Major Incident Hospital Simulations in Hospital Based Health Care: A Scoping Review.

Major incidents are occurring in increasing frequency, and place significant stress on existing health-care systems. Simulation is often used to evaluate and improve the capacity of health systems to respond to these incidents, although this is difficult to evaluate. A scoping review was performed, searching 2 databases (PubMed, CINAHL) following PRISMA guidelines. The eligibility criteria included studies addressing whole hospital simulation, published in English after 2000, and interventional or observational research. Exclusion criteria included studies limited to single departments or prehospital conditions, pure computer modelling and dissimilar health systems to Australia. After exclusions, 11 relevant studies were included. These studies assessed various types of simulation, from tabletop exercises to multihospital events, with various outcome measures. The studies were highly heterogenous and assessed as representing variable levels of evidence. In general, all articles had positive conclusions with respect to the use of major incidence simulations. Several benefits were identified, and areas of improvement for the future were highlighted. Benefits included improved understanding of existing Major Incident Response Plans and familiarity with the necessary paradigm shifts of resource management in such events. However, overall this scoping review was unable to make definitive conclusions due to a low level of evidence and lack of validated evaluation.

Effects of mass casualty incidents on anxiety, depression and PTSD among doctors and nurses: a systematic review protocol.

INTRODUCTION: Both doctors and nurses showed a greater risk of being exposed to different mental health conditions following mass casualties. This systematic review aims to synthesise the existing evidence on the prevalence of anxiety, depression and post-traumatic stress disorder and their associated risk factors among doctors and nurses following mass casualty incidents. METHODS AND ANALYSIS: Seven electronic databases (PubMed, PsycINFO, MEDLINE Ovid, Embase, CINAHL, Web of Science and Nursing & Allied Health database) will be searched from 2010 to 2022 with peer-reviewed articles in English language using the predefined keywords. Two reviewers will independently screen the titles and abstracts, as well as review the full texts using the eligibility criteria, then extract data independently. The National Institutes of Health Quality Assessment Tools (NIH-QAT) for quantitative studies, the Critical Appraisal Skills Programme (CASP) Checklist for qualitative studies and the Mixed-Methods Appraisal Tool (MMAT) for mixed-method studies will be used to measure the quality appraisal of eligible studies. A third reviewer will resolve the discrepancies when the two reviewers cannot reach an agreement in any step. The result from the eligible studies will be described following narrative synthesis with the key characteristics and findings of the included studies, and meta-analysis will be performed, if applicable. ETHICS AND DISSEMINATION: This systematic review deals with existing published studies without any personally identifiable information of participants. Therefore, ethical approval from the research committee is not required. Findings from this review will be disseminated in peer-reviewed journals and presented at relevant international conferences. PROSPERO REGISTRATION NUMBER: CRD42023412852.

Early Evaluation of a New French Surgery Course in the Best Practice of Dealing With Major Incidents and Mass Casualty Events.

OBJECTIVE: The main objective of this study is to evaluate the impact of a nationwide 5-month course aimed to prepare surgeons for Major Incidents through the acquisition of key knowledge and competencies. Learners' satisfaction was also measured as a secondary objective. DESIGN: This course was evaluated thanks to various teaching efficacy metrics, mainly based on Kirkpatrick's hierarchy in medical education. Gain in knowledge of participants was evaluated by multiple-choice tests. Self-reported confidence was measured with 2 detailed pre and post training questionnaires. SETTING: Creation in 2020 of a nationwide, optional and comprehensive Surgical Training in War and Disaster Situation as part of the French surgery residency program. In 2021, data was gathered regarding the impact of the course on participants' knowledge and competencies. PARTICIPANTS: The study included 26 students in the 2021 cohort (13 residents and 13 practitioners). RESULTS: Mean scores were significantly higher in the post-test compared to the pre-test, showing significant increase in participants' knowledge during the course: 73,3% vs. 47,3% respectively (p ≤ 0.001). Average learners' confidence scores to perform technical procedures showed at least a +1-point increase on the Likert scale for 65% of items tested (p ≤ 0.001). 89% of items showed at least a +1-point increase on the Likert scale when it came to average learners' confidence score on dealing with complicated situations (p ≤ 0.001). Our post-training satisfaction survey showed that 92% of all participants have noticed the impact of the course on their daily practice. CONCLUSION: Our study shows that the third level of Kirkpatrick's hierarchy in medical education was reached. This course therefore appears to be meeting the objectives set by the Ministry of Health. Being only 2 years old, it is on the road to gathering momentum and further development.

