provide exceptional forward-looking and early-warning and is a proactive step toward making our future safe. This will be achieved both by surveilling populations for new biothreats, fusing and disseminating data, and then reaching out to target assistance to reduce disease spread in unprotected populations.

The Hospital Ship as a Strategic Asset in21st Century Foreign Policy and Global Health Crises.

INTRODUCTION: Current U.S. hospital ships-USNS Mercy and Comfort-are old, slow, cumbersome, and indefensible, and due for retirement. As new challenges and new threats emerge in the 21st century, the U.S. Navy should field new afloat medical platforms to potentially deal with both mass casualty scenarios and humanitarian disaster relief in a rapid and tactical manner. New hospital ships should be able to defend themselves with more modern weapons and to be interconnected with encrypted communications. They must be fast, nimble, tactical, defensible, and forward deployed in the risky global commons of the 21st century. MATERIALS AND METHODS: Systematic review of the literature on hospital ships, U.S. Navy policy, the Geneva Conventions, and current global threat conditions. RESULTS: Hospital ships provide medical support for U.S. forces in conflict and promote goodwill and a positive image of the U.S. abroad. Current hospital ships do not fit the operational paradigm of the current needs for forward deployed and rapidly deliverable operational medicine. There is a need for a new and more capable platform to deliver operational health care in the forward deployed setting. CONCLUSIONS: Multiple high-speed medical response vessels-whether reconfigured from an existing ship, or an entirely new platform developed for more robust medical delivery-need to be urgently fielded for future combat operations, humanitarian missions, and participation in cooperative security engagements. These medical platforms need to be able to defend themselves and be tactically interconnected with the Fleet and Fleet Forces.

Engineering microscale systems for fully autonomous intracellular neural interfaces.

Conventional electrodes and associated positioning systems for intracellular recording from single neurons in vitro and in vivo are large and bulky, which has largely limited their scalability. Further, acquiring successful intracellular recordings is very tedious, requiring a high degree of skill not readily achieved in a typical laboratory. We report here a robotic, MEMS-based intracellular recording system to overcome the above limitations associated with form factor, scalability, and highly skilled and tedious manual operations required for intracellular recordings. This system combines three distinct technologies: (1) novel microscale, glass-polysilicon penetrating electrode for intracellular recording; (2) electrothermal microactuators for precise microscale movement of each electrode; and (3) closed-loop control algorithm for autonomous positioning of electrode inside single neurons. Here we demonstrate the novel, fully integrated system of glass-polysilicon microelectrode, microscale actuators, and controller for autonomous intracellular recordings from single neurons in the abdominal ganglion of Aplysia californica (n = 5 cells). Consistent resting potentials (<-35 mV) and action potentials (>60 mV) were recorded after each successful penetration attempt with the controller and microactuated glass-polysilicon microelectrodes. The success rate of penetration and quality of intracellular recordings achieved using electrothermal microactuators were comparable to that of conventional positioning systems. Preliminary data from in vivo experiments in anesthetized rats show successful intracellular recordings. The MEMS-based system offers significant advantages: (1) reduction in overall size for potential use in behaving animals, (2) scalable approach to potentially realize multi-channel recordings, and (3) a viable method to fully automate measurement of intracellular recordings. This system will be evaluated in vivo in future rodent studies.

Lead, Follow, or Get out of the Way-How Bold Young Surgeons Brought Vascular Surgery into Clinical Practice from the Korean War Battlefield.

The maturation of vascular surgery into widespread clinical practice was accelerated by events that took place in Korea during the conflict of 1950-1953. Early research and anecdotal clinical trials were just then resulting in publication of cases of the successful vascular repairs and replacements. Noncrushing vascular clamps were being developed and limited manufacture begun. The stage was set for a major advance in the treatment of arterial injury, just as war commenced in Korea, which provided a clinical laboratory. When the war on the Korean Peninsula erupted in June 1950, the policy of the Army Medical department was to ligate all arterial injuries unless a simple transverse or end-to-end anastomosis could be performed, and repair was "contrary to policy and orders." Despite pressure and threats of "courts martial for vascular repairs" from the senior military medicine leaders-clinical experiments in arterial repair were carried out at Mobile Army Surgical Hospital facilities at battlefield locations across Korea. The young surgeons, mostly draftees and reservists, resisted rigid doctrine and orders to desist, and in the face of threatened punishment, were committed to do the right thing, and ultimately went on to change military medicine and vascular surgery. The "on-the-job" training in vascular surgery that was carried out in Korea by military surgeons who demonstrated substantially higher limb salvage rates energized the field from the battlefield laboratory. Many wounded soldiers had limbs saved by the new techniques in vascular repair pioneered by surgeons in the Korean War, and countless thousands who entered civilian hospitals for emergency vascular surgery in subsequent years also ultimately benefited from their work.

