Irregular Warfare Must Combine Good Medicine, with Both Good Tactics and Good Strategies: Position Paper by the French Special Operations Forces Medical Command.

INTRODUCTION: Military operations are no longer limited to the application of counterterrorism and counterinsurgency strategies; they are now characterized by hybrid, irregular, and unconventional features. While some authors have indicated the need for medical support to adapt to these new modes of military operations, they have focused mainly on the tactical level of care on the battlefield. As Sun Tzu states, "Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat," further proposals are still needed on the application of both medical tactics and medical strategies in irregular warfare. METHODS: Medical experts from the French Special Operations Forces (SOF) Medical Command have identified specific medical challenges that special operations face in the context of the current transformation of armed confrontations into irregular warfare. RESULTS: This position paper presents original tactical medical proposals for improving medical support in irregular warfare, ranging from the definition of a Primary-Alternate-Contingency-Emergency medical plan to the promotion of telemedical support. Original strategic medical proposals have highlighted the importance of recognizing medical issues in irregular warfare, including the medical actions carried out through and with local partners and the multiple approaches to countering medical threats. CONCLUSIONS: The SOF medical community must be closely involved with and facilitate the responses to the shift to irregular warfare. International collaboration and interoperability are more necessary than ever, as they will enable a more effective combination of good medicine with both good tactics and good strategies. These perspectives can also be extended to improve medical care in the conventional armed forces and austere civilian settings. LEVEL OF EVIDENCE: N/A. STUDY TYPE: Original research.

Combat Casualties Treated With Intranasal Ketamine for Prehospital Analgesia: A Case Series.

Optimal pain management is challenging in Tactical Combat Casualty Care (TCCC), particularly in remote and austere settings. In these situations, appropriate treatment for prehospital analgesia can be limited or delayed due to the lack of intravenous access. Several guidelines suggest to implement intranasal (IN) analgesia in French Armed Forces for forward combat casualty care (Sauvetage au Combat), similar to the US TCCC. Four medical teams from the French Medical Military Service were deployed to the Middle East and Sahel from August 2017 to March 2019 and used IN ketamine for analgesia in 76 trauma patients, out of a total of 259 treated casualties. IN administration of ketamine 50mg appeared to be safe and effective, alone or in addition to other opioid analgesics. It also had minimal side effects and led to a reduction in the doses of ketamine and morphine used by the intravenous (IV) route. The French Military Medical Service supports current developments for personal devices delivering individual doses of IN ketamine. However, further studies are needed to analyze its efficacy and safety in combat zones.

Musculoskeletal diseases among French military high-speed boat pilots.

In 2016, the French Navy acquired a new high-speed boat, called ECUME. It exposes crewmembers to significant Whole Body Vibrations. This work explores the musculoskeletal diseases among this population. We conducted a retrospective declarative epidemiologic study using anonymous questionnaires. Eighty-four sailors were included. Fifty-six (66.7%) report acute traumas during a nautical raid during the 12 months study period. Sixty (71.4%) report chronic pains, which they associate with their nautical activity. Among them, only 16 (26.7%) have consulted a doctor, but 32 (53.3%) report consuming medication, including 18 through selfmedication. More than half rely to alternatives medicine, especially osteopathy. The traumatic risk of ECUME riding is obvious. Many crewmembers minimize their symptoms, and consult rarely a physician. They give preference to selfmedication and alternative medicines.

Whole blood transfusion closest to the point-of-injury during French remote military operations.

To improve the survival of combat casualties, interest in the earliest resort to whole blood (WB) transfusion on the battlefield has been emphasized. Providing volume, coagulation factors, plasma, and oxygenation capacity, WB appears actually as an ideal product severe trauma management. Whole blood can be collected in advance and stored for subsequent use, or can be drawn directly on the battlefield, once a soldier is wounded, from an uninjured companion and immediately transfused.Such concepts require a great control of risks at each step, especially regarding ABO mismatches, and transfusion-transmitted diseases. We present here the "warm and fresh" WB field transfusion program implemented among the French armed forces. We focus on the followed strategies to make it applicable on the battlefield, even during special operations and remote settings, and safe for recipients as well as for donors.