Can Live-Actor Patients in a Mass Casualty Incident Exercise Benefit as Exercise Players?

OBJECTIVES: In a mass casualty incident (MCI) exercise, live-actor patients (LAPs) simulated different scenarios in the exercise. This study compared the benefit to LAPs with that to exercise players (EPs) and nonparticipants (NPs). METHODS: An MCI exercise was conducted in 2018. Emergency department (ED) nurses were assigned as EPs, LAPs, or NPs and asked to attend a pre-exercise lecture. A pre-exercise survey evaluated all ED nurses' background, confidence level, and knowledge of MCI management. Knowledge assessment included disaster medicine knowledge (DMK) and on emergency operation plan familiarity (EOPF). The same survey was conducted again after the exercise. A paired t-test was used to analyze the difference before and after the exercise in the 3 groups. RESULTS: Twenty-nine ED nurses completed both surveys. Confidence improved significantly for both the EP and LAP groups. The DMK of the LAP group improved significantly. EOPF also improved significantly for all 3 groups. A comparison of the improvement levels showed no significant difference between the EP and LAP groups for confidence, DMK, and EOPF. CONCLUSIONS: ED nurses can benefit from participating as LAPs in full-scale MCI exercises. Having ED nurses act as LAPs makes it possible to train more staff in 1 exercise.

La odontología en la identificación de sucesos con víctimas múltiples / Forensic odontology in human identification in multiple victims’ incidents

La aprobación en 2009, del Protocolo Nacional de actuación Médico-Forense y de Policía Científica en sucesos con víctimas múltiples, supuso la base normativa para regular formalmente los procedimientos y técnicas que deben aplicarse, como las distintas tareas forenses que se tienen que realizar en los supuestos de sucesos con víctimas múltiples en España. En este artículo se revisan los procedimientos y métodos que se emplean en odontología forense para la identificación humana en casos de grandes catástrofes con múltiples víctimas. Dado que el reconocimiento de las características individualizadoras de las piezas dentarias, y en general los datos bucodentales, supone un proceso altamente especializado, resulta imprescindible el apoyo técnico de odontólogos/as forenses con experiencia en este campo, quienes dispondrán de la formación y los conocimientos necesarios para la realización de la toma de registros dentales, la interpretación precisa de los resultados y la obtención adecuada de las conclusiones. Finalmente se incluyen recomendaciones para la elaboración de los informes forenses de identificación odontológica. (AU)

The approval in 2009, of the Protocolo Nacional de actuación Médico-Forense y de Policía Científica en sucesos con víctimas múltiples, was the basic normative to formally regulate both the technical procedures that must be applied, and the different tasks to be carried out in a disaster victim incident in Spain. This article reviews the procedures and techniques used in forensic odontology for human identification in DVI incidents with multiple victims. Given that the recognition of the individualizing characteristics of the teeth, and in general the odontological data, supposes a highly specialized process, it is essential the assistance of forensic dentists with experience in this field, who will have the training and the knowledge to carry out the dental procedures such as documenting dental records, accurate interpretation of the results and withdraw precise dental identification conclusions. Finally, recommendations for the preparation of forensic dental identification reports are included in this review. (AU)

Aportaciones y avances de la genética forense en los sucesos con víctimas múltiples / Contributions and advances of forensic genetics in mass fatality incidents