Casualties of the Global War on Terror and their future impact on health care and society: a looming public health crisis.

This article is a primer to understand the medical advances and the future health care consequences of the current conflicts in the Middle East and Southwest Asia, known as the Global War on Terror. There have been significant advances in health care learned in caring for those injured by the conflict--often a polytrauma blast victim, but there are also very high incidence rates of the hidden injuries of war--traumatic brain injury, post-traumatic stress disorder, suicide, and depression. These lead to disruptive behaviors, homelessness, and family violence. Global War on Terror returnees are using medical services and applying for disability at higher rates than in previous conflicts. The costs for veterans' care may peak 30 to 40 years or longer following the conflict, and will inflict an enormous burden on services and resources. The effects of the war will linger for years and impact across generations because of the stress on families and children. We must mobilize government agencies, create public-private partnerships, and invest our resources now to mitigate the approaching tsunami of veterans' health care needs, the impact on our social services, and the devastating costs to society.

Military medical advances resulting from the conflict in Korea, Part I: Systems advances that enhanced patient survival.

The Korean War started several years after the World War II had ended and no recognition of the threat or preparation was made for this possibility. The military and its medical service had been downsized after World War II and had to quickly ramp up to meet the surprise attack. The war provided the laboratory for trials and experimentation with the new technological developments of the era. The Korean conflict led to numerous advances in medical systems and patient care. The Mobile Army Surgical Hospital came of age, and was instrumental in saving many lives. Helicopters saw their first regular use as flying ambulances to take the injured to definitive care in a timely fashion. The national blood banking program was rapidly geared up and new techniques such as plastic bags for collection and delivery resulted. Body armor was developed that would allow mobility while offering protection and was widely used for the first time. Each of these systems improvements saved the lives of soldiers in combat and were soon to be used in the civilian sector to save and improve lives around the world.

Military medical advances resulting from the conflict in Korea, Part II: Historic clinical accomplishments.

Throughout the recorded history of civilization, there has been armed conflict. Warfare has been associated with advances in care for the wounded. Many of these advances when shown effective on the battlefield become incorporated into civilian health care. It is a laboratory where there is unfortunately much clinical material and presents opportunity for the creative, curious, and innovative. This article reviews the medical advances that resulted from the Korean War. There were notable advances in neurosurgery, vascular surgery, and plastic surgery. Tools from prior wars were rediscovered, dusted off, and used to stop combat losses from psychiatric trauma. A treatment was developed for cleft lip by a plastic surgeon, thus giving hope to young lives. War is a disruptive, destructive, and harrowing experience--but can lead to improvements in care for the wounded and these developments can improve the lives of people everywhere.

Finite element modeling and testing of a deformable carbon fiber reinforced polymer mirror.

Thin-shelled composite mirrors have been recently proposed for use as deformable mirrors in optical systems. Large-diameter deformable composite mirrors can be used in the development of active optical zoom systems. We present the fabrication, testing, and modeling of a prototype 0.2 m diameter carbon fiber reinforced polymer mirror for use as a deformable mirror. In addition, three actuation techniques have been modeled and will be presented.

Packaging and Non-Hermetic Encapsulation Technology for Flip Chip on Implantable MEMS Devices.

We report here a successful demonstration of a flip-chip packaging approach for a microelectromechanical systems (MEMS) device with in-plane movable microelectrodes implanted in a rodent brain. The flip-chip processes were carried out using a custom-made apparatus that was capable of the following: 1) creating Ag epoxy microbumps for first-level interconnect; 2) aligning the die and the glass substrate; and 3) creating non-hermetic encapsulation (NHE). The completed flip-chip package had an assembled weight of only 0.5 g significantly less than the previously designed wire-bonded package of 4.5 g. The resistance of the Ag bumps was found to be negligible. The MEMS micro-electrodes were successfully tested for its mechanical movement with microactuators generating forces of 450 µN with a displacement resolution of 8.8 µm/step. An NHE on the front edge of the package was created by patterns of hydrophobic silicone microstructures to prevent contamination from cerebrospinal fluid while simultaneously allowing the microelectrodes to move in and out of the package boundary. The breakdown pressure of the NHE was found to be 80 cm of water, which is significantly (4.5-11 times) larger than normal human intracranial pressures. Bench top tests and in vivo tests of the MEMS flip-chip packages for up to 75 days showed reliable NHE for potential long-term implantation.