La identificación de los afectados por un suceso con víctimas múltiples es una prioridad por razones humanitarias y legales. La genética forense juega un importante papel en estas situaciones que, por su complejidad, a menudo se convierten en un reto para los distintos profesionales implicados. El establecimiento de guías y recomendaciones facilita el seguimiento de protocolos estandarizados que permiten garantizar la fiabilidad del resultado final de la identificación. Así mismo, los avances en la genética forense contribuyen a agilizar la respuesta, aportando nuevas estrategias de análisis y herramientas de tipo bioinformático. Con este artículo, se pretende ofrecer una visión general de cómo la genética forense y sus avances pueden contribuir en estas situaciones, así como algunas claves para entender la labor de los laboratorios de genética forense en la identificación de cadáveres en sucesos con víctimas múltiples. (AU)

Disaster victim identification is crucial for humanitarian and legal reasons. Forensic genetics plays an important role in these situations which often become a challenge for the different professionals involved due to their complexity. The establishment of guidelines and recommendations makes it easier to follow standardized protocols that make it possible to guarantee the reliability of the identification final result. Likewise, advances in forensic genetics contribute to speeding up the response, providing new analysis strategies and bioinformatic tools. This article aims to provide an overview of how forensic genetics and its advances can contribute in these situations, as well as some keys to understanding the work of forensic genetics laboratories in the identification of corpses in events with multiple victims. (AU)

Hacia un cambio de paradigma en la atención psicológica en grandes emergencias: de incidentes con múltiples víctimas a incidentes con múltiples afectados / Towards a paradigm shift in psychological care in major emergencies: from incidents with multiple victims to incidents with multiple victims

Las grandes emergencias o desastres plantean grandes retos a la sociedad y en especial a todos los servicios de emergencia. En las últimas décadas, se ha incorporado la perspectiva de la salud mental como una parte importante de la atención sanitaria integral a los afectados. Así, el cambio conceptual de «incidente de múltiples víctimas» (IMV) a «incidente de múltiples afectados» (IMA) se centra en la atención y bienestar de todas las personas afectadas por un incidente, no solo en aquellos que han sufrido lesiones físicas. El objetivo del presente artículo se centra en conocer las posibilidades de intervención con afectados etiquetados en un triaje como verdes psicológicos (sin afectación y/o lesiones físicas), a partir de la intervención psicológica avanzada en emergencias (IPA). La IPA, más allá de alejar a los afectados del peligro, persigue aumentar su sensación de control y eficacia, tanto para afrontar la situación como para aumentar su sentido de competencia en la vivencia de trauma posterior respecto a esa experiencia. En este sentido, las posibilidades recientes de evaluación, así como los enfoques de primeros auxilios psicológicos, permiten nuevas aplicaciones de intervención en emergencias como las que posibilitan los soportes aéreos remotos (drones). Se discute su aplicación y posibilidades como opciones de futuro. (AU)

Major emergencies or disasters pose great challenges to society and especially to all emergency services. In the last decades, the Mental Health perspective has been incorporated as an important part of comprehensive health care for those affected. Thus, the conceptual change from “multiple casualty incident” (MCI) to “multiple affected incident” (MAI) focuses on the care and well-being of all people affected by an incident, not only those who have suffered physical injuries. The objective of this article is focused on finding out the possibilities of intervention with patients labeled in triage as psychological green (without affectation and/or physical injuries), based on advanced psychological intervention in emergencies (IPA). The IPA, beyond removing those affected from danger, seeks to increase their sense of control and efficacy, both to face the situation and to increase their sense of competence in the experience of subsequent trauma with respect to that experience. In this sense, recent assessment possibilities, as well as psychological first aid approaches, allow new intervention applications in emergencies such as those made possible by remote air support (drones). Its application and possibilities as future options are discussed. (AU)

[Validation of secondary triage algorithms for mass casualty incidents-A simulation-based study-German version]. / Validierung innerklinischer Sichtungsalgorithmen für den Massenanfall von Verletzten ­ eine simulationsbasierte Studie ­ deutsche Version.

BACKGROUND: In the event of a mass casualty incident (MCI), the situation-related shortage of medical resources does not end when the patients are transported from the scene of the incident. Consequently, an initial triage is required in the receiving hospitals. In the first step, the aim of this study was to create a reference patient vignette set with defined triage categories. This allowed a computer-aided evaluation of the diagnostic quality of triage algorithms for MCI situations in the second step. METHODS: A total of 250 case vignettes validated in practice were entered into a multistage evaluation process by initially 6 and later 36 triage experts. This algorithm-independent expert evaluation of all vignettes-served as the gold standard for analyzing the diagnostic quality of the following triage algorithms: Manchester triage system (MTS module MCI), emergency severity index (ESI), Berlin triage algorithm (BER), the prehospital algorithms PRIOR and mSTaRT, and two project algorithms from a cooperation between the Federal Office of Civil Protection and Disaster Assistance (BBK) and the Hashemite Kingdom of Jordan-intrahospital Jordanian-German project algorithm (JorD) and prehospital triage algorithm (PETRA). Each patient vignette underwent computerized triage through all specified algorithms to obtain comparative test quality outcomes. RESULTS: Of the original 250 vignettes, a triage reference database of 210 patient vignettes was validated independently of the algorithms. These formed the gold standard for comparison of the triage algorithms analyzed. Sensitivities for intrahospital detection of patients in triage category T1 ranged from 1.0 (BER, JorD, PRIOR) to 0.57 (MCI module MTS). Specificities ranged from 0.99 (MTS and PETRA) to 0.67 (PRIOR). Considering Youden's index, BER (0.89) and JorD (0.88) had the best overall performance for detecting patients in triage category T1. Overtriage was most likely with PRIOR, and undertriage with the MCI module of MTS. Up to a decision for category T1, the algorithms require the following numbers of steps given as the median and interquartile range (IQR): ESI 1 (1-2), JorD 1 (1-4), PRIOR 3 (2-4), BER 3 (2-6), mSTaRT 3 (3-5), MTS 4 (4-5) and PETRA 6 (6-8). For the T2 and T3 categories the number of steps until a decision and the test quality of the algorithms are positively interrelated. CONCLUSION: In the present study, transferability of preclinical algorithm-based primary triage results to clinical algorithm-based secondary triage results was demonstrated. The highest diagnostic quality for secondary triage was provided by the Berlin triage algorithm, followed by the Jordanian-German project algorithm for hospitals, which, however, also require the most algorithm steps until a decision.

[Care of the severely injured in mass casualty incidents : What is the difference compared to emergency room management?] / Schwerstverletztenversorgung beim Massenanfall von Verletzten : Worin besteht der Unterschied zum Schockraummanagement?

The management of a severely injured patient according to the standards and principles of individualized trauma care is a well-established procedure in many hospitals. The process is structured and standardized by the content of several course formats. In contrast, a mass casualty incident (MCI, MANV) is a rare and exceptional situation. In this case the treatment priorities and approaches are changed. The main aim in this situation is to ensure the best possible chance of survival for every casualty by organizational measures to mobilize rooms, personnel and material and to temporarily abandon the standards of individualized trauma care. To be prepared for a MCl situation it is necessary to know the realistic scenarios, to update the hospital emergency plan and to adapt all treatment procedures to the transient lack of resources. This article gives an overview of this process and summarizes the current clinical concepts to cope with a MCl situation and the current principles for the care of the severely injured involving many casualties.

Comparing different models to forecast the number of mass shootings in the United States: An application of forecasting rare event time series data.

The number of mass shootings in the United States has increased in the recent decades. Understanding the future risk of the mass shootings is critical for designing strategies to mitigate the risk of mass shootings, and part of understanding the future risk is to forecast the frequency or number of mass shootings in the future. Despite the increasing trend in mass shootings, they thankfully remain rare events with fewer than 10 mass shootings occurring in a single year. Limited historical data with substantial annual variability poses challenges to accurately forecasting rare events such as the number of mass shootings in the United States. Different forecasting models can be deployed to tackle this challenge. This article compares three forecasting models, a change-point model, a time series model, and a hybrid of a time series model with an artificial neural network model. Each model is applied to forecast the frequency of mass shootings. Comparing among results from these models reveals advantages and disadvantages of each model when forecasting rare events such as mass shootings. The hybrid ARIMA-ANN model can be tuned to follow variation in the data, but the pattern of the variation may not continue into the future. The mean of the change-point model and the ARIMA model exhibit much more less annual variation and are not influenced as much by the inclusion of a single data point. The insights generated from the comparison are beneficial for selecting the best model and accurately estimating the risk of mass shootings in the United States.