Electrothermal Microactuators With Peg Drive Improve Performance for Brain Implant Applications.

This paper presents a new actuation scheme for in-plane bidirectional translation of polysilicon microelectrodes. The new Chevron-peg actuation scheme uses microelectromechanical systems (MEMS) based electrothermal microactuators to move microelectrodes for brain implant applications. The design changes were motivated by specific needs identified by the in vivo testing of an earlier generation of MEMS microelectrodes that were actuated by the Chevron-latch type of mechanism. The microelectrodes actuated by the Chevron-peg mechanism discussed here show improved performance in the following key areas: higher force generation capability (111 µN per heat strip compared to 50 µN), reduced power consumption (91 mW compared to 360 mW), and reliable performance with consistent forward and backward movements of microelectrodes. Failure analysis of the Chevron-latch and the Chevron-peg type of actuation schemes showed that the latter is more robust to wear over four million cycles of operation. The parameters for the activation waveforms for Chevron-peg actuators were optimized using statistical analysis. Waveforms with a 1-ms time period and a 1-Hz frequency of operation showed minimal error between the expected and the actual movement of the microelectrodes. The new generation of Chevron-peg actuators and microelectrodes are therefore expected to enhance the longevity and performance of implanted microelectrodes in the brain. [2011-0341].

Creating order from chaos: part I: triage, initial care, and tactical considerations in mass casualty and disaster response.

How do we train for the entire spectrum of potential emergency and crisis scenarios? Will we suddenly face large numbers of combat casualties, an earthquake, a plane crash, an industrial explosion, or a terrorist bombing? The daily routine can suddenly be complicated by large numbers of patients, exceeding the ability to treat in a routine fashion. Disaster events can result in patients with penetrating wounds, burns, blast injuries, chemical contamination, or all of these at once. Some events may disrupt infrastructure or result in loss of essential equipment or key personnel. The chaos of a catastrophic event impedes decision-making and effective treatment of patients. Disasters require a paradigm shift from the application of unlimited resources for the greatest good of each individual patient to the allocation of care, with limited resources, for the greatest good for the greatest number of patients. Training and preparation are essential to remain effective during crises and major catastrophic events. Disaster triage and crisis management represent a tactical art that incorporates clinical skills, didactic information, communication ability, leadership, and decision-making. Planning, rehearsing, and exercising various scenarios encourage the flexibility, adaptability, and innovation required in disaster settings. These skills can bring order to the chaos of overwhelming disaster events.

Creating order from chaos: part II: tactical planning for mass casualty and disaster response at definitive care facilities.

Current events highlight the need for disaster preparedness. We have seen tsunamis, hurricanes, terrorism, and combat in the news every night. There are many variables in a disaster, such as damage to facilities, loss of critical staff members, and overwhelming numbers of casualties. Each medical treatment facility should have a plan for everything from caring for staff members to getting the laundry done and providing enhanced security or mortuary services. Communication and agreements with local, regional, and federal agencies are vital. Then we must train and drill to shape the tools to impose order on chaos and to provide the most care to the greatest number.

An array of microactuated microelectrodes for monitoring single-neuronal activity in rodents.

Arrays of microelectrodes used for monitoring single- and multi-neuronal action potentials often fail to record from the same population of neurons over a period of time for several technical and biological reasons. We report here a novel Neural Probe chip with a 3-channel microactuated microelectrode array that will enable precise repositioning of the individual microelectrodes within the brain tissue after implantation. Thermal microactuators and associated microelectrodes in the Neural Probe chip are microfabricated using the Sandia's Ultraplanar Multi-level MEMS Technology (SUMMiTV) process, a 5-layer polysilicon micromachining technology of the Sandia National labs, Albuquerque, NM. The Neural Probe chip enables precise bi-directional positioning of the microelectrodes in the brain with a step resolution in the order of 8.8 microm. The thermal microactuators allow for a linear translation of the microelectrodes of up to 5 mm in either direction making it suitable for positioning microelectrodes in deep structures of a rodent brain. The overall translation in either direction was reduced to approximately 2 mm after insulation of the microelectrodes with epoxy for monitoring multi-unit activity. Single unit recordings were obtained from the somatosensory cortex of adult rats over a period of three days demonstrating the feasibility of this technology. Further optimization of the microelectrode insulation and chip packaging will be necessary before this technology can be validated in chronic experiments.