Nonfatal Injuries Sustained in Mass Shootings in the US, 2012-2019: Injury Diagnosis Matrix, Incident Context, and Public Health Considerations.

INTRODUCTION: The epidemic of gun violence in the United States (US) is exacerbated by frequent mass shootings. In 2021, there were 698 mass shootings in the US, resulting in 705 deaths and 2,830 injuries. This is a companion paper to a publication in JAMA Network Open, in which the nonfatal outcomes of victims of mass shootings have been only partially described. METHODS: We gathered clinical and logistic information from 31 hospitals in the US about 403 survivors of 13 mass shootings, each event involving greater than 10 injuries, from 2012-19. Local champions in emergency medicine and trauma surgery provided clinical data from electronic health records within 24 hours of a mass shooting. We organized descriptive statistics of individual-level diagnoses recorded in medical records using International Classification of Diseases codes, according to the Barell Injury Diagnosis Matrix (BIDM), a standardized tool that classifies 12 types of injuries within 36 body regions. RESULTS: Of the 403 patients who were evaluated at a hospital, 364 sustained physical injuries-252 by gunshot wound (GSW) and 112 by non-ballistic trauma-and 39 were uninjured. Fifty patients had 75 psychiatric diagnoses. Nearly 10% of victims came to the hospital for symptoms triggered by, but not directly related to, the shooting, or for exacerbations of underlying conditions. There were 362 gunshot wounds recorded in the Barell Matrix (1.44 per patient). The Emergency Severity Index (ESI) distribution was skewed toward higher acuity than typical for an emergency department (ED), with 15.1% ESI 1 and 17.6% ESI 2 patients. Semi-automatic firearms were used in 100% of these civilian public mass shootings, with 50 total weapons for 13 shootings (Route 91 Harvest Festival, Las Vegas. 24). Assailant motivations were reported to be associated with hate crimes in 23.1%. CONCLUSION: Survivors of mass shootings have substantial morbidity and characteristic injury distribution, but 37% of victims had no GSW. Law enforcement, emergency medical systems, and hospital and ED disaster planners can use this information for injury mitigation and public policy planning. The BIDM is useful to organize data regarding gun violence injuries. We call for additional research funding to prevent and mitigate interpersonal firearm injuries, and for the National Violent Death Reporting System to expand tracking of injuries, their sequelae, complications, and societal costs.

An assessment of mass casualty triage systems using the Alberta trauma registry.

OBJECTIVE: Triage is the process of identifying patients with both the greatest clinical need and the greatest likelihood of benefit in the setting of limited clinical resources. The primary objective of this study was to assess the ability of formal mass casualty incident triage tools to identify patients requiring urgent lifesaving interventions. METHODS: Data from the Alberta Trauma Registry (ATR) was used to assess seven triage tools: START, JumpSTART, SALT, RAMP, MPTT, BCD and MITT. Clinical data captured in the ATR was used to determine which triage category each of the seven tools would have applied to each patient. These categorizations were compared to a reference standard definition based on the patients' need for specific urgent lifesaving interventions. RESULTS: Of the 9448 records that were captured 8652 were included in our analysis. The most sensitive triage tool was MPTT, which demonstrated a sensitivity of 0.76 (0.75, 0.78). Four of the seven triage tools evaluated had sensitivities below 0.45. JumpSTART had the lowest sensitivity and the highest under-triage rate for pediatric patients. All the triage tools evaluated had a moderate to high positive predictive value (> 0.67) for patients who had experienced penetrating trauma. CONCLUSIONS: There was a wide range in the sensitivity of triage tools to identify patients requiring urgent lifesaving interventions. MPTT, BCD and MITT were the most sensitive triage tools assessed. All of the triage tools assessed should be employed with caution during mass casualty incidents as they may fail to identify a large proportion of patients requiring urgent lifesaving interventions.

ABSTRAIT: OBJECTIFS: Le triage est le processus qui consiste à identifier les patients qui ont à la fois les besoins cliniques les plus importants et les avantages les plus probables dans le contexte de ressources cliniques limitées. Le principal objectif de cette étude était d'évaluer la capacité des outils formels de triage des incidents impliquant des blessés de masse à identifier les patients nécessitant des interventions urgentes de sauvetage. MéTHODES: Les données du Alberta Trauma Registry (ATR) ont été utilisées pour évaluer sept outils de triage : START, JumpSTART, SALT, RAMP, MPTT, BCD et MITT. Les données cliniques saisies dans l'AR ont servi à déterminer la catégorie de triage que chacun des sept outils aurait appliquée à chaque patient. Ces catégories ont été comparées à une définition standard de référence fondée sur le besoin des patients d'interventions de sauvetage urgentes. RéSULTATS: Sur les 9448 enregistrements saisis, 8652 ont été inclus dans notre analyse. L'outil de triage le plus sensible était le TPMD, qui présentait une sensibilité de 0,76 (0,75, 0,78). Quatre des sept outils de triage évalués présentaient une sensibilité inférieure à 0,45. JumpSTART avait la sensibilité la plus faible et le taux de sous-triage le plus élevé chez les patients pédiatriques. Tous les outils de triage évalués avaient une valeur prédictive positive modérée à élevée (>0,67) pour les patients qui avaient subi un traumatisme pénétrant. CONCLUSION: La sensibilité des outils de triage pour identifier les patients nécessitant des interventions de sauvetage urgentes variait grandement. Les outils de triage les plus sensibles ont été le TCPR, le BCD et le MITT. Tous les outils de triage évalués doivent être utilisés avec prudence lors d'incidents impliquant des pertes massives, car ils peuvent ne pas identifier une grande proportion de patients nécessitant des interventions de sauvetage urgentes.

Toward A Serious Game to Help Future Military Doctors Face Mass Casualty Incidents.

INTRODUCTION: To prepare military doctors to face mass casualty incidents (MCIs), the French Army Health Service contributed to the development of TRAUMASIMS, a serious game (SG) for training medical responders to MCIs. METHODS: French military doctors participated in a three-phase training study. The initial war trauma training was a combination of didactic lectures (Phase 1), laboratory exercises (Phase 2), and situational training exercises (STX) (Phase 3). Phase 1 lectures reviewed French Forward Combat Casualty Care (FFCCC) practices based on the acronym MARCHE (Massive bleeding, Airway, Respiration, Circulation, Head, hypothermia, Evacuation) for the detection of care priorities and implementation of life-saving interventions, triage, and medical evacuation (MEDEVAC) requests. Phase 2 was a case-control study that consisted of a traditional text-based simulation of MCIs (control group) or SG training (study group). Phase 3 was clinical: military students had to simultaneously manage five combat casualties in a prehospital setting. MCI management was evaluated using a standard 20-item scale of FFCCC benchmarks, 9-line MEDEVAC request, and time to evacuate the casualty collection point (CCP). Emotional responses of study participants were secondarily analyzed. RESULTS: Among the 81 postgraduate military students included, 38 took SG training, and 35 trained with a text-based simulation in Phase 2. Regarding the error rates made during STX (Phase 3), SG improved FFCCC compliance (11.9% vs. 23.4%; p < .001). Additionally, triage was more accurate in the SG group (93.4% vs. 88.0%; p = .09). SG training mainly benefited priority and routine casualties, allowing faster clearance of the CCP (p = .001). Stress evaluations did not demonstrate any effect of immersive simulation. CONCLUSION: A brief SG-based curriculum (2 hours) improved FFCCC performance and categorization of casualties in MCI STX.

A Descriptive Analysis of the Use of Chemical, Biological, Radiological, and Nuclear Weapons by Violent Non-State Actors and the Modern-Day Environment of Threat.

INTRODUCTION: The use of chemical, biological, radiation, and nuclear (CBRN) weapons is not new, and though rare, it is an issue of concern around the world due to their ability to cause large-scale mass-casualty events and their potential threat to global stability. The purpose of this study is to explore the use of CBRN weapons by non-state actors through analysis of the Violent Non-State Actor (VNSA) CBRN Event database, and aims to better inform health care systems of the potential risks and consequences of such events. METHODS: Data collection was performed using a retrospective database search through the VNSA CBRN Event database. RESULTS: A total of 565 events were recorded. Five hundred and five (505) events (89.4%) involved single agents while 60 events (10.6%) involved multiple agents. Fatalities numbered 965 for chemical agents, 19 for biological agents, and none for radiological and nuclear events. Injuries numbered 7,540 for chemical agents, 59 for biological agents, 50 for radiological events, and none for nuclear attacks. Fatality and injury per attack was 2.22 and 17.37, respectively, for chemical event agents and 0.15 and 0.48, respectively, for biological event agents. CONCLUSION: Violent Non-State Actors were responsible for 565 unique events around the world involving the use of CBRN weapons from 1990-2020. The United States (118), Russia (49), and Iraq (43) accounted for the top three countries where these events occurred. While CBRN events remain relatively rare, technological advances have the potential to facilitate the use of such weapons as part of a hybrid warfare strategy with significant repercussions for civilian health and health care systems.

The last days: The medical response of United States and allied military teams during the Afghanistan Exodus.

OBJECTIVES: The objective of this study is to describe the United States and allied military medical response during the withdrawal from Afghanistan. BACKGROUND: The military withdrawal from Afghanistan concluded with severe hostilities resulting in numerous civilian and military casualties. The clinical care provided by coalition forces capitalized on decades of lessons learned and enabled unprecedented accomplishments. METHODS: In this retrospective, observational analysis, casualty numbers, and operative information was collected and reported from military medical assets in Kabul, Afghanistan. The continuum of medical care and the trauma system, from the point of injury back to the United States was captured and described. RESULTS: Prior to a large suicide bombing resulting in a mass casualty event, the international medical teams managed distinct 45 trauma incidents involving nearly 200 combat and non-combat civilian and military patients over the preceding 3 months. Military medical personnel treated 63 casualties from the Kabul airport suicide attack and performed 15 trauma operations. US air transport teams evacuated 37 patients within 15 hours of the attack. CONCLUSION: Lessons learned from the last 20 years of combat casualty care were successfully implemented during the culmination of the Afghanistan conflict. Ultimately, the effort, teamwork, and system adaptability exemplify not only the attitudes and character of service members who provide modern combat casualty care but also the paramount importance of the battlefield learning health care system. A continued posture to maintain military surgical preparedness in unique environments remain crucial as the US military prepares for the future.Retrospective observational analysis. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Novel design of inspiratory flow generation and gas mixing for critical care ventilators suitable for rapid production and mass casualty incidents.

Scarcity of medical resources inspired many teams worldwide to design ventilators utilizing different approaches during the recent COVID-19 pandemic. Although it can be relatively easy to design a simple ventilator in a laboratory, a large scale production of reliable emergency ventilators which meet international standards for critical care ventilators is challenging and time consuming. The aim of this study is to propose a novel and easily manufacturable principle of gas mixing and inspiratory flow generation for mechanical lung ventilators. Two fast ON/OFF valves, one for air and one for oxygen, are used to control the inspiratory flow generation using pulse width modulation. Short gas flow pulses are smoothed by low-pass acoustic filters and do not propagate further into the patient circuit. At the same time, the appropriate pulse width modulation of both ON/OFF valves controls the oxygen fraction in the generated gas mixture. Tests focused on the accuracy of the delivered oxygen fractions and tidal volumes have proved compliance with the international standards for critical care ventilators. The concept of a simple construction using two fast ON/OFF valves may be used for designing mechanical lung ventilators and thus suitable for their rapid production during pandemics.

Military Burn Care and Burn Disasters.

Mass-casualty incidents can occur because of natural disasters; industrial accidents; or intentional attacks against civilian, police, or in case of combat, military forces. Depending on scale and type of incident, burn casualties often with a variety of concomitant injuries can be anticipated. The treatment of life-threatening traumatic injuries should take precedent but the stabilization, triage, and follow-on care of these patients will require local, state, and often regional coordination and support.